U.S. Department of Health and Human Services

Health Resources and Services Administration

Office of Rural Health Policy

This document was prepared under HRSA contract # 250-03-0022, U.S. Department of Health and Human Services, Health Resources and Services Administration, Office of Rural Health Policy.

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Contents

Foreword

Introduction

Establishing Community Readiness

Role of the EMS Director or Service Chief

Sample Memorandum of Agreement

Description of the Process

Sample Timeline

Sample Process Description Outline

How to Choose a Facilitator

Customizing the Process

How to Fund the Process

Questionnaires: Prior to each Instruction of Distribution

(target audience, purpose of survey, methods of distribution)

EMS/Community Demographic Profile

EMS Agency Self-Assessment

The Healthcare System

The Public Safety System

The Political System

The School System

The Local/Regional Media

The Community at Large

Tally Sheet

Using the Information for Planning

Frequently Asked Questions

APPENDIX A: Sample Planning Report

APPENDIX B: Acknowledgements

Contributors and Reviewers

APPENDIX C: REMSTTAC Stakeholders' Group

APPENDIX D: References

Foreword

The face of rural and frontier Emergency Medical Services (EMS) is changing. The number of potential volunteers in many areas is dwindling due to the ever increasing age of the population. At the same time, expectations and requirements have increased, with all-hazards preparedness, pandemic disease and other preparedness requirements.

Rural health care, in general, has also changed, hospitals have closed, downsized, or converted to Critical Access Hospitals. These changes sometimes result in longer transport times to specialty care facilities in neighboring communities.

The community at large may have unrealistic expectations about access to and availability of prehospital services fueled by periodic doses of highly efficient and effective responses portrayed on television. During their moment of need, they may expect immediate personnel response with all of the latest gadgetry capable of plucking them from the very jaws of death.

Prehospital care providers themselves also often have unrealistic expectations fueled by the same media and reinforced by articles and vendor ads in trade magazines and catalogues suggesting that the next higher level of certification is always better and that the newest piece of equipment will always result in improved outcomes. These beliefs are often developed even in the face of irrefutable evidence to the contrary.

The reality is that sometimes a rock-solid basic response sustained day in and day out may be superior to a hit and miss system of advanced care. The challenge is to gather enough information from the community itself to determine the best level, type, and configuration of EMS for that community. A process that engages other health care providers, public safety personnel, the community at large, the schools, the political leadership, and the media is essential to facilitate appropriate planning and decision making at the local level. That is what the community planning process is about.

Many rural EMS agencies are fighting for their very existence. Others enjoy relative prosperity. Both want to do better. The process outlined in this document can help either take the next step, one towards survival, the other towards excellence.

When people call for medical help in a rural area, they expect a rapid response, competent staff, and good equipment from the local Emergency Medical Services (EMS). Too often, their expectations are formed by what they see on TV, not by the reality in their own community. Surprisingly, few EMS systems rely on sound assessment techniques to ensure that they understand and can meet the needs of the community.

Rural communities and their EMS agencies need a tool to evaluate their strengths and weaknesses and to provide a clear understanding of the needs of their customers. With this understanding, the EMS service can focus its limited resources and the community can have a greater voice in determining the EMS service it needs and is willing to support.

Even more importantly, the EMS agency needs to function as a member of its community. People may think that their local ambulance service is supported completely by government taxes - and have a negative reaction when they are billed for an ambulance call. Or they may think that the ambulance is fully tax supported and be offended when a volunteer service conducts a fundraising event.

Even more serious is the fact that most people outside the medical field (and some within the medical fields) do not understand the difference between an EMT-Basic, EMT-Intermediate, and EMT-Paramedic. They do not understand the different skill requirements, training demands, financial demands, and medical supervision in each of these levels of service.

For most people, the EMS agency is invisible until an emergency happens. And then it is too late. EMS agencies need to become an integral part of the community so that people know what it takes to provide the kind of service they want. The community needs to understand what is provided and the costs in both financial and human resources so it can make informed decisions about the level of service that is possible.

Community planning is about questioning. The community planning and integration process needs to involve the ambulance service staff and volunteers, the hospitals and medical assistance facilities, governing bodies, schools, service clubs, the business community, and the public at large in assessing its emergency health care and how that service interacts with and impacts each entity. This guide contains questions to help your community evaluate the EMS service's place in the community.

This is not a project for the EMS agency to conduct and present to the community. Instead, it must be a community-wide effort that involves many individuals. The point of this planning exercise is to discover the EMS agency's role in the community and determine if the community needs the agency's role strengthened in some areas or whether the community actually needs the EMS agency to assume a different role altogether. Is an autonomous EMS service the best for your community or would people be better served by a service that operated in conjunction with another community organization? Is the community best served by an all-volunteer service or a paid service? Should the EMS service provide only emergency care or should it take on expanded duties, such as conducting health assessments?

This guide is a step-by-step plan on how to evaluate the role of EMS in your community. Each of the questionnaires discusses a specific community group and guides your community in assessing the EMS service in relation to that segment of the community.

You will need assistance along the way to conduct this planning assessment. The facilitator in this process should bring a broad breadth and depth of EMS experience and a fresh "outside" perspective. The outside facilitator should be embraced as a partner in this process (see pg. 13; How to Choose a Facilitator). The facilitator will assist community leaders in gathering information through a series of questionnaires targeting specific segments of the community. These include:

EMS/Community Demographic Profile
This profile will assist the facilitator in understanding the unique qualities of each EMS system and the community. It provides a snapshot of the EMS system organizational structure and the community's current status.

EMS Agency Self-Assessment
It is critical to examine your own perception of how well the current system meets the needs of the community in general. This section provides an overview of the entire process and gives you a quick internal snapshot of your agency's employee/volunteer perception about how well the agency interacts with other community resources.

The Health Care System
The goal of prehospital medicine is to stabilize, treat, and transport those who are critically ill or injured to definitive care. Definitive care may be a hospital, critical access hospital or rural health clinic. Is the continuum of care from the street to these facilities being handled efficiently and productively? This section establishes whether the EMS agency integrates well with the community's overall health care system.

The Public Safety System
Managing an emergency scene often requires help from fire fighters and law enforcement. Fire fighters can assist in extrication or provide initial medical care. Law Enforcement officers secure the scene. How does the EMS service interact with public safety personnel? Does everyone have a defined role and work well together? This section explores the interactions and relationship between the EMS service and other public safety emergency responders.

The Political System
Behind any EMS agency is the political system - those who govern the community. The political system governs many aspects of prehospital care regardless of whether EMS is a public, private, volunteer or hospital-based system. Is the EMS service accountable financially? What is the cost of poor quality? Do the political bodies understand the State and national regulations governing EMS? This section details the main concerns in making sure the political system and the EMS service are working together.

The School System
How well does the EMS service work with the school system? Schools are great venues for injury prevention education and recruitment of future EMS providers. Do educators and faculty interact seamlessly with EMS personnel during an emergency? Is the community prepared for tragedies like school shootings? This section helps evaluate the EMS service in relation to the school system from education to policies and procedures.

The Local/Regional Media
There is no argument that media influences the community's perception of an industry. Does the EMS service notify the media of new programs, equipment, volunteers, and other possible feature stories? Does the EMS service maintain a positive working relationship with the media? Do EMS and media representative have established guidelines for handling news coverage during an emergency? This section examines the roles of the EMS service and the media.

The Community at Large
As stated in the EMS Agenda for the Future, "Emergency Medical Services (EMS) of the future will be community-based health management that is fully integrated with the overall health care system…it will improve community health and result in more appropriate use of acute health care resources. EMS will remain the public's emergency medical safety net." Does the EMS service provide the best possible care (protocol compliance, response time, clinical error rate)? Is the EMS service meeting customers' needs and expectations? Is there a system to continually reassess whether their needs are being met? Does the general public understand the service provided by the EMS service and its limitations? Does the general public have an accurate perception of the rules governing EMS practice and how the EMS operates financially? This section researches your influence on the community.

Using the Information for Planning.
The data gathered from the sections described above should provide the facilitator and community leaders with an initial outlook on its EMS service's strengths and weaknesses. At this point, the community must decide how to respond to this information. The information provides a sound basis for making decisions about how to meet the goal of this process: that the community has an EMS service that covers its needs within its financial and human resource limits and that the community understands and supports that level of service.

This EMS community-planning guide is helpful for:

• Understanding and shaping the community's perception of the local EMS service.
• Determining the appropriate level of care (i.e. Basic Life Support (BLS) vs. Advanced Life Support (ALS)) in a community.
• Building citizen "ownership" of the EMS service for support in financial decisions.
• Increasing public awareness of the EMS service capabilities and limitations.
• Increasing the EMS service's awareness of how it fits into the community.
• Examining the EMS service's perception of the community.
• Understanding how the needs of different groups in the community are difficult to identify and how they are interrelated.
• Understanding how to set priorities where the public demands are often high and the budget is often limited.

The Guide for Community-Based Needs Assessment is a tool. The process of communicating with various entities and individuals is far more important than making sure that each question is answered by all respondents. The tool is meant to open channels of dialogue. The questions and thoughts in this guide are suggestions, not policy. There are no documentation requirements, nor will following these viewpoints ensure compliance with any Federal, State or local codes or regulations that may apply to your EMS agency.

ESTABLISHING COMMUNITY READINESS

The extent to which the Community Assessment process is successful, and how the report is used, will depend to some degree on the "readiness" of the community. A growing body of evidence suggests that community-based change is heavily dependent on the degree to which the community sees the challenge and is willing to respond. According to Oetting, et al (2001), there are nine specific stages of community readiness. These are:

1. No Awareness. The issue is not recognized as a problem by the community. For instance, they may not be aware that volunteer recruitment and retention is an issue.
2. Denial. While some leaders may perceive a simmering problem they don't think it is critical or will impact the community directly. As an example, community members may notice that the ambulance is at the service shop frequently but don't acknowledge that this could affect the agency's ability to respond.
3. Vague Awareness. There is a general consensus that there is a problem and that something should be done about it… but no one is taking action. This discussion often occurs around the coffee shop or other local gathering places and might go something like, "Did you know that it took the ambulance 45 minutes to get to the McEwen farm after Charlie fell off the barn?"
4. Preplanning. The problem is clearly identified and some action is occurring, e.g. there may be a committee looking into it. There is no specific action. As an example, the county commissioners may have referred the EMS agency's request for a new building to the health care subcommittee, but discussion has not occurred because of a more pressing (perceived) need.
5. Preparation. Focused and effective planning is occurring; various options are being considered. An EMS oversight committee is considering staffing options that include establishing paid staff and sharing services with a neighboring community from 8 a.m. to 5 p.m. M-F. Pros and cons are being discussed.
6. Initiation. Change is underway. A new data collection software program has been purchased, some training has taken place but there is not widespread adoption.
7. Stabilization. Portions of the program are running and are achieving support but the entire change has not occurred. A decision concerning outsourcing billing functions has been made, the firms is now handling all accounts receivable but has no role in other financial planning such as accounts payable.
8. Confirmation/Expansion. Community decision makers are informed by local data and are supportive of maintenance or expansion of services. Based on improved response times using paid personnel to cover daytime shifts, the county commission has voted to include paid staffing at a satellite station as well.
9. Professionalism. Ongoing quality improvement is occurring, the program is secure. The EMS agency is vitally involved in the health care quality improvement task force for the community, sets benchmarks and measures performance against those criteria.

The degree of success of the community planning process is predicated on the fact that, at very least, the EMS agency director and other key medical and political stakeholders are beyond the denial stage. Without support from these key individuals the process is doomed to failure. There must be a willingness to critically assess current activities and outcomes from a systems perspective and map strategies to capitalize on strengths and opportunities while minimize threats and weaknesses.

The community assessment process itself can help create community awareness and move the community toward stage four and beyond.

ROLE OF EMS DIRECTOR OR SERVICE CHIEF

During the application of earlier versions of this community planning process, the single greatest obstacle to the timely and accurate completion of the project in a given community has been the lack of commitment and buy-in from the EMS agency director. In those cases where he or she is leading the charge, the process goes quickly and efficiently. Conversely, if the process is being "driven" by someone else, i.e. a hospital administrator or city father, without the full knowledge and support of the EMS director, then the process is arduous and unnecessarily time consuming.

Some of the duties and responsibilities of the EMS agency director include:

• Fully supporting the process
• Being willing to commit necessary personal time resources to the process
• Being available to the facilitator/consultant to answer questions in a timely manner
• Promoting the process and the outcome across the community
• Assisting in identifying key stakeholders and issues
• Convening and attending various meetings
• Active listening

SAMPLE MEMORANDUM OF AGREEMENT

[PUT ON FACILITATOR LETTERHEAD!!}

John/Jane Doe
XYZ EMS Service
XYZ Town, XYZ State, zip

Dear ------

Thank you for your interest in the Community Based Needs Assessment process. Americans often think EMS systems are well established throughout the country and are fully funded to meet their respective needs. In truth however, EMS is a fledgling development of the late 1960s and largely a minimally locally funded enterprise, many of which are surviving on a "wing and a prayer."

In order for the Community Based Needs Assessment process to begin we want to ensure that there is 100 percent cooperation and desire from you, the EMS Service Director. There are numerous tasks that rely heavily on the participation of the EMS Service Director in order for their successful completion.

Please take a moment to look at the enclosed Task/Duties Timeline, then complete the enclosed Letter of Agreement and return to us.

Again, thank you for your interest; we look forward to working with you.

Sincerely,

[Signature]

[FACILITATOR LETTERHEAD]

I, ___________________________________________ hereby agree and commit myself, and the

_______________________________________________ EMS Service to the completion of the EMS Community Planning Project.

I or my designee __________________________________________ will serve as the Site Coordinator for the project.

EMS Service Director Signature/Date

Designee (if applicable) Signature/Date

DESCRIPTION OF PROCESS

This section provides step-by-step assistance on how to assess your community's needs and perceptions in EMS. From there, you can develop a plan to enhance EMS integration into the community as a whole.

Where do you begin? The following outlines the steps involved.

1. Complete the "Memorandum of Agreement." Ensuring that there is true commitment between the EMS agency and the facilitator is crucial to the success of the project.
2. Form the EMS Planning Project Team. Without internal support, this process will falter. The EMS service needs the encouragement and assistance from the entire staff. A strong company succeeds based on the beliefs of its workers. The internal team size may vary, but typically, there will be one or two people doing most of the leg work. The role of the internal team is to keep the process moving. This involves handing out the questionnaires to both agency personnel and external respondents, scheduling meetings, answering questions, communicating with your facilitator and generally making the process a priority in their already overburdened lives. With commitment and focus, this process is relatively painless. Conversely, without this commitment, the process can drag on forever and become burdensome. Find people affiliated who are willing to help ensure that this effort is an unqualified success.
3. Complete the EMS/Community Demographic Profile. The profile was developed in order for the facilitator to obtain a snapshot of the EMS System and how it operates within State and local statues. It also provides a basis to which the facilitator can garner important information about the structure of the community, the trends in economic, social, and educational sectors.
4. Complete EMS Agency Self-Assessment. All members of the EMS agency should perform the self-assessment to find out how the organization perceives itself. Questions that will be answered from this exercise include: Do policies and procedures need to be updated? How is internal morale? Remember that the responses to the internal survey are completely confidential. They will be processed by the facilitator and the summaries provided back to the planning team in a manner that will not identify individual respondents. In this way, you are more likely to receive candid feedback.
5. Form a Community Assessment Team. The size of the team depends on the specific needs of the community. But you should include at least one representative from these areas:
1. EMS Agency Planning team members
2. Health Care System (Hospital, Critical Access Hospital, etc.)
3. Public Safety System (Fire Department, Law Enforcement, etc.)
4. Political System (Mayor's Office, County Commissioner, etc.)
5. School System (Administrators, Health Nurse, etc.)
6. Local/Regional Media (Newspaper, Television, etc.)
7. Community At Large (Service Groups, Senior Citizen's Organizations, Community Members, Church Congregations, Etc.)
Involving a group provides a broader perspective on the issues and enhances visibility of the planning process. The more support you get in the beginning, the easier it will be to facilitate discussions, activities, and change.
6. Establish a Schedule. Developing an EMS integration plan can be a daunting task. Once you have determined a start date, you and the facilitator can utilize the sample timeline for specific benchmarks. Your facilitator will also help coach your team through this schedule. Creating project deadlines assists in keeping the endeavor moving. People's time is your most precious commodity. Use it wisely. Appointing someone as the administrative contact to maintain efficiency and communications is a great idea. Timelines may be modified but resist the temptation to put off various tasks.
7. Complete Community Questionnaires. This is the heart of the community planning exercise. This is where you look at the EMS service in relation to other community sectors and determine how the service fits into that sector. This also should prompt the assessment team to question whether the community needs to make some changes to improve the way things work.
8. Using the Information for Planning. After collecting the survey or interview information, you analyze what you have found by averaging the scores or counting the responses. The facilitator will assist in making sense of the information and in formulating the final report. Someone should take the responsibility for presenting the information to the others in the group.
9. Develop an Integration Plan. Once again, the facilitator will assist with this portion of the process. However, you must be involved in its development so that you "own" it and are proud of both the process and the final product.

This community integration plan is the response to the information you have gathered, a plan that is shaped by the entire community assessment. You look at the strengths and weaknesses that have been identified and make decisions on whether changes are needed and where to focus your energy. This is a dynamic process. The integration plan is something that you should review frequently to see if the plan is working and whether it needs to be revised.

Click Here to see the Forms

SAMPLE PROCESS DESCRIPTION OUTLINE

Identification of community

Acceptance by EMS Director/EMS Service (written acceptance)

Assignment of facilitator

Facilitator contact with EMS service director

Written agreement with EMS service director

Service Questionnaire

EMS Director Questionnaire

Medical Director Questionnaire

Add additional questions to surveys (based on local needs)

Identify tentative meeting dates

Schedule initial meeting with EMS agency

Meeting with EMS agency

Project description

Conduct internal survey (self-assessment - Section 2)

Identify local resource for conduct of project

Identify key community contacts

Assign responsibility

Finalize process structure/details

Schedule date/location for community meeting

Facilitator completes data entry and tabulation of internal surveys

Facilitator provides anonymous, aggregate summary of internal surveys

Service Directors identifies recipients of external surveys

Facilitator provides copies of appropriate external surveys

Service Director distributes external surveys

External surveys are returned to Service Director/facilitator

External surveys are tabulated

Community meeting is conducted with facilitator present

Provides overview of process

Presents tabulated results of internal/external surveys

Facilitates discussion

Identifies issues/concerns of participants

Identifies strengths/weaknesses/opportunities/threats (SWOT)

Facilitator drafts project report

Local review and comment on project report

Final on-site meeting to review project report

Final edits to report

Assign tasks/responsibilities/timelines

Submission of final report

HOW TO CHOOSE A FACILITATOR

The success and effectiveness of any Community Planning process is directly related to the skills and knowledge the facilitator brings to the process. It must be said that the facilitator cannot arrive in town on a white horse and provide solutions to problems and issues that may have existed in an EMS system for months or years. An experienced facilitator can, however, provide unbiased guidance through the Community Planning process and ensure the best possible outcome.

Qualified facilitators do not grow on trees. Effective facilitation of the Community Planning process requires two important attributes:

1. A background in and experience with both patient care and leadership in EMS. It is important that the facilitator has been "in the trenches" of EMS and knows the street side of EMS. It is equally important that the facilitator has held leadership roles within EMS or other organizations in order to understand the challenges facing EMS organizations and their leaders. The facilitator must understand that the core function of an EMS agency is to provide quality and timely patient care. He or she must also understand that, in order to provide those core functions, it is necessary to have a healthy infrastructure that includes well trained and competent human resources as well as functional buildings, vehicles and equipment. It is difficult to appreciate the challenges of managing a healthy EMS organization unless one has some level of experience in EMS leadership.
2. Experience in facilitation and consensus building. The EMS Community Planning process implies the community, in a broad sense, becomes involved with EMS, public safety, and healthcare to learn about strengths and challenges to rural EMS agencies and to provide "informed" input that can make the EMS agency healthier and more sustainable within the resources of the community. With this diverse group, meeting facilitation and consensus building is essential to the process.

The facilitator assists the EMS agency leadership in working through the process and assists the community in working toward an integrated EMS system. The facilitator fulfills the following tasks:

• Reaching agreement on meeting agendas and processes before and during the meeting
• Conducting the meeting - making sure the group keeps to ground rules and agendas
• Guiding discussion
• Staying neutral - asking questions and suggesting ways to proceed
• Keeping the group on track and keeping the energy up
• Making sure everyone participates and no one dominates
• Creating a safe, non-threatening environment for problem identification and problem solving
• Ensuring that consensus is reached, that timelines and responsibilities are identified.

The facilitator should be familiar with the EMS Community Planning Guide and process and have the personal or organizational resources to assist EMS agency leadership with survey customization and tabulation. Tabulation can be accomplished with a spreadsheet program such as Microsoft Excel or with more powerful statistical programs such as SPSS.

The facilitator should be familiar with SWOT analysis and be able to identify and capture Strengths, Weaknesses, Opportunities, and Threats in a manner that enables the EMS agency and its community to utilize the SWOT analysis for planning and decision making.

After surveys are completed and tabulated and meetings are held, the facilitator assists the EMS agency leadership in formulating a short and intermediate range plan that will implement action items agreed to through the consensus process. This plan will document the Community Planning process, describe the results on internal and external surveys, and summarize discussions held at meetings. The SWOT analysis is summarized and integrated into the plan.

The facilitator needs to be dedicated to meeting the needs of the EMS agency, its public safety and healthcare partners and its community. A person with a personal or professional bias or who is "only in it for the money" will make a poor facilitator. Choose your facilitator wisely for the best possible outcome.

For assistance in identifying and selecting a qualified facilitator you are encouraged to contact the Critical Illness & Trauma Foundation (CIT), (300 North Willson Avenue, Suite 502E, Bozeman, MT 59715, (406) 585-2659, www.citmt.org, info@citmt.org). As of the printing date, CIT had assisted more than thirty communities across seven States complete this process.

CUSTOMIZING THE PROCESS

While the general form and format of the community planning process has withstood the test of time across dozens of communities in multiple States, the questionnaires can be expanded to address specific issues. For instance if consolidating the local EMS agency with a neighboring town is an option, you may want to elicit feedback from the general public on that specific strategy. It may also be necessary for you to broaden the scope of the participants to include representation from that neighboring town. While expanding the scope is encouraged, experience would indicate that narrowing either depth or breadth of the questionnaires or the range of participants is not a good strategy. Broad, inclusive representation is essential to creating an informed public who will support the specific action steps as you begin to implement the findings.

HOW TO FUND THE PROCESS

The community planning process represents a significant investment in time, money and other resources. Once again, experience would suggest that the costs for a qualified facilitator, associated travel and expenses will be at least $6,000 and will climb to as much as $15,000 depending on customization needs and travel requirements. In rare instances it may be possible to conduct the assessment for less, if a qualified facilitator is willing to donate his/her time. Funds for previous assessments have come from agency budgets or reserves, State EMS "mini-grants," State Offices of Rural Health, and local health care facilities. While the investment may seem daunting to rural volunteer services operating on a "bake sale" budget, without such an investment, the odds are that you might be trying to bake enough cookies, 5, 10, or 15 years from now to continue to keep the doors open, the lights on, and the wheels turning. You can find names and contact information for State EMS Offices on the National Association of State EMS Official's Web site at www.nasemso.org and Offices of Rural Health contacts on the National Rural Health Association's Web site at www.nrharural.org.

QUESTIONNAIRES and TALLY SHEET

Click Here to see the Questionnaires and Tally Sheet

USING THE INFORMATION FOR PLANNING

Analyzing the Data
Having mountains of data does no good because you have more information than anyone can easily digest. You need to analyze what you have collected so you can understand what it means. While some of the initial tabulations of each section should be done by your EMS Planning team, remember that the facilitator's job is to help you sort through and make sense of the information you have gathered. He or she will need to communicate frequently with you to determine how to best support your efforts in looking at your strengths and potential areas for improvement.

Presenting the Information
At the very least, you will want to prepare a written report that lists the average score on each section and the average score of each question for the assessment team to look at. If you met with any community groups or agencies in collecting the data, you may want to present the results to the group, especially if you will be seeking its help in developing an action plan. If you are making a presentation to a larger group, it can help to describe the planning process and present the main results with a PowerPoint presentation. Once you have written the growth and development plan, you may want to give more presentations outlining your goals for the EMS service to EMS members and community groups.

The presentation of these data should be the basis for your final external team meeting. Share what you have found and ask them to help you identify solutions to challenges that have been identified. This helps bring the process to closure for your external team.

Community-Based Needs Assessment
There are no "good" or "bad" scores from these data - they are just numbers. Your community planning team decides how to react to the numbers and how to set priorities. Just because the "score" is low on some section does not make that section an automatic priority. Only the team, often in conjunction with the facilitator, can set the priorities.

Following are some questions to discuss:

1. What areas are our strengths?
1. What do we need to concentrate on right now?
2. What things do we need to continue doing correctly?
2. What areas are our weaknesses?
1. What areas need immediate change?
2. What areas need change later on?
3. Opportunities
4. Threats

The answers to these questions will form your short and long-term goals. Take your time with these discussions. They are the main point of the community planning exercise. Make sure someone is recording the ideas: write them on a chalkboard or flipchart, or have someone type them into a computer and display them with an LCD projector.

You may find after studying the situation carefully that the best action is to make a major overhaul in how EMS is structured in your community. If ongoing funding is a problem, you may decide that you need to change the very basic structure of your community's EMS service, i.e., moving from a government-funded service to one allied with a local health facility or vice versa. Or maybe your community needs a service with paid EMS staff rather than relying on volunteers or vice versa. Or maybe your community is better off with EMT-Intermediate service rather than EMT-Basic or vice versa. No one can tell what system will work best in your community. These are tough decisions.

Finding Solutions
This part of planning calls for real brainstorming. Take the goals you have identified and come up with suggestions for achieving them. You want to foster a lively discussion and encourage all ideas - even the silliest suggestion may lead to something useful.

As you work through the discussions, you will probably generate a long list of actions. You must choose those that are the top priorities. You can take a vote on each action item individually to set its priority as high, medium, or low or you can ask everyone to list their top five priorities and then identify those that are chosen most often. Whatever method you use, encourage discussion about these priorities.

Take your top priorities and set a time frame for completion. If the action is ongoing, such as: "Meet quarterly with city council," set a time frame for when the ongoing activity is going to start. For example, "Meet quarterly with city council with the first meeting no later than the end of this year." Be sure your time frames are realistic both in relation to the individual action and to other actions that will be going on at the same time. You will probably have to adjust several time frames after you look at the big picture.

Finally, you should figure out how you are going to measure your progress. The time frames you set up will help you determine how often you should evaluate your progress. You may decide to review the entire plan in a year or 6 months. Or you may want to review several critical goals after their time frames for action have elapsed.

Following are some questions to guide your evaluation:

1. Was the action completed in the set time frame?
2. Was the action successful in achieving the goal or moving toward achieving the goal? If not, what alternative action could be attempted?
3. Have circumstances changed any priorities?

Writing the Final Report and Action Plan
After you, the external team, and the facilitator have analyzed the data and worked through some of the issues above, the facilitator will help you draft the plan.

The integration plan is a formal document that describes the planning process used to develop the plan, your goals and actions, and how you are going to evaluate your progress. The format of the plan varies based on community needs and desires. The following table of contents has been used in many plans that have resulted from this process.

Introduction
Orientation to the community planning and integration process
A description of the local EMS system
Formation of the assessment team

Internal survey results/findings
External survey process
External survey results/findings
Results and action agenda
Priority tasks
Conclusion

A sample final report is attached as an appendix to this document (Appendix A: Sample Final Report).

Review the Plan
The action plan should be reviewed regularly. The needs of a community are constantly changing. After a certain amount of time, you may want to re-do the community planning exercise entirely, or re-do specific sections, to see whether there have been any changes in the scores. Any time there are major changes in the EMS service or some segment of the community, is a good time to re-do all or some of the planning process.

It is important to set measurable objectives supported by action steps in various areas where you would like to see improvement. Develop one objective across several categories such as finance, public relations, quality improvement, and healthcare resource integration rather than several objectives in one area. This broad-based approach to system improvement results in a more balanced scorecard for your agency. For additional information on a balanced scorecard approach to system quality improvement, see: Niven (2003) (Appendix D).

In some communities the planning and assessment team that was organized to conduct this initial assessment have agreed to meet on an occasional basis to keep the project moving forward.

FREQUENTLY ASKED QUESTIONS

Over 30 services across the country have successfully completed the Community Planning Process. From these communities the following "Frequently Asked Questions" have been formulated.

Whom should I choose for my Internal Team, and how many?
As the Site Coordinator you need to be able to delegate some of the duties to various individuals which will help you to accomplish the various tasks within their respective timeframes. Most sites have chosen one or two individuals to serve as part of the team. These individuals have been EMS service providers and/or individuals from the Critical Access Hospital.

What is the Internal Assessment Orientation?
This is for the members of the EMS Service. Ideally the assessment orientation is done on a regular meeting night with all members requested to be in attendance.

Whom do I select for the External Team?
Representation from each of the identified stakeholders needs to be a part of the team. An individual with strong leadership should ideally be appointed as the lead for that particular stakeholder area.

How do I set up the External Stakeholder Orientation?
Planning the meeting over the lunch hour or dinner where there is food served has been successful. Various individuals from the respective stakeholder groups should be invited with the expectation that one person from each area will serve as the lead and part of the external team.

How much time will this process take?
Ideally this is a 60-90 day process; therefore, communities need to be ready and prepared to conduct the meetings and disseminate the survey assessment questionnaires in a timely fashion.

What type of resources do I need to do the process?
EMS services need to be able to copy and disseminate the various survey assessment tools. Secure a meeting location for both the internal, external, and final meetings. Additions of food, drink, and/or survey assessment completion incentives are up to each independent service.

APPENDIX A:

Community Planning Project Profile - Sample Report

LOCATION: Anywhere USA

ENTITIES/PARTICIPANTS:
USA Ambulance Service

LOCAL CONTACT:
EMS Director

CONSULTANT:

************************************************************************
PROCESS TO COMPLETE PROJECT:
==> Project Orientation
==> Internal Assessment-Analysis
==> External Assessment-Analysis
==> Project Summation

************************************************************************
KEY ISSUES IDENTIFIED:

• Strong leadership
• Recruitment
• Dedication of providers

RECOMMENDATIONS & COMMENTS:

• Development of a strategic plan
• Establish recruitment program
• Increase service visibility within the community

ANYWHERE Emergency Medical Services
Community Assessment

FINAL REPORT
And

ACTION PLAN

Part of the:

Supported by:

DATE

Introduction
This report is based on the results of a process of internal and external assessments of the effectiveness of the current EMS system in ANYWHERE USA. The process was designed to serve as a tool to evaluate strengths and identify areas of challenge.

Delivery of health care services is in a rapid state of change, and delivery of care in the out-of-hospital setting by Emergency Medical Services (EMS) agencies and providers is no exception. Advancing technology and increasing State and national standards for training and certification is increasing the standard of patient care. Increasingly, volunteerism is no longer able to sustain full-time transporting ambulance services in every community. Systems of care need to be built on collaborative community partnerships.

Community planning is about questioning and assessing how the service interacts with the community and each of the agencies and systems that impact emergency medical care.

This EMS community planning process was conducted to enable ANYWHERE USA Ambulance to identify, modify, or enhance local resources to reduce suffering, disability, and death from injury or illness while ensuring access, quality, and affordability of out-of-hospital EMS for the community of ANYWHERE USA.

The following narratives briefly summarize each step in the process, identify some immediate action items, and will serve as a template that can be used to generate a long-term community strategic plan.

Community Planning Overview Orientation
An overview of the EMS Community Planning process was presented to the various communities involved with the following outcome expectations:

• Development of clear expectations about what the process could do for each respective community within the State of ANYWHERE USA.
• Define roles and responsibilities for all process participants.
• Provide clear expectations about what outside resources would be available to draw upon.
• Assign target dates for various stages of the process.

Formation of Internal Assessment Team
Internal support from the EMS agency in the community planning process is vital to its success. A strong EMS agency succeeds based on the beliefs of its members. Therefore assistance and participation from the entire staff was imperative to the success of this project.

The internal team was identified and included EMS Ambulance Director for ANYWHERE USA, HELPER ONE and HELPER TWO. With the identification of the internal team, the process began with an orientation for agency personnel. On August 1, 2003, a meeting was conducted at the ANYWHERE USA Ambulance station to provide an overview of the community-planning process and to identify various participants' roles and responsibilities. All of the EMS personnel were present at the meeting and completed their assessment surveys that evening following the orientation.

Various questions were answered concerning the process and ideas were generated in an effort to provide solutions to challenges they as providers felt were the highest priority.

Internal Assessment Survey Results
Nine of the sixteen EMS personnel provided responses and comments to the 45 questions comprising the internal assessment. The responses to the internal surveys were mailed directly to and tabulated by CIT to ensure the maintenance of confidentiality among the members of ANYWHERE USA EMS. Based on these responses the following observations were made.

Overall the members of the ANYWHERE USA Ambulance service hold it in high regard. The service scored high in several key areas including numerous positive working relationships among other community agencies, protocol compliance, and opportunities for education. Numerous comments were written concerning the strength that the current service director brings to the organization. Other comments concerning the strengths of ANYWHERE USA Ambulance included loyal and dedicated volunteers, good educational opportunities, great community support, and low turnover.

The internal survey did point out, however, opportunities for improvement in a number of areas. Strong relationships have been forged between members of ANYWHERE USA EMS, the Healthcare system, and public safety systems, yet that same integration is lacking within the school, media, and political systems. Within the written comments there was an underlying theme of concern over the depletion of human resources and lack of EMS providers to handle the needs of the service. There was a distinct feeling that a main challenge to overcome is the primary staffing comprised of volunteers, which leaves day shift work hours slim. Despite the numerous praises given to the current administration, there is concern over who will carry the service into the future.

Formation of External Assessment Team and External Survey Process
Similar to the process used in the formation of an internal team the external team was formed to be inclusive of key community stakeholders. A clear understanding of these stakeholders' perception of ANYWHERE USA EMS provides the catalyst for change. Involvement of an external group broadens the perspective on the various issues and enhances visibility of the planning process.

Individuals from the health care, public safety, political, and the school systems as well as representatives of the media and community at large were invited to participate in a meeting held in ANYWHERE USA on August 3, 2003.

Responses were mailed directly to and tabulated by EMS DIRECTOR to ensure the maintenance of confidentiality among the various external stakeholders. Based on these responses, the following observations were made. EMS DIRECTOR streamlined his process through color-coding the respective surveys, which made it easier for individuals who represented more than one area of expertise, to participate in all of the applicable surveys. The number of surveys handed out into the respective subcategory is listed on the table within the subsection column.

Numerous comments were given in each of the various categories with a continual underlying theme: the EMS providers of ANYWHERE USA should be paid; yet there were no informative solutions as to how to budget such an expense. There is also a worry that the standard of care that has been provided in the past is in jeopardy due to the inability to recruit new providers.

Final Report and Recommendations
The Community Planning Process can be further broken down by the utilization of the SWOT Analysis tool (Strengths, Weaknesses, and external Opportunities and Threats.) Feedback provided by both the internal and external surveys can be integrated into the analysis as follows:

Internal Strengths:

• High morale and dedication
• Strong leadership
• Opportunity for patient care continuing education
• Low incidence of work-related injuries

Internal Weaknesses:

• Understanding of future direction
• Training for management education (people skills, problem solving skills)
• Decrease in staff during daytime on-call hours

External Opportunities:

• Utilization of media as a community education tool
• Increase service visibility within the community
• Utilization of cross training among various systems
• Partnership building among various external stakeholder systems
• Strong community and stakeholder support

External Threats:

• Diminishing volunteer pool
• Increase in standard of care (inclusion of disaster preparedness)
• Increase in Federal and State regulations (HIPPA)

Actions to be considered in planning of long and short term goals within the ANYWHERE USA Ambulance Service Strategic Planning process:

1. Continue to convene the stakeholders quarterly (at a minimum) each year.
1. Each meeting should provide a forum to which progress benchmarks can be discussed and measured as to their accomplishments.
2. Formulate a strategic plan inclusive of the challenges noted within the community planning process.
1. Develop long and short term goals which address the issues of, but not limited to:
1. Public information and education (public perception)
2. Human resource development (recruitment and retention)
3. Appointment of county EMS representatives to State, regional, and local committees
4. Cross discipline training and educational opportunities
3. Establish working relationships with various media outlets to provide public education of EMS to the community
   (Include EMS within various brochures that highlight the community of ANYWHERE USA and Ottawa County, provide information to city hall to include EMS within the demographic information of the county)

Internal and External Stakeholder Final Report Meeting
On January 5, 2004, a final meeting was conducted at the ANYWHERE USA Ambulance building. A total of 37 individuals were present.

Discussion centered on the recommendations and challenges that were identified in both the internal and external assessments. The group discussed the need to proactively address recruitment and increasing visibility of the services within the community.

It was noted that the overall scores received by ANYWHERE USA EMS were above average in every category expect one. Internally, the ANYWHERE USA EMS organization appears to be extremely strong with positive comments made concerning the current leadership.

Recommendation was made to accept the final report and begin the process of addressing and prioritizing the various identified challenges within a strategic plan format.

ANYWHERE USA
Community Planning Data/Comment Summation

Summary of Section Tally: [scale of 1 (not at all) - 7 (very well)]

Internal = 6.10
Health Care = 4.44
Public Safety = 5.45
Political System = 5.14
School System = 4.5
Media = 5.10
Community = 5.69

Comments:

Internal-

Greatest Strengths:

Service director's leadership; dedicated volunteers; community support; low turnover; excellent training officers and training opportunities; good vehicles and equipment.

Greatest Challenges:

Daytime coverage; maintaining a high level of community appearance; future leadership; level of certification; lack of personnel; roads are bad, which hampers response times

Solutions to the Challenges:

Paid staff; clear understanding of personnel's private vs. public time; offer class on filling out-run reports

Other Comments:

We are a very lucky community; Ambulance Advisory Council needs to do a better job of meeting; educate the community of our needs

Healthcare

Greatest Strengths:

Patient care; patient always comes first; pleasant, friendly staff; willingness to serve

Greatest Challenges:

Keeping volunteers; time commitments; money for equipment; staying current on medical trends and scope of practice

Solutions to the Challenges:

Recruitment and retention program; continuing education; grant funding

Other Comments:

Recommend joint training with ANOTHER ANYWHERE USA EMS

Public Safety

Greatest Strengths:

Personnel; leadership; dedication; well trained; work together as a team; equipment

Greatest Challenges:

Improve incident command and usage of 10 codes, recruitment and retention, funding, response time, 24/7 coverage

Solutions to the Challenges:

More cross training; more public information; split response; reimburse for staff per call; secure more staff

Political System - Nothing noted

School System

Other Comments:

Teach more CPR/First Aid classes; need more volunteers; pay the volunteers; doing a great job; not familiar with the EMS system or the providers

Media

Greatest Strengths:

Care and concern of staff; local people; good equipment

Greatest Challenges:

Maintaining quality staff

Other Comments:

We have a good relationship due to their designated public information person.

Community

Greatest Strength:

Well-trained staff; committed staff; availability; response time; our community would be lost without them; glad we have them; great leadership

What would you like to see different:

More public information; full-time staff; more public programs; pay for the volunteers; don't know

Other Comments:

PROUD OF PERSONNEL, DOING A FINE JOB

APPENDIX B: ACKNOWLEDGMENTS

This product and process were originally developed under grant # 1 DO4 RH 00143-02 from the U.S. Department of Health and Human Services - Office of Rural Health Policy. Since that time many other agencies and individuals have made substantial financial and intellectual commitments to this effort.

This guide was made possible by funds provided by Office of Rural Health Policy (ORHP) and the Rural Emergency Medical Services and Trauma Technical Assistance Center (REMSTTAC), and the Critical Illness & Trauma Foundation (CIT). Special thanks for producing this compendium go to REMSTTAC staff Joe Hansen, Assistant Director; Heather Soucy, Program Support Specialist; Nels Sanddal, Director; and Teri Sanddal, Associate Director and to members of the Community Planning Workgroup at REMSTTAC.

Joseph D. Hansen, EMT-B, Co-chair
Assistant Director
Rural Emergency Medical Services and Trauma Technical Assistance Center

Katrina Altenhofen, MPH, PS, Co-chair
State Program Director
Iowa Department of Public Health

Contributors and Reviewers:

Fergus Laughridge, Program Manager
Nevada State Health Division
EMS Bureau of Licensure & Certification

Tami Lichtenberg, TASC Program Manager
Technical Assistance and Services Center
Rural Health Resource Center

Jacob L. Rueda III, PhD, Project Officer
U.S. Department of Health and Human Services
Health Resources and Services Administration
Office of Rural Health Policy

Mary Sheridan, Director
State Offices of Rural Health
Idaho Department of Health and Welfare

Chris Tilden, PhD, Director
Kansas Department of Health & Environment
Office of Local & Rural Health

Gary Wingrove, Technical Consultant
Technical Assistance and Services Center
Rural Health Resource Center

APPENDIX C: REMSTTAC STAKEHOLDERS GROUP

Katrina Altenhofen, MPH, REMT-B
State Coordinator
Emergency Medical Services of for Children
Iowa Department of Public Health

Jane W. Ball, RN, DrPH
Executive Director (Retired)
EMSC National Resource Center
Trauma-EMS Technical Assistance Center

Bethany Cummings, DO
Rural Affairs Ad Hoc Committee
National Association of EMS Physicians

Drew Dawson, Chief, EMS Division
National Highway Traffic Safety Administration

Tom Esposito, MD
Medical Director
Rural EMS and Trauma Technical Assistance Center

Blanca Fuertes, Past Project Officer
U.S. Department of Health and Human Services
Health Resources and Services Administration
Office of Rural Health Policy

Christian L. Hanna, MPH
Michigan Public Health Institute
Child and Adolescent Health

Bob Heath, EMS Education Coordinator
Nevada State Health Division
Intermountain Regional EMS for Children Coordinating Council

Marilyn Jarvis
Assistant Director for Continuing Education
Extended University
Montana State University

Douglas F. Kupas, MD
Rural Affairs Ad Hoc Committee
National Association of EMS Physicians

Fergus Laughridge, Program Manager
Nevada State Health Division
EMS Bureau of Licensure & Certification

Tami Lichtenberg, Program Manager
Technical Assistance and Services Center
Rural Health Resource Center

Tommy Loyacono, MPA
National Association of Emergency Medical Technicians

Patrick Malone, Director
Initiative for Rural Emergency Medical Services
University of Vermont

N. Clay Mann, PhD, MS
Center Director of Research
Professor of Pediatrics
Intermountain Injury Control Research Center
University of Utah

Evan Mayfield, MS
U.S. Department of Health and Human Services
Center for Disease Control
Office of the Commissioner

Charity G. Moore, PhD
Research Assistant Professor
Cecil G. Sheps Center for Health Services Research
Univ. of North Carolina at Chapel Hill

Carol Miller, Executive Director
National Center for Frontier Communities

Kimberly K. Obbink, M.Ed, Director
Extended University
Montana State University

Jerry Overton, Executive Director
Richmond Amublance Authority

Daniel Patterson, PhD
AHRQ-NRSA Post-Doctoral Research Fellow
Cecil G. Sheps Center for Health Services Research
Univ. of North Carolina at Chapel Hill

Davis Patterson, PhD, Research Scientist
Battelle Centers for Public Health Research and Evaluation

Ana Maria Puente, Past Project Officer
U.S. Department of Health and Human Services
Health Resources and Services Administration
International Health / Office of Rural Health Policy

Jacob L. Rueda III, PhD, Project Officer
U.S. Department of Health and Human Services
Health Resources and Services Administration
Office of Rural Health Policy

Kristine Sande, Project Director
Rural Assistance Center
University of North Dakota Center for Rural Health

Mary Sheridan, Director
State Offices of Rural Health
Idaho Department of Health and Welfare

Dan Summers, RN, BSN, CEN, EMT-P
Director of Education
Center for Rural Emergency Medicine
West Virginia University

Chris Tilden, PhD, Director
Kansas Department of Health & Environment
Office of Local & Rural Health

Robert K. Waddell II
Secretary /Treasurer
National Association of EMS Educators

Bill White, President
National Native American EMS Association

Gary Wingrove, Technical Consultant
Technical Assistance and Services Center
Rural Health Resource Center

Jill Zabel Myers, Healthcare Consulting
Wipfli LLP

APPENDIX D: REFERENCES

Nordberg, M. (2006). Improving ambulance safety. EMS Responder Annual Vehicle Issue, 78-79.

Oetting, E.R., Jumper-Thurman, P., Plested, B., & Edwards, W. (2001). Community readiness and health services. Substance Use & Misuse, 36(6&7), 825-84