Contact: Aarron Reinert, MA, Partner

29251 Potassium Street NW • Isanti, MN  55040  |   Tel 651.248.4239  •  Fax 858.777.5455   

aarron@safetechsolutions.us  • www.safetechsolutions.us 

Final Report    

ASSESSMENT  OF  

EMERGENCY MEDICAL SERVICES  IN  

KEMMERER, WYOMING, AND SOUTH LINCOLN COUNTY, WYOMING 

 April 2017 

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Table of Contents 

ExecutiveSummary................................................................................................................................3

I. Introduction&Methodology..............................................................................................8

II. OverviewofKemmererandSouthLincolnCounty,Wyoming....................10

III. OverviewofKemmererEMSSystem.............Error!Bookmarknotdefined.

IV. DescriptionofKemmererEMS.......................................................................................21

V. KeyFindings................................................................Error!Bookmarknotdefined.

VI. Recommendations...................................................Error!Bookmarknotdefined.

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ExecutiveSummary SafeTechSolutionsspentfourmonthsbetweenDecember2016andApril2017studyingtheEMSsysteminSouthLincolnCounty,Wyoming.Thestudyincludedtwositevisits,approximately20interviewswithkeystakeholders,extensiveresearchaboutSouthLincolnCountyanditsEMSsystem,thoroughanalysisofWyomingAmbulanceTripReportingSystemdata,andin‐depthanalysisofprovidedfinancialandoperationaldatafromSouthLincolnMedicalCenterEMS.Basedonitsfindings,SafeTechSolutionsrecommendsthatSouthLincolnMedicalCenterandSouthLincolnMedicalCenterEMS:1.EnsureSouthLincolnCountyisservedbyhigh‐qualityEMSthatremainsstrongandunthreatenedbythelocaleconomy: KeepEMSwithinSouthLincolnMedicalCenter.

PrioritizeEMSwithinSouthLincolnMedicalCenter’ssystem‐widestrategic

visioningandplanning.

AcceptthattheEMSdepartmentoperatesattheintersectionofhealthcareandpublicsafetyandmayhaveoperationalandculturalelementsalongwithneedsandpracticesthataredistinctfromthehospital.

CreateaclearvisionandstrategicplanfortheEMSdepartmentthatincludesthefollowingelements:

o Adedicateddepartmentalvisioningandplanningprocess;

o Adescriptionofthelevel,quantity,andqualityofservicesneeded,wanted,andfundable;and

o Attentiontoleadership,management/supervision,successionplanning,departmentalculture,efficiency,workforcedevelopment,andgrowth.

ExploretheexpansionofEMSintegration.

2.DevelopanEMSleadershipteamanddepartmentstructuredesignedtorealizeaclearvisionforEMSby:

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EnsuringtheEMSleaderhasaleadershipteamthatfocusesonoperationswhileheorshefocusesondeepandmeaningfulconnectionswiththehospital.

Providingareasonablebalancebetweentheleaders’clinical,management,andleadershipresponsibilities.

PrioritizingleadershipdevelopmentandsuccessionplanningwithintheEMSdepartment.

EnsuringtheEMSleadershipteamisregularlyexposedtootherEMSsystemsandindustrybestpracticesthroughnationaleducation,conferences,andnetworking.

3.StrengthenfinancialperformanceofSouthLincolnMedicalCenterEMSby:

UnderstandingtheEMSdepartment’scurrentfinancialperformance.

Maximizingrevenuesfromallbusinesssegments(911responseandtransport,interfacilitytransports,andcapturingmissedtransfers).

Creatingarealisticandappropriatestaffingmodelwithacompetitivewageandpaystructure(acknowledgesthecosttorecruitandretainEMSworkers).

BringingtoresolutionCokevilleandLaBargelocations.4.StructureEMSoperationstosupportlong‐termsuccessby:

Developingaresourcedeploymentstrategythatmatchescallvolumeandcommunityneeds.

Prioritizinginterfacilitytransfersandstructuringresourcedeploymenttocapturetransfers.

Trackingandmanaginguseofairmedicalresources.5.Createahighengagement“bestEMSplacetowork”culturecharacterizedby: Ensuringtheleadershipteamiscapableandempowered.

Eliminating,asneeded,internalorganizationaldrama.

Quicklydealingwithpoorperformance.

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Regularlymonitoringemployeeengagementthroughinformalfeedbackand

surveying.Theserecommendationsarebasedonthefollowingkeyobservations.1.SouthLincolnMedicalCenterEMSisavitalelementofthehealthcaresysteminSouthLincolnCounty. Demographics,geography,climate,distances,andthelimitsoflocalmedical

specialtiescreateanimportantneedforEMSinSouthLincolnCounty.2.EMShasalwaysbeenandwilllikelyalwaysneedtobesubsidizedgoingforward. Donatedlaborcontinuestobethelargestsubsidyofthesystem.

Itisunlikelythatfeefortransportwillprovideenoughfinancialresourcesto

closethegapbetweenexpensesandrevenues.

Asvolunteerismcontinuestodeclineandclinicalandoperationalexpectationscontinuetogrow,therewillbetheneedformorepaidstaff.

3.EMSfacesmajorchallengesassociatedwiththecurrentlocaleconomy,itspositionwithinthehospital,andtheneedforacleardepartmentalleadershipstructure.

Therehasbeenasignificantandunprecedenteddownturninthelocal

economy.

SouthLincolnMedicalCenterEMSdoesnothaveaclearguidingvisionandplanforitsfuture.

ItisunclearifthehospitalseesEMSasanessentialservice.

ThereisaneedforabetterunderstandingandacceptanceofthedualroleEMShas(healthcareandpublicsafety).

TheEMSleadershipstructureisunclear.4.SouthLincolnMedicalCenterEMSissustainable,providingthatEMSismadeaprioritywithintheorganizationandresourcesareappropriatelyallocatedandleveragedefficiently. SouthLincolnMedicalCenterEMSissustainable.

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EMSisavaluableandimportantassettoSouthLincolnMedicalCenter.

EMSpatientbillingratescouldbemaximized,andthereisinsufficientdata

specifictotheambulancedepartment,whichmakesitdifficulttotrackEMSfinancialperformancewithinthehospitalsystem.

ExecutiveleadershipwithinSouthLincolnMedicalCenterisprogressiveandconcernedaboutthefutureofEMS.

5.Thetrendtowardabusinessstructureandfull‐timestaffingshouldcontinue. Thereisclearevidencethatvolunteerismandpaidon‐callpersonnelarenot

along‐termsustainablemodeloraviablestaffingmodelmovingforward.

Thedepartmentshouldconsiderinvestmentstosupportfull‐timestaff,suchassleeproomsandEMScrewquarters.

Themedicaldirector,hospitalstaff,andEMSpersonnelreportthattheclinicalqualityofcareprovidedisgenerallygood.

Theamountandfrequencyofmeetingsmaybeinconsistentwitha“bestplacetowork.”

Thereshouldbeaclearandeasilyunderstoodleadershipteamandstructurethatalignsauthoritywithresponsibility.

6.Asoperatingtoday,EMSisnotasefficientasitiscapableofbeing.

Currentcallscheduleresultsininconsistencieswhenorifleadershippersonnelareonsiteandavailable.

Thecombinationoffull‐timestaffandon‐callpersonnelmayresultinunnecessaryresponsedelays.

EMSmaynotbemeetingtheneedforreliableandpromptinterfacilitytransfers,resultinginunnecessaryflightsandlostrevenue.

7.ItisunclearwhatthecommunityexpectsandiswillingtofundforEMSinCokevilleandLaBarge.

ThecurrentvolumeandstaffingmodelinCokevilleisnotsustainable.

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TherearetimeswhenCokevillefirst‐responds,duetothelackofstaff,areunabletorespondasanambulanceservice.

ItmaynotbenecessarytostaffthreeattheCokevillestation.

LaBargeappearstobeasourceoffrustrationbothinsideandoutsidetheorganization.

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I.Introduction&MethodologyLikemanyruralcountiesinAmerica,SouthLincolnCounty,Wyoming,isfacingchallengesinmeetingitsout‐of‐hospitalemergencymedicalcareneeds.TheawarenessofthesechallengesandthedesiretomoredeeplyunderstandthemledSouthLincolnMedicalCentertofileanapplicationwiththeWyomingOfficeofEMSandTraumaforanassessmentoftheEMSsysteminSouthLincolnCounty.SafeTechSolutions,LLP,wascontractedtoconducttheassessment.SafeTechSolutionsisanEMSconsultingfirmwithextensiveexpertiseevaluatingEMSorganizationsandassistinginthedevelopmentofruralambulanceservicesandsystems.SafeTechSolutionshasworkedwithruralWyomingEMSagenciesthroughitsEMSLeadershipAcademyandpreviousassessmentsinnumerouscountiesthroughoutWyoming.ThegoalsoftheSouthLincolnMedicalCenterassessmentprojectwasto:

Evaluatethesustainability,reliability,andlong‐termsurvivabilityofEMSinSouthLincolnCounty,includingthecurrentstructureandoperationsofSouthLincolnMedicalCenterEMS;

Validatesystemcomponentsthatareworkingwell;and Makerecommendationsforchangeandimprovementasneeded.

Theassessmentfocusedonlocalneeds,currentoperations,systemdesign,andavailablesupportingresourceswithaneyeonsustainability.Thescopeoftheassessmentwaslimitedandwasnotanauditofoperations,finances,orclinicalperformance.Airmedicalservicewasnotpartoftheassessment.MethodologySafeTechSolutions’assessmentteamusedaprocessofinquiryandinvestigationthatcapitalizesonthefirm’sextensiveunderstandingofruralEMSsystems.Itsprincipalsgatheredquantitativeandqualitativedatathroughresearch,sitevisits,interviews,and,whenneeded,communitymeetings.SafeTechSolutionsconsultantsvisitedSouthLincolnMedicalCentertoreviewdocumentsanddata,conductinterviews,andassessoperations.Inadditiontoevaluatingtheambulanceorganization(organizationalstructure,leadership,andoperations),SafeTechSolutionspaidspecialattentiontothesocial,economic,demographic,cultural,andpoliticalissuesinSouthLincolnCounty,carefullyanalyzingdataandmakingitsrecommendationsbasedonindustrybestpractices,aswellaswhatismeaningful,actionable,andmeasurableinSouthLincolnCounty.RecommendationswerepresentedtokeystakeholdersinApril2017.

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Thisreportsummarizesthefindings,keyobservations,andrecommendationsfortheEMSsysteminSouthLincolnCounty.InformationpertainingtothecurrentsystemofEMSatSouthLincolnMedicalCenterwasgatheredthroughinterviews,datarequests,andwrittenstatementsfromkeyindividualswithinthecurrentEMSsystem.TothebestofSafeTech’sabilities,thedatahasbeenverifiedandvalidatedandbelievedtobemateriallycorrectaspresentedbytheleadersofthecurrentsystem.

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II.OverviewofKemmererandSouthLincolnCounty,WyomingLocatedinSouthLincolnCounty,Wyoming,thecityofKemmererstartedoutasacoalminingtownwiththefoundingoftheKemmererCoalCompanyin1897.1NamedafterPennsylvaniacoalmagnateMahlonS.Kemmerer,thecoalcompanysoldlotsinsteadofleasingthem,creatinganindependenttownthatpromotedthedevelopmentofbusinessesseparatefromtheinfluencesofthecoalcompany.ElectricitytothetownwassuppliedbytheFrontierSupplyCompany,whichwasownedbytheKemmererCoalCompany,intheformofanelectricgenerator.WhiletheformationoftheKemmererCoalCompanysignaledaperiodofsignificantgrowthinthearea,SouthLincolnCountyhadalwaysbeenabigcoalminingarea.2WhiletheNorthernhalfofthecountycontainsalargeportionoftheWyomingRange,theSouthernsectionismadeupmostlyofdesertandisrichincoal,oil,andnaturalgas.3OthertownsinSouthLincolnCountyincludeCokeville,Frontier,Diamondville,Oakley,andLaBarge.SittingjusttotheeastoftheFossilButteNationalMonument,theareaaroundKemmererandSouthLincolnCountyingeneralcontainsawidevarietyoffishfossils,popularwithtourists,especiallyatareaquarries.4TheschoolsintheKemmererareaareonparwithmanyschooldistrictsinthestate.TheprimaryproviderofmedicalservicesinKemmereristheSouthLincolnMedicalCenter,whichoffersavarietyofemergency,inpatient,andoutpatientservices.SummaryofKemmererandSouthLincolnCountyKemmererandSouthLincolnCounty’sdiverserangeofgeographylendsitselftoavarietyofrecreationalandindustrialuses.Kemmerer’srelativelysmallpopulation(see“ThePeople”sectionbelow),whencomparedtoothercitiesinthemorepopulatedNorthernpartofLincolnCounty,isexpectedtogrowbymorethan400populationpointsby2040.5Tourismisalsoathrivingindustryinthearea,withtwoofthefourU.S.governmentprotectedareasinLincolnCounty,locatedinitsSouthernregionatCokevilleMeadowsNationalWildlifeRefugeandFossilButteNationalMonument.61WyomingTalesandtrails:http://www.wyomingtalesandtrails.com/kemmerer.html2ibid3ibid4GreenRiverShale—Kemmerer,WY:http://www.nautiloid.net/fossils/sites/kemmerer/kemmerer.html5PopulationforWyoming,Counties,Cities,andTowns:2010to2040:http://eadiv.state.wy.us/pop/wyc&sc40.pdf6LincolnCounty,Wyoming:http://www.wyohistory.org/encyclopedia/lincoln‐county‐wyoming

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TheLandKemmererservesasthecountyseatofLincolnCounty,Wyoming.LincolnCountywasformedfromtheNorthernpartofUnitaCountyin1911.Thecountygaineditspresentboundariesin1921,whenSubletteandTetoncountieswereformedoutoflandfromitsterritory.Spanningmorethan110milesfromnorthtosouth,LincolnCountysitsontheborderofIdaho.Itswidestpoint,at50miles,liesintheSouthpartofthecounty.TheL‐shapedWyomingcountynarrowsasyoutravelfurthernorth.TheWyomingRangeislocatedintheNorth,withthehighestelevationat11,300feet.ThelandlevelsoutsomewhatintheSouthofLincolnCountyandcontainslittleinthewayoffoliage.7TheGreenRiverFormationintheSouthcontainsadiversearrayoffossilizedanimal,insect,andplantlifefromtheregion’spastandincludestheFossilButteNationalMonument.ThemajorriverintheareaistheHamsForkRiver,whichrunsfromtheKemmererReservoirtothenorthintothesouthandthenrunsfromwesttoeasttowardOpal.OthertributariesandbodiesofwaterintheareaincludeRockCreektothewestofFossilButteNationalMonument,AlkaliCreektothesoutheastofKemmerer,andLakeVivaNaughtonintheCentralpartofthecounty.8Almost75percentoflandinLincolnCounty,whereKemmererislocated,isfederalpublicland.9WhilemostofitisadministratedbytheU.S.ForestService,publiclandintheareaisusedprimarilyforcamping,hiking,skiing,andotheroutdooractivities.TransportationLincolnCounty,Wyoming,occupiesanareaalmost4,100milesinsize,includingboththeNorthernandSouthernpartsofthecounty.10Kemmerer,Wyoming,hasalandareaof7.37squaremiles.11ThemainroadwaysinKemmererandSouthernLincolnCounty,ingeneral,includeU.S.Highways189,30,andAlternate30.U.S.Highway189runsnorthtosouth,enteringthecountyatLaBargetothenorth,passingthroughFrontier,Kemmerer,andDiamondville,beforeheadingsouthtowardUnitaCounty.U.S.Highway30entersLincolnCountyfromthesoutheast,passingthroughOpal,Oakley,andKemmererbeforeheadingtothewest.JustbeforeU.S.Road30hitstheIdahoborder,itbranchesoff,headingnorththroughCokeville.TheU.S.Highway30AlternateBusiness/BypasspassesnorthofKemmerer,goingeasttowestfromU.S.Highway189,andprovidessometrafficreliefinthearea.Thebypassalsofollows189toapointsouthofKemmerer,whereitcutsbackacrossandconnectstoU.S.30tothewest.StateHighwaysinclude302,304,and345tothesouth;233,234,and327tothenorth;and209,300,322,328,331,341,and342westofKemmerer.

7LincolnCounty,Wyoming:http://www.wyohistory.org/encyclopedia/lincoln‐county‐wyoming8FossilButteNationalMonument:http://www.wyohistory.org/encyclopedia/fossil‐butte‐national‐monument9NACoCountyExplorer,MappingCountyData:http://explorer.naco.org/#10http://www2.census.gov/geo/docs/maps‐data/data/gazetteer/counties_list_56.txt11http://www.city‐data.com/city/Kemmerer‐Wyoming.html

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KemmererMunicipalAirportsitstwomilestothenorthwestofthecity.Theairportcontainsthreerunways,thelongestat2,671feet.12Theairportservicessmall,single‐engineaircraft,13averagingabout57aircraftoperationsperweek.14LandUse,Tourism,andIndustryThepredominantuseoflandinSouthLincolnCountyincludestheexploitationofcoal,oil,andnaturalgasresources.WhiletheeconomyinSouthLincolnCountyisgearedtowardminingandotherformsofresourceexploitation,tourismisalsoafactor,withmanyvisitorsstoppingintheareaontheirwaytotheBridger‐Teton,TargheeandCaribouNationalForestfurthernorth;FossilButteNationalMonumenttothewestofKemmerer;orlocaloutdoordestinations,suchasLakeVivaNaughtonandtheCokevilleMeadowsNationalWildlifeRefuge.ActivitiesavailabletoarearesidentsandvisitorsintheSouthLincolnCountyareaincludeboating,camping,hiking,andfishing,amongotheroutdooractivities.ThemostcommonemploymenttypesinLincolnCounty,Wyoming,ingeneral,includeconstructionandextraction,management,andadministrativeareas.MajoremployersinKemmererincludetheWestmorelandCoalCompany,whichoperatestheKemmererMine;constructionfirms,suchasHamsForksConstruction;theLincolnCountySchoolSystem;andtheSouthLincolnMedicalCenter.ThePeopleThepopulationinKemmerer,Wyoming,hasgrownsignificantlysince1910whenitwasat843.Therewasadownturninthe1950s,andthepopulationdiddeclinefollowingthe1980s.Since2005,however,thepopulationhasseenasteadyrise,goingfrom2,579in200515towhereitisnowat2,692attheendof2016.16

Source:http://population.us/wy/kemmerer1

12http://www.gcr1.com/5010web/airport.cfm?Site=EMM&AptSecNum=313http://www.gcr1.com/5010web/airport.cfm?Site=EMM&AptSecNum=214KemmererMunicipalAirport,FAAInformationEffective02March2017:http://www.airnav.com/airport/KEMM15PopulationofKemmerer,WY:http://population.us/wy/kemmerer/16Kemmerer,WyomingDemographicsData:http://www.towncharts.com/Wyoming/Demographics/Kemmerer‐city‐WY‐Demographics‐data.html

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KemmererplacesslightlyaboveLincolnCountyingeneralwiththenumberoftraditionalfamilyhomesat66percentofallhouseholds,17ascomparedto63percentinLincolnCounty.18Atotalof41percentofthepopulationisconsideredsingle,with25percentofthosenevergettingmarried,11percentdivorced,andsixpercentwidowedasthereasonforbeingsingle.19

Source:http://www.towncharts.com/Wyomin1

ThepopulationinKemmererbrokendownintovariousagegroupsincludesthefollowing:27.9percentofthepopulationisbelowtheageof20,11percentareintheir20s,12percentareintheir30s,10percentareintheir40s,19.7percentareintheir50s,11percentareintheir60s,and8.3percentare70orabove.20Thelargepercentageofindividualslivinginthearea,over39percent,whohaveretiredorwhoareabouttoretireisdueinparttothelowtaxratefoundinWyomingascomparedtootherstates.Over96percentofthepopulationinKemmererisWhite,leavingfourpercentasotherethnicities.21Thistendstokeepinlinewiththegeneralracialbreakdown17Kemmerer,WyomingDemographicsData:http://www.towncharts.com/Wyoming/Demographics/Kemmerer‐city‐WY‐Demographics‐data.html182016StarValleyEconomicandDemographicReview:https://www.bosv.com/pdfs/2016EconomicReport.pdf19Kemmerer,WyomingDemographicsData:http://www.towncharts.com/Wyoming/Demographics/Kemmerer‐city‐WY‐Demographics‐data.html20ibid21ibid

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withinthegreaterLincolnCountyarea.RacialbreakdowninLincolnCountysitsatabout95percentWhite,withtheotherfivepercentofthepopulationintheareadesignatedasanotherrace,suchasBlack,Asian,AmericanIndian,andHispanic.22

Source:http://www.towncharts.com/Wyomin2

KemmererrepresentsthelonecityinLincolnCountyandservesasthecountyseat.IncorporatedtownsinSouthLincolnCountyincludeCokeville,Diamondville,LaBarge,andOpal.Frontier,northofKemmerer,iscurrentlyunincorporated.About25percentofthetotalpopulationinLincolnCounty(4,578)residesinoneoftheincorporatedtownswithinthesouthhalfofthecounty,withmostofthat(2,656)livinginKemmerer.23TherestofthepopulationinLincolnCountyresidesintheunincorporatedpartsofthecountyorthemorepopulatednorth,insuchplacesasAfton,Alpine,andThayneinStarValley.LincolnCounty,ingeneral,isseeinganincreaseintheageofthepopulation,whetherthroughtheagingofthenativepopulationorthroughretireesmovingtotheareatotakeadvantageofitslowtaxrate.IncomparisontoKemmerer,Wyoming,LincolnCountyhasasmallerpercentageofretiredindividualsorresidentsnearingretirementage,withalittleover36percentofthepopulationinLincolnCountyretiredornearretirementage.24LincolnCountyisseeinganagingofitspopulationasmoreretireesmovetotheareaandanever‐increasingnumberofyoungerresidentsleavethecountytopursuetheireducationortoseekemploymentelsewhere.Oneofthepredominateage

22USCensusBureau:https://factfinder.census.gov/faces/nav/jsf/pages/community_facts.xhtml23PopulationDemographicsforLincolnCounty,Wyomingin2016and2017:https://suburbanstats.org/population/wyoming/how‐many‐people‐live‐in‐lincoln‐county24LincolnCounty,WyomingDemographicsData:http://www.towncharts.com/Wyoming/Demographics/Lincoln‐County‐WY‐Demographics‐data.html

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groupsinthecountyincludesindividualsaged55yearsandolder.25TakingalookatcurrentLincolnCountypopulationnumbers,58percentofresidentsinthecountyareworking‐ageadults,another28percentareundertheageof18,andtheremaining14percentareovertheageof65.26

Source:https://datausa.io/profile/geo/l1

InadditiontoresidentsofLincolnCounty,theKemmererareaalsoseesaninfluxoftouristsduringvariouspartsoftheyear.Visitorstotheareamainlycomeforthemanyoutdooractivities,includingcamping,hiking,hunting,andfishing.Thearea’scloseproximitytoNationalForestsandotherpublicprotectedlandsmakesitapopulartouristdestination.EstimatesforpopulationgrowthinLincolnCounty,morespecificallyKemmerer,seeanincreaseinthetotalpopulationtoroughly19,180individualsinLincolnCountyand2,814inKemmererby2020.Thepopulationisfurthersettoincreasetoaround20,320individualsinLincolnCountyand2,981inKemmererby2030.27TheEconomyThemedianhouseholdincomeinLincolnCounty,Wyoming,isabout$68,200annually,about$8,000abovestateaverages.28MedianhouseholdincomeinKemmerercomesinat$64,234,29slightlybelowthecountyaverage.

25ibid26https://datausa.io/profile/geo/lincoln‐county‐wy/#demographics27http://eadiv.state.wy.us/pop/wyc&sc40.htm28http://www.city‐data.com/county/Lincoln_County‐WY.html29http://livability.com/wy/kemmerer

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LincolnCountyhasaratherlowper‐capitaincomelevel,usuallysignifyingincomeinequality.Atoddswiththissignifier,thepovertyrateoftheareaisatninepercent,underthepovertyrateof11.2percentforthestateofWyomingandalsobelowthepovertyrateof14.8percentfortherestoftheU.S.Kemmerer’spovertylevelisonlyat4.8percent,waybelowthestateandnationalaverage.30AdecreasehasbeennotedinthepovertyrateintheLincolnCountyareaasestimatedusingthelevelsofparticipationintheSupplementalNutritionAssistanceProgram(SNAP).ParticipationinSNAPwasatalowof5.95percentofthetotalpopulationparticipatingintheprogram.31Theunemploymentrateinthecounty,aswellasinKemmerer,isalsoatalowof4.5percent,32downfromapeakof10.6percentin2010.33Thisisduetoafewfactors,includinganincreaseinthenumberofjobsandareductioninthenumberoflaborersintheworkforce.OnetrendthathasbeennotedabouttheLincolnCounty,Wyoming,areaingeneralisthetendencyofyoungindividualsleavingtheareatoattendcollegeorseekemploymentelsewhere.Incontrast,themedicalfieldhasseenanincreaseinrecentyearsasmoreresidentsreachretirementageorrelocatetotheSouthLincolnCountytoretire.

Morethan86percentofresidentsinKemmerer,Wyoming,currentlyhavehealthinsurance.Thevastmajority,77percent,isprivateinsurance,withtherest,20percent,madeupofindividualswithpublichealthinsurance.34Thisisinkeepingwiththe85percent35ofresidentsundertheageof65intheLincolnCountyarea,whichincludesKemmerer,whocurrentlyhavehealthinsurance.

30https://datausa.io/profile/geo/kemmerer‐wy/312016StarValleyEconomicandDemographicReview:https://www.bosv.com/pdfs/2016EconomicReport.pdf32ibid33https://fred.stlouisfed.org/series/WYLINC3URN34http://www.towncharts.com/Wyoming/Healthcare/Kemmerer‐city‐WY‐Healthcare‐data.html35http://www.census.gov/did/www/sahie/data/interactive/sahie.html?s_appName=sahie&s_statefips=56&s_stcou=56023&s_measures=ic_snc

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III.OverviewofKemmererEMSSystemEmergencymedicalcareinSouthLincolnCountyincludesa911emergencymedicalcallsystem,emergencymedicaldispatch,limitedfirstresponse,groundambulance,airmedicaltransport,medicaloversightandqualityassurance,anda16‐bedacutecare,community‐receivinghospital.ThesystemfunctionsthroughthecollaborationofavarietyofagenciesthatincludesLincolnCountySherriff’sDepartment,KemmererandDiamondvillepolicedepartments,variousfiredepartments,severalenergyindustryfirst‐responseteams,andSouthLincolnMedicalCenterEMS.LincolnCountySheriff’sOfficeCommunicationCenterreportsthatbetweenitstwocommunicationcenters(onelocatedinKemmerer,andonelocatedinAfton),itreceivedmorethan24,000requestsforserviceinLincolnCountyperyear;ofthose,morethan300wereEMSrelated.

EMSIncidentsbyYearYear EMSIncidents2011 4312012 4602013 3482014 4402015 3452016 322

Source:WyomingAmbulanceTripReportingSystem

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2011  2012 2013 2014 2015 2016 

Cokeville  58  67 63 68 71 64 

Diamondville  27  29 30 84 26 19 

Kemmerer  257  284 244 270 237 228 

La Barge  75  59 6 4 2 0 

Other  14  21 5 14 9 11 

System Total  431  460 348 440 345 322 

Transfers  39  31 25 23 23 25 

CommunicationsandDispatchRequestsforemergencymedicalresponsecomeintotheSheriff’sDepartmentCommunicationsCenter.EMScallsaredirectedtoandresourcesaredispatchedbytheSheriff’sDepartmentCommunicationsCenterusingMedicalPriorityDispatchingandProQAprotocols.SouthLincolnMedicalCenterEMSusesananalog,two‐way,VHFradiosystem.ThestatedigitaltrunkedWYOLINKsystemisinplacebutnotusedbyEMS.EMSandpublicsafetyreportthatradioandcellphonereceptionthroughoutSouthLincolnMedicalCenterEMSprimaryserviceareaisgenerallyadequate,withafewareaswherethereispoorornoservice.SouthLincolnMedicalCenterEMSreceivesnotificationfromtheCommunicationsCenterthroughapagersystem.EMSstaffalsousestheWeb‐basedphoneappIamRespondingtotrackresponders’locations,and,whenneeded,coordinateresponsesfrompaidon‐call(volunteer)staff.FirstResponseandCo‐ResponseThereisnoformalmedicalfirstresponsewithinSouthLincolnCounty.Often,agenciessuchasSouthLincolnCountySheriff’sDepartmentandKemmererandDiamondvillepolicedepartmentsco‐respondtoassistonmedicalcalls.Variousfiredepartmentsprovideheavyrescueandvehicleextricationand,whenrequested,otherassistance,suchasliftingandmanpower.Severaloftheenergyindustrycompanieshavetheirownfirst‐responseteams.Thereareanunknownnumberofenergycompanyfirst‐respondersinSouthLincolnCountywhoarehired,trained,andoverseenin‐house.TheserespondersoperateindependentlyofthecountyEMSsystem,providingvaryinglevelsofcare.TheyarenotregulatedbytheStateofWyomingandwerenotpartofthisassessment.SouthLincolnMedicalCenterEMS,lawenforcement,andfiredepartmentsgenerallyreporthavingpositiveandcollaborativeworkingrelationshipswithoutsignificantissues.

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911ResponseandMedicalTransportSouthLincolnMedicalCenterEMSprovides911ambulanceresponseandtransportthroughoutSouthLincolnCounty.SouthLincolnMedicalCenterEMSmaintainstwoambulancestations,oneinKemmererandoneinCokeville,andusesafixed‐stationdeploymentmodel.EMSservicesareprovidedthroughoutSouthLincolnCountywithoutaformalcontractwiththecountyorlocalmunicipalities.SouthLincolnMedicalCenterEMSalsohasrealorperceivedresponsibilityforprovidingEMSinLaBarge.Historically,thisareawasservedbySouthLincolnMedicalCenterEMS,includingtwoambulances,whichsitidletheretoday;but,overtime,disagreementsarose,andtoday,SubletteCountyEMSprovidesservicesinthisarea.Itisunclearwhatthedisagreementsaretrulyabout.Thereisalsodisagreementaboutwhoownstheambulances;theyaretitledandinsurancebySouthLincolnMedicalCenter.TheSouthLincolnMedicalCenterEMSstationinKemmererstaffsanALSambulance24/7usingacombinationoffull‐timestaffandpaidon‐callstaff.TwoadditionaltrucksareavailableinKemmerer,buttheyarenotstaffed.Oneofthethreecaptains(theyareactivelyseektofillanopenfourthcaptainposition)fillstheALSroleonthefirst‐outstaffedambulance;apaidon‐callEMT(therearevariouscertificationlevelsofpersonnel,suchasEMT,AEMT,andEMTIntermediate)staffsthesecondposition.Duringtheinitialdata‐gatheringphase,thereweretwopaidon‐callpersonnelonthefirst‐outambulance.ThiswaschangedJanuary1,2017,tojustone,resultinginatwo‐personcrew.Captainsworkatwo‐day‐on,four‐day‐offschedule,24hoursonduty,48hoursoffduty.Duringthistime,theyareexpectedtoputin40hoursof“working”time;thiscanbeacombinationofworkattheambulancegarage(administrativeduties,projects,dutiesasassigned)andtimewhileonambulancecalls.Duetothe40‐hourrequirement,thereareoftenmultiplecaptainsatthegarageatonetime,duplicatingthelimitedresource.Paidon‐callstaffareoffsiteandreceivecallpaywhilenotonanambulancecall.TheCokevillestationstaffsaBLScrew24/7usingallpaidon‐callstaff.WhenaBLSunitisnotavailableinCokeville,aKemmerercrewprovidesintercept,asneeded.A911responsefromKemmerertoCokevilleisatleast40minutesoneway.Today,thereisnodynamicdeploymentmodelused,whereasaunitwouldmovetoamidwaypointtoprovideoptimalgeographiccoverage.SouthLincolnMedicalCenterEMSfrequentlystaffsadditionalunitstoprovidecoverageforspecialevents,suchasrodeos,motorcycleandautoraces,athleticevents,schoolevents,andpublicgatherings.Typically,911patientsaretransportedtoSouthLincolnMedicalCenter,whichisdesignatedasaTraumaReceivingHospital–Provisional(similartoACSLevelV)bythestateofWyomingDepartmentofPublicHealthEmergencyServices.

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Whenpatientsneedahigherlevelofspecializedcare,theyaretransferredtoout‐of‐countyhospitals,suchasSaltLakeCity,primarilybygroundambulance.Itwasreportedthattheremaybeasmanyasfivetosixpatientspermonthtransportedbyairmedicalservices.AirMedicalServiceAirmedicalservicesinLincolnCountyareprovidedbyavarietyofvendors.WhileSafeTechSolutionswasunabletoidentifyexactnumbersofairmedicalflightsfromSouthLincolnCounty,informationprovidedsuggestsroughly50to60flightsannually.EMSEducationEMSeducationinLincolnCountyislargelyprovidedbySouthLincolnMedicalCenterEMS.CPR,first‐aid,first‐response,andEMTtrainingallareprovidedlocally.Thedepartmentsponsorsweeklycontinualeducationclassesforitsstaff.ThereisnoparamedictrainingprograminSouthLincolnCounty.EMSSystemOversightandPlanningThereisnoformalentitychargedwithoverallEMSsystemoversightandplanninginSouthLincolnCountyorinLincolnCounty.Systemcoordinationisdoneinformally,mainlythroughthecollaborationofvariousorganizationsinvolvedinemergencyresponse.EmergencyplanningiscoordinatedthroughLincolnCountyEmergencyManagement.

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IV.DescriptionofKemmererEMS OrganizationalOwnershipandStructureSouthLincolnMedicalCenterEMSisadepartmentofSouthLincolnMedicalCenter.SouthLincolnMedicalCenteristhebusinessnameusedbySouthLincolnHospitalDistrict,aspecialtaxingdistrictthatreceivesthreemillsvaluedatthetimeoftheassessmentasroughly$1.5million.ThedirectorofSouthLincolnMedicalCenterEMSishiredbyandreportstoSouthLincolnMedicalCenterCEOandhasadottedlinereportingfunctiontotheEMSMedicalDirector,Dr.Krell.WorkforceSouthLincolnMedicalCenterEMSmaintainsaworkforceof31employees,includingthedirector.Threeoftheseemployeesarefull‐time;theremainderarepaidon‐callemployees.Certificationlevelsareasfollows:

0EMTParamedics 9EMT‐Intermediates 3AEMTs 4EMTs 7EMRs 8Drivers

Bylocation:Kemmerer Cokeville 0EMTParamedics 0EMTParamedics 9EMT‐Intermediates 0EMT‐Intermediates 2AEMT 1AEMT2EMT 2EMT5EMR 2EMR4Drivers 4DriversEmployeesarepaidregularhourlywageswhenonduty.Full‐timeemployeesreceiveabenefitpackagefromSouthLincolnMedicalCenterthatisdescribedbyemployeesas“adequate.”Employeesarepaidastipendof$2.00perhourtobeavailableor“oncall.”

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HourlyWagesforEMSPersonnelComparedtoNationalAveragesNational Averages 

SLMCEMS  Minimum Mid‐ Point  Maximum 

Director  $31.88  $40.23  $48.65 

Captain  $16.50  

Lt  $14.00  

EMT‐I  $14.00  

AEMT  $12.00  

EMT  $9.25   $13.21  $16.26  $19.21 

EMR  $8.75  

Driver  $8.25  

On‐call pay  $2.00   $2.11 $2.78 $3.38 

Paramedic  $17.60 $22.02 $26.38 Lead 

Paramedic  $19.87 $24.65 $29.19 

Supervisor  $22.62 $27.64 $32.76 

Facilities,Vehicles,andEquipmentSouthLincolnMedicalCenterEMSisheadquarteredinaSouthLincolnMedicalCenter‐ownedbuildingjustoffthecampusofthehospitalinKemmerer.Thebuildinghasamulti‐baygarage,officespace,andatrainingarea.Thereislimitedroomfordepartmentadministrationandon‐dutycrewsandnosleeproomsorcrewquartersspace.Employeesexpressedconcernsabouttheneedforsleeprooms.SouthLincolnMedicalCenterEMShasafleetofsevenvehiclesthatrangeinagefromeightto21years,including:Kemmerer

2009FordF450 Lifeline 4WDambulance–87,591miles 1999FordF350 WheeledCoach 4WDambulance–65,113miles 1996ChevyK3500 Lifeline 4WDambulance–85,862miles

Cokeville 2004FordF450 Lifeline 4WDambulance–97,442miles 1998ChevyK3500 Lifeline 4WDambulance–29,732miles

LaBarge 1990ChevyK3500 Lifeline 4WDambulance 1994ChevyK3500 Lifeline 4WDambulance

One1984C3500sitsintheparkinglotoutofservice.Generally,SouthLincolnMedicalCenterEMShasmodernequipmentingoodworkingorderandconsistentwithcurrentmedicalguidelinesandprehospitalcarepractices.Anareaofnote:AllofSouthLincolnMedicalCenterEMSvehiclescould

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benefitfromreplacement.Theirageandmileageraisedoubtabouttheirlong‐termdependability,andassuchtheywarrantconsiderationforreplacement.MedicalOversightandQualityAssuranceMedicaldirectionatSouthLincolnMedicalCenterEMSisoverseenbyaphysicianmedicaldirectorprovidedbySouthLincolnMedicalCenter.Themedicaldirectorisresponsibleforallmedicalaspectsofthecoordination,monitoring,andimplementationofSouthLincolnMedicalCenter’semergencymedicalservicespolicies,procedures,andeducationactivities.Protocolsappearuptodate,reflectclinicalbestpracticesinsimilarEMSagencies,andallowfieldproviderswidelatitudeinprovidingadvancedmedicalcarewithoutcallingfororders.Internalqualitypracticesincludestaffreviewofpatientcarereportstoensureprotocolcomplianceforalllow‐volume/high‐riskprocedures,cardiacarrests,traumaactivations,STEMIalerts,alteredmentalstatus,seizures,andabdominalcomplaints.Inaddition,themedicaldirectorreviewseverychartandoftenattendstheWednesdaycontinuingeducationmeetings.Themedicaldirectorishighlyengagedandenthusiasticabouthisrole.FinanceandFundingAsadepartmentofSouthLincolnMedicalCenter,SouthLincolnMedicalCenterEMS’financialpictureiscombinedwiththehealthsystem’soverallfinances.Whilethisisverycommonforhospital‐basedEMSsystems,whatissomewhatuncommonisthatdiscountsandallowancesarenottrackedbydepartment.Thisissignificant,asitpresentsapicturethatmaynotfullyrepresentthetruefinancialpictureoftheEMSdepartment.Forexample,aspresentedbyfinancialleadersatSouthLincolnMedicalCenter,EMSrecoversapproximately60centsoneverydollar,averypositivereturnrate.However,bynotaccountingforthe40centsoneverydollarwithintheambulancefinancialstatements,thefinancialstatementsmayleadthosereviewingthemtobelievetheservicehasastrongerfinancialpositionthanitactuallydoes.Thefollowingchartsillustratethispointbyshowingthecurrentfinancialstatementprofitabilityingraphicform,bothwithoutdiscountsandallowancesandwithestimateddiscountsandallowances.Today,SouthLincolnMedicalCenterisforecastedtolosemorethan$138,000attheendofits2016/2017fiscalyear.Whenestimatingitsdiscountsandallowances,thelossiscloserto$268,000.SafeTechSolutionsconsideredthatEMSrevenuesfrompatienttransportsreflectamixofpayers(29percentMedicare,51percentprivateinsurance,sevenpercentMedicaid,11percentself‐pay,andtwopercentworkman’scompensation).Apayermixof62percentprivatepayersand38percentgovernmentalpayerstypicallyresultsindiscountsandallowancesof38percent.Usingthisdata,SafeTechSolutionscalculatesthatnetrevenuecollectedbytheEMSdepartmentinFY2016/2017isactually$194,600.06.Asshowninthechartsbelow,netrevenuesarenotkeepingupwithexpenses,regardlessofwhetherornotoneaccountsfordiscountsandallowances.

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Kemmerer  Cokeville  Total 

Gross Revenue  $299,143.20  $25,190.23  $324,333.43 

Discounts and Allowances  $119,657.28  $10,076.09  $129,733.37 

Gross Revenue After D&A  $179,485.92  $15,114.14  $194,600.06 

Salaries  $247,631.09  $46,125.70  $293,756.79 

Remaining Expenses  $159,488.14  $9,136.71  $168,624.86 

Total Expenses  $407,119.23  $55,262.42  $462,381.65 

Net Revenue Before D&A  ‐$107,976.03  ‐$30,072.19  ‐$138,048.22 

Net Revenue  ‐$227,633.31  ‐$40,148.28  ‐$267,781.59 

 

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V.KeyFindings Finding 1:    South Lincoln Medical Center EMS is a vital element of 

the healthcare system in South Lincoln County.  Therearenumerousfactors/interviewsthatsupportthisfinding.Throughouttheassessmentsfieldwork,individualsconsistentlyspokeoftheneedforarobustEMSsystemtosupporttheirqualityoflifewithinthevalley.Duetotheruralnatureofthearea,EMSplaysanimportantroleasasafetynetwithinthehealthcaresystemtoprovidebothaccesstothesystemandprehospitalcareandstabilization.EMSprovidesalinkbetweenthelocalhealthcaresystemandhigherlevelsofcare.Oftenwhenacriticallyillpatientisinneedoftransfer,ground‐basedEMSistheonlyresourceavailabletomovethepatientwhilemaintainingtheirin‐hospitallevelofcare. Finding 2:    EMS has always been and will likely always need to be 

subsidized going forward.Donatedlabor36hasbeenandcontinuestobethelargestsinglesubsidyofEMSintheSouthLincolnCountyEMSsystem.Withalowcallvolume,limitedabilitytogeneraterevenue,andacommunityexpectationtoprovideandmaintainEMSwithinCokeville,itseemsreasonablethattherewillbeaneedtoprovidefundstoclosethegapbetweenrevenuesandexpenses.Thisgapwillcontinuetogrowaslessandlessdonatedlaborisavailable.Donatedlaborisaboardtermthatreferstothecostbetweenwhatafull‐timepersonwouldcostcomparedtothecostofwhatSouthLincolnMedicalCenterEMScurrentlypaysfortheirpaidon‐callstaff.

36AnoteaboutSafeTechSolutions’determinationofthevalueofvolunteerlabor:Thevalueofdonatedlaboriscalculatedusingthevalueofavolunteerhour,whichinWyomingis$23.46/hourasdeterminedbytheIndependentSector,anot‐for‐profitorganizationthatcalculatesvalueofvolunteerhoursforall50statesusingBureauofLaborStatisticsdata.The$23.46/hourrateincludesthecosttoreplaceavolunteerwithafull‐time,benefittedemployee.Inourexperience,IndependentSectorvolunteerlaborvalueisgenerallyaccuratealthoughtendstobeontheconservativeside.SafeTechSolutionscalculatedthevalueofvolunteerlaborbasedon$23.46/hourmultipliedbythenumberofpeopleandthenumberofhoursthatvolunteersservedon‐calloron‐dutyshifts.

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Finding 3:    EMS faces major challenges associated with the current 

local economy, its position within the hospital, and the need for a clear departmental leadership structure.

AstheenergysectorwithinSouthLincolnCountydeclined,sodidtheresourcesavailabletoSouthLincolnMedicalCenterEMS.Thisoccurredintwoways;first,runvolumedecreased,whichlowereddollarsreceivedbytheambulanceservicefrompatienttransportrevenue.Second,EMSreceivesasmallamountoftaxsubsidiesthroughtheEMSAssociation.Thesesubsidiesarelargerorsmallerbasedonmineraltaxes.Asmineralproductiondecreases,sodothetaxesassociatedwithproduction.ItisunclearifSouthLincolnMedicalCenterviewsEMSasanessentialserviceandiswillingandabletoallocatetheneededresourcesitrequirestoprovideanALS‐levelserviceduringboththeboomandbusttimes,aswellaswhendonatedlaborisplentifulandwhenitisscarce.Theambulancedepartment’sfleetisaging,anditsfacilitiesareinneedofspacedesignedforafull‐timeEMSdepartment,suchascrewspaceandsleeprooms.Today,theEMSdepartmentisledbyaleaderwho,duetostaffandscheduling,isprimarilyaclinicianandthenaleaderwhentheclinicaldemandsallow.Theroleofcaptainisunclearaswell.Aretheysupervisors,oristhetitlemeanttoidentifythemasoneofthethreefull‐timeemployees?Withthesignificantorganizationalchallengesfacingthedepartment,suchasfinanciallosses,findingandkeepingmoreoftherightpeople,thelowtransportvolumeyethighoperationalcostsofCokeville,andthetensionanduncertaintywithinthecommunityofLaBargeaboutwhoshouldprovideEMSandwhoownsthetwoambulancesstationedtherebutnotinuse,theEMSdepartmentneedsastrong,united,andfocusedleadershipteamthatensuresdailyexpectationsarebeingmetwhilefocusingonsignificantlong‐termorganizationchallenges.

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Finding 4:    South Lincoln Medical Center EMS is sustainable, providing that EMS is made a priority within the organization and resources are appropriately allocated and leveraged efficiently. 

Asdescribedabove,clarifyingtheroleSouthLincolnMedicalCenterplayswithinthegoalsandobjectivesofthehospitalwillbecriticallyimportant,ashospitalexecutiveleadershipneedstomakedifficultdecisionsaboutlimitedresources.Therearefinancialresourcesthatcouldbeleveragedtoassistinthelong‐termsuccessoftheorganization.WhencurrentbillingratesareconsideredagainstthecurrentcostsofprovidingEMS,boththedirectcostsandindirectcosts(donatedlabor),itappearsthatratesarenotsetaccordingtoexpenses.Inaddition,ratesareinconsistentwithnationalaverages.Seebelow:

Finding 5:    The trend toward a business structure and full‐time 

staffing should continue. SouthLincolnMedicalCenterEMShasbegunatransitionfromanorganizationthatinpastyearslookedmorelikeaclubwithprimarilyvolunteerstafftoanorganizationthatisstructured,led,andmanagedmorelikeabusiness.Duringthistransition,theorganizationhasbroughtinpaidleadership,full‐timestaff,andstructuredvolunteerstafftobepaidason‐callstaff.Asvolunteerismdeclines,theorganizationhashigherclinicalandoperationalexpectationsandtheneedformorefull‐timestaffwillrise.Itseemsreasonablethatthistrendshouldcontinueandtheculturechallengesthatemergealongthewayshouldbeseenasanormalandexpectedpartofthejourney.  

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Finding 6:    As operating today, EMS is not as efficient as it is capable of being. 

ThereareseveralopportunitiestomakeEMSoperationsasefficientaspossible.First,thecaptain’sscheduleshouldbeadaptedinsuchawayastonotduplicatethisresource.Today,duetothe40‐hour“work”requirement,thereareoftentimeswhentwocaptainsareintheofficeatthesametime.Thislimitedandimportantresourceshouldbestructuredsothereisalwaysatleastonecaptainintheofficeeverydayoftheweektoallowforcontinuityandaleadershipresource.Withinthecurrentscheduletheremaybeopportunitiesforimprovement.Twenty‐fourhoursondutyinarowraisesconcernsoverfatigue,burnout,employeeengagement,andthepossibilityofmedicalandoperationalerrors.Also,asthescheduleoperatestoday,therecouldbedelaysin911responsesandinterfacilitytransfersasfull‐timestaffwaitforpaidon‐callstaff.Asdescribedpreviously,EMSbillingratesmaynotbemaximized.Finding 7:    It is unclear what the community expects and is willing 

to fund for EMS in Cokeville and La Barge.Throughoutthefieldwork,numerousindividualsraisedquestions,comments,concerns,andfrustrationsaboutCokevilleandLaBarge.Thesecommentsrangedfromfrustrationabouttheamountofresourcesprovidedcomparedtothefinancialcontributionmadebythecommunities,todispleasureatthelackofALSandfull‐timeambulancesinthecommunity,touncertaintyaboutwhypeopleareupset.BeginningtoaddresstheseissuesandconcernswillbeimportantastheycontinuetodrawonthelimitedresourcesofSouthLincolnMedicalCenterEMS.OftenasuccessfulapproachistoformacommitteeofconcernedcitizenstoallowtheusersofthesystemtoarticulatewhattheywantinEMS,suchasnoEMS,full‐timeEMS,part‐timeEMS,orvolunteerEMS.TheymightalsobeaskedwhatlevelofEMStheydesire,suchasALSorBLS.Lastly,thefollowingmustbeunderstood:thecommunity’slevelofdesiredservice(volunteer,part‐time,full‐time),knowingitmustbelong‐termsustainable,andoutliningtheclinicallevelofservice,suchasBasicLifeSupportorAdvancedLifeSupport,thatwouldallowthecommitteetodecidewhattheyandtheirfellowresidentsarewillingtopayforEMS.

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VI.Recommendations Recommendation 1: Ensure South Lincoln County is served by high‐quality 

EMS that remains strong and unthreatened by the local economy.

DevelopinganEMSmodelthatcanthriveduringthebusttimesandtheboomtimeswillensurethecommunityhasalong‐term,sustainable,reliable,andviableEMSsystem.ThiswillrequireaclearunderstandingoftheroleEMSplayswithinSouthLincolnMedicalCenterandifitisseenasanessentialservice.ResourceswillneedtobeallocatedtoprovidemodernEMSequipmentandfacilities,andfacilitieswillneedtobeprovidedtosupportthetransitiontomorepaidstaff.Developingrevenuestreamsthatcanwithstandchangesintheeconomywillalsobecriticallyimportant.Asdonatedlaborneedstobereplacedwithpaidstaff,theexistingfinancialresourceswillbeexhausted.Asacommunity,threesimpleyetpowerfulquestionsmustbeanswered:

1. Whatlevelofservicedoesthecommunitywant?2. Howmuchambulanceservicedoesitwant(howmanyambulancesinwhat

locations)?3. Howwillitgainthefinancialresourcesneededforquestiononeandtwo?

Recommendation 2: Develop an EMS leadership team and department 

structure designed to realize a clear vision for EMS.ThecurrentleadershipteamstructureisonethatappearstoprimarilybefocusedonfillingEMSshifts.Whentimeallows,considerthelargerissuesfacingSouthLincolnMedicalCenterEMS.Rebalancingtheteam’sclinicalandnon‐clinicalexpectationswouldallowthedepartmentleadersmoretimetoleadthechallengesfacingthedepartment.Arebalancingwouldalsoprovideamorereasonablework‐lifebalance,whichcouldmakefindingandfillingcurrentandfutureleadershippositionswithintheorganizationmoresuccessful.Lastly,therealignmentwouldempowerthedepartmentdirectortofocushisorhertimeandtalentonthefutureoftheorganization,trustinghisorherleadershipteamtoensuredailyoperationsandexpectationsarebeingmetandexceeded.Recommendation 3: Strengthen financial performance of South Lincoln 

Medical Center EMS. Closingthegapbetweenever‐risingexpensesandever‐decreasingrevenuestreamwillrequireamulti‐pathapproach.Criticalinanypathwillbetoensureallexisting

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revenuesarebeingmaximized.Today,ambulanceratesdonotappeartomatchexpenses,norarethetruecostofservicesbeingrepresented,suchasthecostofdonatedlaborandaccountingfordepartment‐specificdiscountsandallowances.Oncetheseitemsarecorrected,SouthLincolnMedicalCenterEMScanbegintoleadacommunityconversationabouthowtheEMSsystemwillbefundedlongterm.Thispowerfulstorywouldthenbebuiltonthefoundationofefficiency,transparency,andusualandcustomarybusinessaccountingpractices.ThisfoundationwillprovideatruecostofEMSforalltoseeandunderstand.Recommendation 4: Structure EMS operations to support long‐term 

success.Theschedule,asoperatingtoday,mightbenefitfromchangesthataligntheworkthatisneededwiththeavailabilityofpeopleandresources.Forexample,thecurrentcaptainstructureattimeshasmultiplecaptainsinhouseatthesametime.Therecouldbegreaterefficiencyandvalueifthescheduleallowedforasignalcaptaintobeinhouseatagiventime.Requestsforservicemightbedelayedasonefull‐time,in‐housepersoniswaitingforthesecondpaid,on‐callperson.Asthedepartmentaddsmorepaidstaff,itwillneedfacilitiesandresourcestomatchtheneedsoffull‐timepersonnel,suchassleeprooms,crewquarters,andleadershipandadministrativeofficesseparateofgeneralusespace.AlsoneededinthisgrowthwillbetheacceptanceandrecognitionthatEMSoperatesattheintersectionofhealthcareandpublicsafety.EMSpersonnelareneeded24/7duetotheunpredictablenatureofEMSrequestsforservice.ThisoftenmeansacceptingthatEMSpersonnelwillhavedowntimebetweencallsandmaysleepwhileonduty.ThisalsooftenmeansthatEMSpersonneldonotreceiveregularbreaksandmealswhentheywantthem.BalancingwhatisusualandexpectedwithinthehospitalwithwhatisusualandexpectedwithEMSwillbeimportanttothelong‐termsuccessofthedepartment.Recommendation 5: Create a high engagement “best EMS place to work” 

culture. FindingandkeepingmoreoftherightpeoplewillmostlikelybecomemoreandmoreimportantforSouthLincolnMedicalCenterEMSasdonatedlaborishardertofindandmaintainandasthemigrationofpeopleoutoftheareacontinuesduetothechangesintheruralsocioeconomicfoundationofSouthLincolnCounty.Creatingaworkenvironmentthatisfun,friendly,andfamily‐likewillstrengthenthevaluepropositionthatSouthLincolnMedicalCenterEMShastooffer,allowingtheorganizationtorecruitandretainmoreoftherightstaff,evenwithlimitedfinancialresources.

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UnderstandingwhereSouthLincolnMedicalCenterisonthisjourneywillenablethedepartmenttounderstandwhatpartsofitscultureareworkingwellandwhereimprovementsneedtobemade.Toolssuchassurveys,listeningsessions,andregularemployeeengagementsessionsarehelpfulingaininginsightandmeasuringprogress.Alsoimportanttothisprocessisprepared,competent,rested,andempoweredleaders.EnsuringthattheleadershipofSouthLincolnMedicalCenterEMSisexposedtootherleadersandparticipatesinEMS‐specificleadershipdevelopment—notjustmanagement‐specificleadershiporclinical‐specificleadership—willbecritical.