Performance audit, Department of Health Services, office of emergency medical services

              PERFORMANCE AUDIT
DEPARTMENT OF HWTH SERVICES
OFFICE OF EMERGENCY MEDICAL SERVICES
Report to the Arizona Legislature
By the Auditor General
December 1988
DOUGLAS R. NORTON, CPA
AUDITOR GENERAL
STATE OF ARIZONA
OFFICEOFTHE
AUDITOR GENERAL
LINDAJ. BLESSING, CPA
DEPUTY AUDITOR GENERAL
December 22, 1988
Members of the Arizona L e g i s l a t u r e
The Honorable Rose Mofford, Governor
Mr. Ted Williams, D i r e c t o r
Department of Health Services
Transmitted herewith i s a report of the Auditor General, A Performance
Audit of the Department o f Health Services, O f f i c e o f Emergency Medical
Services. This report i s i n response to a June 2, 1987, r e s o l u t i o n of
the J o i n t L e g i s l a t i v e Oversight Committee. The performance a u d i t was
conducted as a p a r t of the Sunset Review set f o r t h i n Arizona Revised
Statutes $ 941- 2351 through 41- 2379.
This i s the second i n a s e r i e s of reports to be issued on the Department
of Health Services. This report addresses serious problems i n the
r e g u l a t i o n of ambulance companies and t h e i r personnel. Complaints have
been l o s t and mishandled, and the Department has f a i l e d to take a c t i o n
on even the most serious complaints.
My s t a f f and I w i l l be pleased to discuss or c l a r i f y items i n the r e p o r t .
S i n c e r e l y ,
~ obq. las R. Norton
Auditor General
S t a f f : W i 1 1 iam Thomson
Peter N. Francis
Martha Dorsey
Kurt Schulte
Gregg Halemba
Jean Wood
Enclosure
2700 NORTH CENTRAL AVE, @ SUITE 700 @ PHOENIX, ARIZONA 85004 e ( 602) 255- 4355
The O f f i c e o f the Auditor General has conducted a performance audit of
the Arizona Department of Health Services, O f f i c e of Emergency Medical
Services, i n response to a June 2, 1987, r e s o l u t i o n of the J o i n t
L e g i s l a t i v e Oversight Committee. This performance audit was conducted as
part of the Sunset Review set f o r t h i n Arizona Revised Statutes ( A. R. S.)
$ 941 - 2351 through 41 - 2379.
This i s the second i n a series of reports to be issued on the Arizona
Department of Health Services ( DHS). The report focuses on the functions
o f the O f f i c e o f Emergency Medical Services under the D i v i s i o n of
Emergency Medical Services/ Health Care F a c i l i t i e s .
Although t h i s report i d e n t i f i e s serious problems which need a t t e n t i o n ,
DHS management has recognized the need for improvement i n the O f f i c e o f
Emergency Medical Services and made several changes since August 1987.
These include a new emphasis on regulation, major reorganizations of the
EMS o f f i c e and i t s regional system a d m i n i s t r a t i o n , and several
operational changes to improve effectiveness and e f f i c i e n c y .
The Office of Emergency Medical Services
Has Lost and Mishandled Complaints ( see pages 7 - 10)
In November 1986, DHS received a complaint a l l e g i n g that a p a t i e n t died
due to inadequate treatment and unusable equipment. The complaint was
not logged- in u n t i l almost two years l a t e r , and i t was never acted upon.
No f i l e was created, and no one was assigned to i n v e s t i g a t e the
complaint. Instead, t h i s complaint only came to l i g h t whenowe discovered
i t i n July 1988. DHS' treatment of t h i s complaint i s not an i s o l a t e d
incident. DHS' handl ing of complaints against i n d i v i d u a l emergency
medical technicians and companies has been so poor i n the past two years
that i t cannot t e l l how many complaints i t has received nor what actions
i t has taken. These condi t ions have arisen i n p a r t because DHS' previous
complaint- handling procedures were dismantled and not replaced w i t h an
adequate system.
Although DHS recognized the s e v e r i t y o f t h i s problem e a r l y i n the a u d i t ,
i t s actions to resolve the s i t u a t i o n were not adequate. DHS has not yet
implemented adequate p o l i c i e s and procedures regarding complaint
hand I i ng, even though these pol i c i es and procedures have been planned
since at least July 1988.
DHS Has Not Acted on Serious Complaints
Against Emergency Medical Technicians
and Ambulance Companies ( see pages 11 - 16)
In addition to mishandling the complaints, DHS has allowed the m a j o r i t y
of the complaints discussed above to go uninvestigated and unresolved.
Although i t has broad s t a t u t o r y a u t h o r i t y t o take a c t i o n regarding
complaints, even very serious complaints have been ignored. Complaints
such as the f o l l o w i n g have not been adequately investigated o r resolved:
0 A complaint a l l e g e d t h a t inadequate treatment and unusable equipment
contributed to a p a t i e n t ' s death. The complainant a l l e g e s t h a t the
ambulance crew was slow i n a r r i v i n g , they would not take over CPR
begun by the v i c t i m ' s neighbor, and they did not appear to know how
t o c l e a r the airway. Once the airway was cleared, the EMTs attempted
to administer oxygen but discovered the oxygen tank was empty. The
complainant f u r t h e r a l l e g e s t h e ambulance took an i n d i r e c t route to
the h o s p i t a l . The p a t i e n t u l t i m a t e l y died.
0 A funeral home d i r e c t o r alleged that an ambulance transported an
autopsied, leaking body infected w i t h the AIDS v i r u s to the mortuary
using l i t t l e or no precaution i n the handling o f the b o d i l y f l u i d s
and blood. The complainant stated that no d i s i n f e c t a n t was used to
clean the ambulance cot which c a r r i e d the body, and that the
ambulance was used for transport immediately t h e r e a f t e r without
adequate s a n i t a t i o n safeguards taken to protect e i t h e r personnel or
the next p a t i e n t being transported.
The Department has also f a i led to act i n cases where some ambulance
companies have accumulated repeated complaints.
The need for DHS to take much greater action on complaints i s shown by
the following f i g u r e s . Of the 157 complaints we could document that DHS
received from July 1, 1986 through June 30, 1988, 92 ( 59 percent) were
not investigated. Of the remaining 65 that were investigated, 44
received no a c t i o n even though at least f i v e o f these were substantiated
by DHS' i n v e s t i g a t i o n s . In f a c t , DHS had taken no formal d i s c i p l i n a r y
actions against any EMTs or ambulance companies during the two- year
period of our review
DHS o f f e r s a number of reasons for i t s i n a c t i o n i n c l u d i n g : other
p r i o r i t i e s , a lack of standards governing qua1 i ty of care, a lack of
intermediate sanctions and a lack of t r a i n e d i n v e s t i g a t o r s . While we
agree there i s a need for i n v e s t i g a t i v e t r a i n i n g , we believe DHS'
apparent lack of a strong enforcement philosophy i s the underlying reason
for inaction.
OEMS Needs to I n s t i t u t e a Mandatory Reporting
Requirement for A l l Instances o f EMT
l ncompetence and Unprofessional Conduct ( see pages 17 - 19)
A mandatory reporting requirement i s needed to ensure that DHS i s aware
of a l l incidents of EMT incompetence and unprofessional conduct which
could threaten p u b l i c h e a l t h and s a f e t y . H o s p i t a l s responsible for
supervising EMTs generally d i s c i p l i n e the EMTs v i a t h e i r own mechanisms
without informing DHS, which i s the agency responsible for c e r t i f y i n g
EMTs. As a r e s u l t , an incompetent EMT may be able to t r a n s f e r from one
h o s p i t a l ' s control to another without any i n t e r v e n t i o n by the Statewide
enforcement body. In contrast to DHS' s i t u a t i o n , several medical
licensing boards i n Arizona have s t a t u t o r y provisions r e q u i r i n g that
i n c i d e n t s o f incompetence and unprofessional conduct be reported. I f
such a requirement were enacted, BHS could enforce the s t a t u t e through
i t s routine review of ambulance transport records.
The State c e r t i f y i n g examination for Basic EMTs has not been v a l i d a t e d as
required by statute and does not meet national standards governing t e s t
development. As a r e s u l t , DHS cannot adequately assure that the Basic
EMT examination assesses knowledge and s k i l l s needed for safe p r a c t i c e .
A d d i t i o n a l l y , DHS has not ensured that the examination i s adequately
secured. The Department has administered the same version of the
150- question, multiple- choice t e s t repeatedly for almost three years,
g i v i n g applicants retaking the t e s t a d d i t i o n a l o p p o r t u n i t i e s to see and
memorize examination questions. ( According to DHS s t a f f , one applicant
took the examination seven times before passing.) Further, t e s t copies
are not locked away, and DHS s t a f f have s t a t e d t h a t anyone could obtain
access to a copy of the t e s t . S t a f f b e l i e v e t h a t at least one provider
has a copy of the examination.
To resolve i t s t e s t v a l i d a t i o n and s e c u r i t y weaknesses, DHS should
consider using a v a l i d a t e d Basic EMT w r i t t e n examination developed by a
n a t i o n a l o r g a n i z a t i o n . DHS should also consider implementing a fee
schedule to cover t e s t a d m i n i s t r a t i o n costs.
TABLE OF CONTENTS
Page
FINDING t V : The State Examination for Basic Emergency Medical
Technicians Has Not Been Validated and I s Not
AdequatelySecured . . . . . . . . . . . . . . . . . . . . . . . 21
Testing I s Intended to InsureCompetence . . . . . . . . . . . . 21
EMT Exam Has Not Been Validated. . . . . . . . . . . . . . . . . 22
ExamIsNotAdequatelySecured . . . . . . . . . . . . . . . . . 23
National Exam Should Be Considered . . . . . . . . . . . . . . . 24
Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . 26
AREASFORFURTHERAUDITWORK . . . . . . . . . . . . . . . . . . . . 27
AGENCYRESPONSE.. . . . . . . . . . . . . . . . . . . . . . . . . .
INTRODUCTION AND BACKGROUND
The O f f i c e of the Auditor General has conducted a performance a u d i t o f
the Arizona Department of H e a l t h S e r v i c e s , O f f i c e of Emergency Medical
Services, i n response t o a June 2, 1987 r e s o l u t i o n of the J o i n t
L e g i s l a t i v e Oversight Committee. This performance a u d i t was conducted as
part of the Sunset Review set f o r t h i n Arizona Revised Statutes ( A. R. S.)
541 - 2351 through 41 - 2379.
This i s the second i n a s e r i e s o f reports to be issued on the Arizona
Department of H e a l t h S e r v i c e s . This report focuses on the f u n c t i o n of the
O f f i c e of Emergency Medical Services under the D i v i s i o n of Emergency
Medical Services/ Health Care F a c i l i t i e s .
Background
The modern era of Emergency Medical Services ( EMS) began i n 1966 w i t h a
report by the National Academy of Science which l e d t o the passage of the
Highway Safety A c t . This Federal law helped to improve the n a t i o n a l EMS
system by r e q u i r i n g a l l s t a t e s to have a highway s a f e t y program which
included standards for the pre- hospital phase of emergency medical
treatment. However, Arizona d i d not have one e n t i t y responsible f o r
a d m i n i s t r a t i o n of a l l phases o f EMS u n t i l the O f f i c e o f Emergency Medical
Services w i t h i n the Department of H e a l t h S e r v i c e s was given t h i s
a u t h o r i t y i n 1982.
A r e c e n t l y published a r t i c l e estimates that one i n two Arizonans w i l l
need emergency trauma care a t some time i n h i s or her l i f e . I t i s DHS'
r e s p o n s i b i l i t y to plan and coordinate the system components to ensure
adequate and h i g h - q u a l i t y emergency medical care. To achieve t h i s , DHS
must overcome the d i f f i c u l t y o f p r o v i d i n g q u a l i t y services i n the S t a t e ' s
many r u r a l areas. The major components of an EMS system - personnel,
t r a i n i n g , communications systems, t r a n s p o r t a t i o n , and emergency
receiving/ speciaIized f a c i l i t i e s - g e n e r a l l y a r e a v a i l a b l e i n the
m e t r o p o l i t a n areas of Arizona w i t h populations o f 100,000 or more. In
the communities o f r u r a l Arizona, w i t h t h e i r d i v e r s e geography and sparse
populations, less extensive systems e x i s t . I n f a c t , there are three
counties which do not have any c e r t i f i e d paramedics, the highest s k i l l e d
level of emergency medical technician.
Functions and Organization - The O f f i c e o f Emergency Medical Services
( OEMs) i s responsible f o r r e g u l a t i n g the a c t i v i t i e s of a l l EMS personnel,
base h o s p i t a l f a c i l i t i e s and ambulance services i n t h e Statewide EMS
system. OEMs i s c u r r e n t l y organized i n t o t h r e e r e g i o n a l u n i t s
responsible for the northwest, c e n t r a l and southeast areas of the State.
Each regional u n i t handles a l l a d m i n i s t r a t i v e and r e g u l a t o r y functions
f o r the EMS personnel, ambulance services and base h o s p i t a l s i n the
region. There i s also a separate u n i t responsible f o r a d m i n i s t e r i n g the
C e r t i f i c a t e of Necessity program for ambulance services on a Statewide
basis. OEMs c u r r e n t l y has 20 autharized p o s i t i o n s ' ) and a f i s c a l
year 1988- 89 general fund a p p r o p r i a t i o n of $ 547,113, w i t h a d d i t i o n a l
funding coming from the EMS Operating ~ und'!)
The Statewide EMS system developed by OEMs contains v a r y i n g l e v e l s or
c e r t i f i c a t i o n s f o r EMS personnel and h o s p i t a l s . I t also includes
r e g u l a t i o n of a v a r i e t y o f ambulance services.
Emergency Medical Technicians - OEMs c u r r e n t l y c e r t i f i e s f i v e levels of
Emergency Medical Technician ( EMT), each of which r e q u i r e s a d i f f e r e n t
level o f t r a i n i n g and s k i l l p r o f i c i e n c y .
0 Basic level - Applicants are required to complete the 110- hour U. S.
Department of Transportation approved curriculum. Some Basic- level
EMT ( BEMT) s k i l l s include: the a b i l i t y to recognize emergencies,
obtain and i n t e r p r e t diagnostic symptoms, perform b a s i c c a r d i a c l i f e
support ( cardio- pulmonary r e s u s c i t a t i o n or CPR), c o n t r o l hemorrhage
and bandage wounds and s t a b i l i z e and s p l i n t f r a c t u r e s . BEMTs are not
c e r t i f i e d to administer any drugs, nor to perform any advanced
cardiac s k i l l s . As o f July 1988, there were 6,635 c e r t i f i e d BEMTs
0 Basic IV level - I n 1983, an o p t i o n a l four- hour BEMT course was
i n i t i a t e d f o r those involved i n the transport of s t a b i l i z e d p a t i e n t s
( 1 ) OEMs also has one l i m i t e d p o s i t i o n which l a s t s u n t i l June 30, 1989.
( 2 ) The EMS Operating Fund i s a s t a t u t o r i l y- authorized r e v o l v i n g fund, from which
approximate1 y $ 2 mi 11 ion i s spent annual 1 y .
with intravenous ( I V ) f l u i d therapy. This e x t r a t r a i n i n g only allows
BEMTs to monitor the IV d u r i n g t r a n s p o r t . They are not authorized to
perform any other I V s k i l l s . As o f J u l y 1988, there were 458 BEMTs
c e r t i f i e d at t h i s l e v e l ! ' )
Q Intermediate IeveI - C e r t i f i e d BEMTs wishing to achieve t h i s IeveI
are required to complete a curriculum 259 hours i n length.
Intermediate level EMTs ( IEMTs) are c e r t i f i e d to s t a r t IVs and
administer drugs through them, and a l s o t o administer drugs through
i n j e c t i o n . Other s k i l l s include the a b i l i t y to i n s e r t tubes i n the
trachea t o e s t a b l i s h an airway and remove stomach contents through
suction. A l l s k i l l s performed and drugs administered must be done
under the medical control of a c e r t i f i e d base h o s p i t a l , IEMTs are
not able to perform advanced cardiac s k i l l s , nor are they able to
s t a r t IVs i n the central v e i n s ( v e i n s w i t h more d i r e c t access to the
heart). As of July 1988, there were 296 IEMTs c e r t i f i e d .
a Intermediate- Cardiac IeveI - C e r t i f i e d IEMTs must complete an
additional 164- hour cardiac care course and pass a c e r t i f y i n g
e x a ~ i n a t i o n . ' ~ ) Successful completion of t h i s course allows an
IEMT- Cardiac to perform advanced cardiac s k i l l s ( p r i m a r i l y
d e f i b r i l l a t i o n , or e l e c t r i c a l l y shocking the h e a r t ) as we1 l as
administer cardiac drugs under the medical c o n t r o l of a c e r t i f i e d
base h o s p i t a l . However, as w i t h IEMTs, IEMT- Cardiacs are also unable
to e s t a b l i s h IVs i n the central veins. As o f J u l y 1988, there are 55
IEMT- Cardiacs c e r t i f i e d .
a Paramedic IeveI - C e r t i f i c a t i o n a t t h i s IeveI requires completion
of a 674- hour curriculum. Any EMT can t r a n s i t i o n t o t h i s l e v e l , w i t h
a d d i t i o n a l t r a i n i n g hours needed ( up to the 67' 4 r e q u i r e d ) v a r y i n g
The Basic I V monitoring c e r t i f i c a t i o n l e v e l i s not authorized by s t a t u t e .
( 2) I n 1983, t h i s new c l a s s i f i c a t i o n of IEMT was developed i n response t o r u r a l
community needs f o r improved advanced cardiac 1 i f e support services. This
c l a s s i f i c a t i o n i s also not authorized by s t a t u t e .
based on present c e r t i f i c a t i o n l e v e l . The only d i f f e r e n c e i n s k i l l s
from an IEMT- Cardiac i s t h a t a Paramedic can s t a r t an I V i n a c e n t r a l
v e i n . Like the lEMTs and IEMT- Cardiacs, paramedic s k i l l s and drug
a d m i n i s t r a t i o n must be done under the medical c o n t r o l of a c e r t i f i e d
base h o s p i t a l . As o f J u l y 1988, there are 874 Paramedics c e r t i f i e d .
Base Hospitals - There are three categories of h o s p i t a l s able to
provide pre- hospital c o n s u l t a t i o n and receive emergency p a t i e n t s .
0 ALS hospitals - There are 41 h o s p i t a l s which serve as advanced
l i f e - s u p p o r t ( ALS) base h o s p i t a l s and provide medical c o n t r o l to
three levels o f emergency advanced l i f e support pre- hospital
personnel: Paramedics, IEMTs and IEMT- Cardiacs. These h o s p i t a l s must
have 24- hour i n - h o s p i t a l a v a i l a b i l i t y of ALS t r a i n e d physician and
nursing s t a f f , plus programs i n qua1 i t y assurance and teaching for
the pre- hospital personnel.
0 IEMT hospitals - There are two h o s p i t a l s which provide ALS medical
c o n t r o l o n l y to IEMT and IEMT- Cardiac personnel, and which are
required to have 24- hour i n - h o s p i t a l p h y s i c i a n s .
0 System hospitals .- There are four r u r a l h o s p i t a l s which can receive
p a t i e n t s under ALS care, but only as d i r e c t e d by an ALS base h o s p i t a l
physician.
A l l categories of emergency- receiving h o s p i t a l s are c e r t i f i e d by the
Department and r e c e r t i f i e d every two years, according t o e s t a b l i s h e d
rules and r e g u l a t i o n s . Included i n the evaluation of the c e r t i f i c a t i o n
process for each h o s p i t a l are q u a l i t y assurance reviews of pre- hospital
c l i n i c a l performance by each category of EMT.
Ambulance Services - P r i o r to 1982, ambulance services were considered
common t r a n s p o r t a t i o n c a r r i e r s and were regulated by the Arizona
Corporation Commission. However, i n November of 1980, Proposition 101
was passed which deregulated t h e e n t i r e t r a n s p o r t a t i o n industry i n c l u d i n g
ambulance s e r v i c e s . T h i s deregulation took e f f e c t i n July 1982. New
l e g i s l a t i o n was immediately enacted to provide pub1 i c h e a l t h and safety
regulation of ambulances and ambulance services by DHS. I n November of
1982, Proposition 100 passed which would allow for economic r e g u l a t i o n of
ambulances and ambulance services through c o n t r o l of area served,
response times and rates charged. L e g i s l a t i o n g i v i n g DHS t h i s a d d i t i o n a l
regulatory a u t h o r i t y was enacted i n May of 1983.
According to OEMs s t a f f , as of August 1988, there were 69 ambulance
services licensed to operate i n Arizona w i t h 313 r e g i s t e r e d ambulance
vehicles. There are also four a i r ambulance services w i t h e i g h t
h e l i c o p t e r s and ten fixed- wing a i r c r a f t r e g i s t e r e d . These services are
p r i m a r i l y run by p r i v a t e companies, municipal f i r e departments, and f i r e
d i s t r i c t s but can also be run by counties, h o s p i t a l s and o t h e r v o l u n t e e r
and non- profit e n t i t i e s .
OEMs regulates these services by r e q u i r i n g a l l ambulance vehicles to be
registered, and a l I services to be I icensed. Each ground transport
service i s a l s o r e q u i r e d to o b t a i n a C e r t i f i c a t e of Necessity which
states i t s geographic operating area as well as i t s rates and response
times.
Recent Attemots to lmorove OEMs
Management has recognized the need f o r improvement i n the O f f i c e of
Emergency Medical Services and made several changes since August 1987.
OEMS underwent a major reorganization, designed to consolidate three
separate o f f i c e s and c o o r d i n a t e o p e r a t i o n s between the three f u n c t i o n s .
O f f i c e s t a f f designed and implemented an automated system to manage the
EMT c e r t i f i c a t i o n process - the f u n c t i o n which had required most of
s t a f f ' s time. According to DHS, t h i s system i s now approximately 75
percent complete. OEMS reports that i t has also 1) developed a p o l i c i e s
and procedures manual addressing a l l major tasks, and 2) c e n t r a l i z e d i t s
f i l e s to avoid f i l e d u p l i c a t i o n .
Another major change has involved t h e regional a d m i n i s t r a t i o n of the
statewide EMS system. OEMs requested and obtained f i n a n c i a l a u d i t s of
the regional c o u n c i l s , w i t h whom OEMS contracted to perform several EMS
functions. The a u d i t r e s u l t s c o n t r i b u t e d to the e l i m i n a t i o n of the
operations contracts w i t h the regional c o u n c i l s . S t a f f i n g of the
counc i I s w i I I now be performed by State OEMS pe rsonne I . Management
reports that these changes w i l l e l imi nate dup l i cat ion and reduce expenses.
The DHS Director indicated that perhaps the biggest change to take place
i s a philosophical one. According to the D i r e c t o r , DHS d i d not
previously view i t s e l f as a regulatory agency. He stated he has changed
t h i s philosophy and c l e a r l y informed h i s s t a f f of the new emphasis on
regulation and enforcement.
Audit Scope and Purpose
This audit was conducted to evaluate the adequacy of r e g u l a t i o n by the
Department of Health Services O f f i c e of Emergency Medical Services,
focusing on these s p e c i f i c areas.
a The adequacy of the complaint- processing system used by the O f f i c e of
Emergency Medical Services.
0 The adequacy of DHS' a c t i o n on complaints received.
8 The need to require a l l members of the emergency medical services
f i e l d to report instances of incompetence and unprofessional conduct
exhibited by c e r t i f i e d personnel or licensed e n t i t i e s to DHS.
a The q u a l i t y of the w r i t t e n examination used for c e r t i f i c a t i o n at the
Bas i c EMT l eve l .
The section Areas For Further Audit Work addresses issues we i d e n t i f i e d
during the course of our audit work, but were unable to research due to
time c o n s t r a i n t s .
This audit was conducted i n accordance w i t h generally accepted
governmental a u d i t i n g standards.
The Auditor General and s t a f f express appreciation to the Director of the
Department of Health Services, and e s p e c i a l l y the s t a f f of the O f f i c e of
Emergency Medical Services, for t h e i r cooperation and assistance during
the course o f our a u d i t .
FINDING I
DHS' EMERGENCY MEDICAL SERVICES OFFICE
HAS LOST AND MISHANDLED COMPLAINTS
In November 1986, DHS received a complaint a l l e g i n g t h a t a p a t i e n t died
due to inadequate treatment and unusable equipment. The complaint was
not logged- in u n t i l almost two years l a t e r , and i t was never acted upon.
No f i l e was created, and no one was assigned to i n v e s t i g a t e the
complaint. Instead, t h i s complaint only came to l i g h t when we discovered
i t i n July 1988. DHS' treatment of t h i s complaint i s not an i s o l a t e d
i n c i d e n t . DHS' handling of complaints against i n d i v i d u a l EMTs and
companies has been so poor i n the past two years that i t could not t e l l
how many complaints i t has received, nor what actions i t has taken.
These conditions have a r i s e n i n p a r t because DHS' previous
complaint- handling procedures were dismantled. Although DHS has
recognized the s e v e r i t y o f t h i s problem, i t s actions to resolve the
problem have not been adequate.
DHS Has Not Kept Track
Of EMS Complaints
For at least the past two years, DHS has not kept track of i t s complaints
concerning ambulance companies and t h e i r personnel. Many complaints have
not been logged i n , f i l e s have not been created and complaint s t a t u s has
not been monitored. Some complaints were stored loose and disorganized
i n a cardboard box. We found f i v e complaint logs which l i s t e d several
complaints we could n o t f i n d , and we found s t i l l other complaints which
were never l i s t e d i n t h e l o g s . Furthermore, when asked to produce a l l
complaints, one DHS supervisor attempted to recreate complaint f i l e s and
create a log from memory.
OEMs management has been uninformed about the number and type of
complaints. When we f i r s t asked to review a l l of the complaints DHS had
received, the O f f i c e Chief gave us a log l i s t i n g 53 complaints, b u t he
only gave us four complaint f i l e s . Later, a f t e r another request, we were
given another copy of the log which had grown to 61 complaints, and two
boxes containing 42 complaints. Following a w r i t t e n request, we were
provided an a d d i t i o n a l 182 complaints. When we asked why these
complaints had not been provided before, the O f f i c e Chief said h i s s t a f f
had not given them to him p r i o r t o our request. We f u r t h e r found that i t
was a f t e r our request that one supervisor attempted to reconstruct from
memory complaint f i l e s and a log for which he had been responsible.
Because of the d i f f i c u l t i e s described above, neither we nor DHS can t e l l
how many complaints the agency has received i n the past two years or what
actions have been taken. We do know, however, that t h i s i s a serious
matter. A t l e a s t three of the complaints we were able to f i n d alleged
that death occurred due to inadequate care or missing equipment.
Previous Complaint- Handling
Process Dismantled
Complaint- handling procedures for two of the three OEMS s e c t i o n s ( ' '
w i t h i n the O f f i c e o f Emergency Medical Services were dismantled i n l a t e
1985 or e a r l y 1986. These two sections had procedures but then abandoned
them, leaving no complaint- handling process.
P r i o r t o January 1986 a s t a f f member i n the ambu! ance- l icensing and
c e r t i f i c a t i o n section( z) kept a formal log of a l l complaints he
received against ambulance companies. He stated he took act ion on every
complaint and was able to obtain refunds for several p a r t i e s . However,
i n January 1986 h i s supervisor issued a memorandum r e q u i r i n g t h i s s t a f f
member and others i n the section to turn a l l complaints over to him.
Although the supervisor had i n d i c a t e d t h a t a log would be maintained, we
found that the log was not maintained and the complaints were forgotten.
When we asked why complaints had been set aside, the supervisor indicated
that other d u t i e s prevented him from attending to complaints, and that he
had n o t i f i e d the D i v i s i o n Assistant Director that he could not handle the
complaints. Yet, among the f o r g o t t e n complaints were several serious
ones, i n c l u d i n g one a l l e g i n g death due to inadequate treatment.
( 1 ) The t h i r d section, which d e a l t w i t h base h o s p i t a l s , apparently never had any
complaint procedures t o begin w i t h . The s t a f f member responsible f o r t h a t o f f i c e
said t h a t no procedures had ever been i n s t i t u t e d ; instead, problems were handled
mostly over the telephone.
( 2) These sections and the ambulance personnel c e r t i f i c a t i o n s e c t i o n operated under a
previous EMS o f f i c e o r g a n i z a t i o n , but have since been abolished as o r g a n i z a t i o n a l
u n i t s .
Another s t a f f member, t h i s one i n the Ambulance Personnel C e r t i f i c a t i o n
s e c t i o n , a l s o maintained complaint f i l e s and took a c t i o n on several
cases. However, he s t a t e d t h a t i n approximately l a t e 1985 or e a r l y 1986.
he informed the previous Assistant Director that he could no longer
handle complaints due to s t a f f i n g shortages. He s t a t e d t h a t h i s s t a f f
had been recently c u t , and c e r t i f i c a t i o n of EMTs was occupying the
remaining s t a f f ' s time.
DHS' Actions Regarding Complaint
Handling Have Been I n s u f f i c i e n t
Although current management acknowledges the problem and has made
complaints a p r i o r i t y , the O f f i c e has not acted s u f f i c i e n t l y to a l l e v i a t e
the problem. Planned procedures have not been implemented to control
complaint handling.
Though planned, adequate p o l i c i e s and procedures regarding complaints
handling have not yet been implemented. In h i s response to our i n q u i r y
regarding newly- proposed complaint- handling procedures, the OEMS O f f i c e
Chief stated that a f i n a l d r a f t of the revised p o l i c y and procedure was
due ". not l a t e r than July 26, 1988." The proposed p o l i c y and
procedure was to require a complaints l o g ( ' ) , an assignment procedure,
and a time deadline for completing complaint reviews. However, as of
September 22, 1988, the f i n a l document had not been f i n a l i z e d .
In a d d i t i o n , management needs to p r o h i b i t the c r e a t i o n o f m u l t i p l e f i les
for one complaint. Several of the complaints we reviewed had m u l t i p l e
f i l e s , leaving no control over where important case documentation might
be placed. For example, one complaint that was s t i l l open as of August
1988 had at least four working f i l e s .
DHS reports that i t has recently addressed i t s complaints handling
problems. As of December 1988, the Agency has developed a p o l i c i e s and
procedures manual and c e n t r a l i z e d i t s f i l e s to avoid d u p l i c a t i o n . I t
has also i n i t i a t e d development of an automated complaint tracking system
that i s planned to be completed i n March 1989. F i n a l l y , a l l OEMS
( ' 1 Management c u r r e n t l y has a complaint- logging system; however, i t has not been used
s y s t e m a t i c a l l y . At the time of our review, several of the complaints had not been
1 ogged .
9
s t a f f except i t s support s t a f f are to be t r a i n e d i n January 1989
regarding invest i g a t ion and f i l e preparat i o n , using a program designed by
DHS and the Attorney General's O f f i c e .
RECOMUENDATIONS
1. DHS needs to f i n a l i z e i t s p o l i c y and procedure regarding complaint
handling. The revised p o l i c y and procedure should r e q u i r e :
e Systematic logging of a l l complaints received; and
e An adequate t r a c k i n g system be implemented.
2. DHS should c l e a r l y f i x the r e s p o n s i b i l i t y for complaint handling, and
the i n d i v i d u a l s responsible should be held accountable for t h e i r
performance i n t h i s area.
FINDING I I
DHS HAS NOT ACTED ON SERIOUS COMPLAINTS
AGAINST EMERGENCY MEDICAL TECHNICIANS
AND AMBULANCE COMPANIES
I n a d d i t i o n to losing and not keeping track of complaints, DHS has not
acted on those complaints of which i t has been aware. During the
two- year period beginning J u l y 1, 1986, DHS f a i l e d to adequately
i n v e s t i g a t e o r resolve more than 73 percent of the 157 complaints i t
received, i n c l u d i n g several serious cases i n v o l v i n g death or deadly
disease; furthermore, i t has taken no enforcement a c t i o n s i n the past two
years. To protect the p u b l i c from p o t e n t i a l harm or i n j u r y , DHS must
place greater p r i o r i t y on enforcement.
OEMs Has Broad Authority
To Enforce Complaint Actions
Against Companies and Personnel
DHS s t a t u t e s give the agency broad a u t h o r i t y t o enforce complaint a c t i o n s
against ambulance companies and c e r t i f i e d ambulance a t t e n d a n t s .
According t o A. R. S. 536- 2211, a c t i o n can be taken against an EMT f o r
several reasons i n c l u d i n g unprofessional conduct, gross incompetence or
gross negligence i n the p r o v i s i o n o f care and treatment, and use of
dangerous drugs or alcohol t o the extent t h a t i t impairs the EMTfs
abi l i t y to provide care and treatment. The s t a t u t e a l lows DHS to
d i s c i p l i n e EMTs by revocation, suspension, probation and censure. A. R. S.
536- 2215 a l lows DHS t o take act i o n against an ambulance or ambulance
company i f , among other items, the licensee " demonstrated incompetence or
has shown himself as otherwise unable to provide emergency medical
services which meet minimum standards prescribed by the D i r e c t o r . " DHS
can suspend or revoke companies' licenses or t h e i r a u t h o r i t y to operate
i n d i v i d u a l ambulances.
DHS Has Failed to Resolve
Complaints Alleging Poor
Treatment or Neg l i gence
DHS has f a i l e d to act on even the most s e r i o u s c o m p l a i n t s . The f o l l o w i n g
case examples i l l u s t r a t e the serious nature of some o f the complaints DHS
has f a i l e d t o act on.
11
0 An emergency department physician a l l e g e d that a cardiac p a t i e n t died
p a r t l y as a r e s u l t of improper treatment by an EMT. The p a t i e n t had
stopped b r e a t h i n g , and the EMT a r r i v i n g on the scene r e p o r t e d l y
created an airway passage to the p a t i e n t ' s stomach instead o f h i s
l ungs .
0 A complaint a l l e g e d that inadequate treatment and unusable equipment
contributed to a p a t i e n t ' s death. The complainant a l l e g e s that the
ambulance crew was slow i n a r r i v i n g , they would not take over CPR
begun by the v i c t i m ' s neighbor, and they d i d not appear to know how
to clear the airway. Once the airway was cleared, the EMTs attempted
to administer oxygen but discovered that the oxygen tank was empty.
The complainant f u r t h e r a l l e g e s t h a t the ambulance took an i n d i r e c t
route to the h o s p i t a l . The p a t i e n t u l t i m a t e l y died.
0 A funeral home d i r e c t o r a l l e g e d t h a t an ambulance transported an
autopsied, leaking body i n f e c t e d w i t h the AIDS v i r u s to the mortuary
using l i t t l e or no precaution i n the handling of the b o d i l y f l u i d s
and blood. The complainant stated t h a t no d i s i n f e c t a n t was used to
clean the ambulance cot which c a r r i e d the body, and t h a t the
ambulance was used for transport immediately t h e r e a f t e r without
adequate safeguards taken to p r o t e c t e i t h e r personnel or the next
p a t i e n t being t r a n s p o r t e d .
0 Another complaint a l l e g e d t h a t ambulance personnel d i d not properly
t r e a t a fourteen- year- old g i r l who had been h i t by a dump t r u c k .
EMTs r e p o r t e d l y f a i l e d to s t a b i l i z e the p a t i e n t ' s f r a c t u r e s or
properly t r e a t her f o r shock.
0 A local f i r e department alleged t h a t an ambulance company was
operating i t s ambulances for two months w i t h empty oxygen c y l i n d e r s .
0 One provider a l l e g e d l y objected t o t r a n s p o r t i n g a p a t i e n t without
p r i o r v e r i f i c a t i o n of insurance coverage, i n defiance of the State
requirement to t r a n s p o r t a l l p a t i e n t s regardless o f t h e i r abi l i t y to
pay. According t o the complainant, the provider also s t a t e d t h a t the
p a t i e n t d i d not appear serious enough to warrant ambulance
t r a n s p o r t . Proof of insurance was provided and the p a t i e n t was
eventually t r a n s p o r t e d . The p a t i e n t spent four days i n i n t e n s i v e
care upon a r r i v a l a t the hospi t a t , and was given a 50 percent chance
of s u r v i v a l .
Despite the s e v e r i t y of these a l l e g a t i o n s - i n c l u d i n g cases of death and
deadly disease - four of the s i x had received no a c t i o n . I n v e s t i g a t i o n s
concerning the other two were inadequate. I n one of these two instances,
the respondent was n o t i n t e r v i e w e d f o r e i g h t months a f t e r the i n c i d e n t .
I n the other case, the respondent was not contacted f o r at lease two
months. Most important, however, DHS never took any formal a c t i o n to
resolve the complaints. Five of the s i x are s t i l l open.
DHS Has Not Acted on Repeated Complaints
Aaainst Ambulance Comoanies
The Department has also f a i l e d t o act i n cases where ambulance companies
have accumulated repeated complaints. The f o l l o w i n g case examples
i l l u s t r a t e t h i s problem:
a COMPANY 1 - During a 24 month period from July 1 , 1986 to June 30,
1988, one ambulance company accumulated 14 complaints. Several of
those complaints represent concerns for pub I i c health and safety
i n v o l v i n g both the ambulance company's operations and management, and
personnel's s k i l l s and medical judgment. The complaints involve
patient death, inappropriate patient care and handling, and running
ambulance operations i n an area for which the company did not have a
C e r t i f i c a t e of Necessity. To date DHS has taken no action against
t h i s ambulance company, according to both the DHS f i les and
interviews w i t h OEMs o f f i c i a l s .
0 COMPANY 2 - Since at least A p r i l 1987, another ambulance company
has reportedly received numerous complaints i n f i v e general areas
including: p a t i e n t treatment, vehicular c o n d i t i o n , lack of necessary
medical equipment on the v e h i c l e s , and i n s u f f i c i e n t as well as
u n c e r t i f i e d s t a f f for transports. Although many of these
d e f i c i e n c i e s could p o t e n t i a l l y endanger p u b l i c health and s a f e t y ,
DHS' only enforcement a c t i o n has been to request t h a t a vehicle be
taken out of service.
Performance on A l l
Complaints I s Simi l a r
The pattern of i n a c t i o n i l l u s t r a t e d i n the above case examples i s not
unusual. Regardless o f s e v e r i t y o r other f a c t o r s , complaint a c t i o n was
generally absent. Of the 157 complaints we could document that DHS
received, 92 ( 59 percent) were not i n v e s t i g a t e d . ( " Of the remaining
65 that were investigated, 44 received no f u r t h e r a c t i o n even though at
least f i v e of these were substantiated by DHS' i n v e s t i g a t i o n s . Only 42
complaints were ever closed and no enforcement actions were taken i n any
of these cases.
( ' 1 21 of the 92 complaints i n t h i s category were closed w i t h o u t i n v e s t i g a t i o n . For
some complaints, i n v e s t i g a t i o n i s not necessary.
DHS Reasons for Inaction
Are Not Sufficient
DHS has suggested several reasons why i t has not acted on complaints
against ambulance companies and EMTs. Some of the reasons may not be
v a l i d , although we agree that i n v e s t i g a t i v e t r a i n i n g i s needed. However,
underlying a l l other reasons f o r i n a c t i o n , DHS appears to lack an
aggressive enforcement philosophy.
Other duties have taken precedence - One reason that DHS has not acted
on complaints i s that the Department has stressed other p r i o r i t i e s at the
cost of enforcement. For example, the OEMs O f f i c e Chief stated that the
c e r t i f i c a t i o n process takes up the greatest amount of resources.
However, we question the wisdom of devoting disproportionate a t t e n t i o n to
c e r t i f y i n g personnel when DHS i s not addressing the p o t e n t i a l enforcement
problems stemming from those already i n the f i e l d .
Furthermore, DHS' current plans to attend to complaints appear r e l a t i v e l y
i n s i g n i f i c a n t . During the next two f i s c a l years, DHS proposes to more
than double i t s OEMs s t a f f size - adding 25 new FTE p o s i t i o n s to i t s
current 21 for a t o t a l of 46 FTEs by the end of Fiscal Year
1989- 90."' However, DHS plans to devote only two FTEs to complaint
investigations.
Quality- of- Care Rules - Although DHS has taken the p o s i t i o n that i t
needs quality- of- care standards before i t can e f f e c t i v e l y d i s c i p l i n e
EMTs, a u t h o r i t i e s say current statutes are s u f f i c i e n t for DHS to a c t .
A. R. S. 536- 2202 . A. 3 requi res the Di rector to "[ aladopt standards and
c r i t e r i a which p e r t a i n to the qua1 i t y of emergency care . . . " , and OEMs
management has determined that i t cannot act e f f e c t i v e l y without these
r u l e s . However, a L e g i s l a t i v e Council representative s t a t e d t h a t c u r r e n t
statutes provide DHS w i t h s u f f i c i e n t a u t h o r i t y t o a c t i n cases i n v o l v i n g
improper treatment or unprofessional conduct by EMTs. Furthermore,
although an Assistant Attorney General assigned to the O f f i c e of
Emergency Medical Services advises that these rules be implemented to
b e t t e r equip DHS to a c t , she agrees that DHS has the s t a t u t o r y a u t h o r i t y
to d i s c i p l i n e EMTs without the r u l e s .
( I ) A l l 25 new p o s i t i o n s w i l l i n i t i a l l y be funded through t h e EMS Operating Fund.
14
Lack o f intermediate sanctions - DHS has s t a t e d t h a t the lack of
s t a t u t o r i l y - a u t h o r i z e d intermediate sanctions has f u r t h e r prevented i t
from taking act i o n against EMTs and ambu lance companies, but according to
the Assistant Attorney General assigned to OEMs i t can act without these
sanctions. DHS s t a t u t e s do not authorize, for example, a d m i n i s t r a t i v e
penalties as do the statutes of several other regulatory agencies. ( 1 )
However, although such penalties may be advisable, i t i s d i f f i c u l t to
know t h e i r importance since DHS has not even investigated most complaints
nor attempted to take a c t i o n . Besides, the absence of sanctions does not
prevent DHS from a c t i n g . DHS c u r r e n t l y has s t a t u t o r y a u t h o r i t y to
censure EMTs who v i o l a t e s t a t u t e s o r r u l e s , yet the Department has issued
no l e t t e r s of censure i n the past two years. Also, the Assistant
Attorney General indicated she feels DHS can use some form of l i m i t e d
suspension of ambulance companies' a u t h o r i t y to operate.
DHS has not provided i n v e s t i g a t i v e t r a i n i n g for s t a f f - DHS has not
provided i n v e s t i g a t i v e t r a i n i n g for i t s s t a f f even though management has
been aware of the need. DHS has chosen i n the past to use i t s regular
s t a f f to conduct i n v e s t i g a t i o n s , instead of designating special
i n v e s t i g a t i v e s t a f f . However, while t h i s can be a wo- rkable arrangement,
DHS has not provided i t s regular s t a f f w i t h p e r t i n e n t i n v e s t i g a t i v e
t r a i n i n g . Management t o l d us of only one e f f o r t to seek t r a i n i n g for i t s
s t a f f , which a l l e g e d l y f a i l e d for reasons beyond DHS' c o n t r o l . In
a d d i t i o n , the O f f i c e Chief said he had conducted a search i n State
government for information on complaint i n v e s t i g a t i o n procedures, but he
admitted h i s search had been l i m i t e d . He apparently d i d not contact
most of the S t a t e r e g u l a t o r y boards, some of which have been conducting
complaint i n v e s t i g a t i o n s f o r many years.
( 1 Six Arizona health regulatory boards we reviewed have s t a t u t o r y p r o v i s i o n f o r
a d m i n i s t r a t i v e p e n a l t i e s . We reviewed the s t a t u t e s governing Arizona o p t o m e t r i s t s ,
nurses, c h i r o p r a c t o r s , osteopaths, pharmacists, and medical doctors. The penalty
amounts authorized f o r these boards range from $ 300 to $ 10,000 per v i o l a t i o n
($ 10,000 being t h e maximum penalty t h a t can be applied against medical doctors).
I n a d d i t i o n , we contacted the EMS agencies i n the states o f Washington, Oregon,
Colorado and New Mexico. O f these, however, only Washington allowed f o r
a d m i n i s t r a t i v e penal t i e s against EMTs of $ 100 per day per v i o l a t i o n .
As a r e s u l t , the invest i g a t ions that have been conducted have been
inadequate. The Assistant Attorney General assigned to OEMs reported she
returned one complaint to DHS because she was given i n s u f f i c i e n t
informat ion. "' In a d d i t i o n , during our complaint f i l e review we
found several cases i n which i n v e s t i g a t i o n s were begun but not c a r r i e d to
t h e i r l o g i c a l concIusion. I n some of these cases, the respondent was
never even contacted.
Further i n d i c a t i o n o f enforcement's low p r i o r i t y - Underlying a1 I other
reasons f o r i n a c t i o n , DHS appears to lack an aggressive enforcement
philosophy. This conclusion i s supported by i n t r a - o f f i c e communication
and s t a f f comments. For example, one employee wrote a memorandum on May
4, 1988 expressing concern that the O f f i c e had not acted against a
company that was v i o l a t i n g i t s a u t h o r i t y . The memorandum stated, i n p a r t :
" From a1 I i n d i c a t i o n s , there i s c l e a r , convincing, and s u b s t a n t i a l
evidence of [ v i o l a t i o n by ambulance company]. I f we do not take
dec i s i ve act i on agai ns t [ ambu l ance company], then the Department/
Division/ EMS O f f i c e has ( 1) ignored a serious prob! em, ( 2 ) acquiesced
to what [ ambulance company] i s doing, ( 3) opened the door to s i m i l a r
problems/ complaints, ( 4) made i t d i f f i c u l t for us to enforce simi tar
problems/ complaints i n v o l v i n g other ambulance services, and ( 5)
ignored i t s regulatory enforcement r o l e . "
DHS should enforce i t s regulatory statutes and r u l e s . To accomplish t h i s ,
DHS should:
1. Give complaint i n v e s t i g a t i o n and follow- up higher p r i o r i t y ,
rearranging other p r i o r i t i e s i f necessary.
2. Expedite complaint i n v e s t i g a t i o n s , providing s t a f f t r a i n i n g i f
necessary.
( ' ) The Assistant Attorney General stated she has been given only two complaints t o
review for formal a c t i o n during her three years as OEMs' l e g a l r e p r e s e n t a t i v e . As
mentioned, one was returned t o OEMs f o r f u r t h e r i n v e s t i g a t i o n , and the other was
hand1 ed by OEMs informal 1 y .
FINDING Ill
OEMs NEEDS TO INSTITUTE A MANDATORY REPORTING
REQUIREMENT FOR ALL INSTANCES OF EMT
INCOMPETENCE AND UNPROFESSIONAL CONDUCT
A mandatory r e p o r t i n g requi rement i s needed to ensure that OEMs i s aware
of a l l incidents of EMT incompetence and unprofessional conduct which
could threaten pub1 i c h e a l t h and s a f e t y . C u r r e n t l y , most base h o s p i t a l s
d i s c i p l i n e EMTs under t h e i r medical c o n t r o l without OEMs involvement.
However, other h e a l t h r e g u l a t o r y boards i n Arizona have such a
requirement to increase t h e i r a b i l i t y to review, d i s c i p l i n e and make a
matter of p u b l i c record cases of alleged incompetence or unprofessional
conduct .
Providers Do Not C u r r e n t l y
Report To OEMS
Most base h o s p i t a l s have n o t reported i n c i d e n t s of EMT incompetence and
unprofessional conduct to OEMS. Instead, the h o s p i t a l s resolve these
incidents i n t e r n a l l y through t h e i r own mechanisms, yet o n l y OEMs i s
empowered to take a c t i o n against an EMT's c e r t i f i c a t i o n .
I n t e r n a l r e s o l u t i o n - Seven of the twelve base h o s p i t a l s " ' we
contacted have not reported i n c i d e n t s of p o t e n t i a l l y dangerous EMT
behavior to OEMS. Instead, most i n c i d e n t s a r e resolved i n t e r n a l l y through
informal discussion between the base h o s p i t a l paramedic coordinator ( who
monitors a l l EMT a c t i v i t i e s ) and the EMT involved. These i n c i d e n t s may
occur several times a month, but are u s u a l l y not of a serious nature.
Typical examples may be f a i l u r e to f o l l o w communication p r o t o c o l s , or not
properly completing relevant paperwork. The EMTs' employer or the base
h o s p i t a l medical d i r e c t o r can be involved i f the matter i s s e r i o u s , or i f
r e s o l u t i o n i s not reached i n f o r m a l l y .
Most paramedic c o o r d i n a t o r s s t a t e d t h a t they may only take formal
d i s c i p l i n a r y a c t i o n a few times per year. A common cause o f d i s c i p l i n a r y
a c t i o n i s when a p a t i e n t ' s c o n d i t i o n i s improperly assessed i n the f i e l d
( ) There are current1 y 41 advanced 1 i f e support base hospi t a l s Statewide.
17
and arrives at the h o s p i t a l i n much more serious condition than reported
by the EMT. D i s c i p l i n a r y a c t i o n can also r e s u l t when the EMT has an
unprofessional a t t i t u d e and refuses a d d i t i o n a l t r a i n i n g to improve
d e f i c i e n t s k i l l s . Even though these d e f i c i e n c i e s may p o t e n t i a l l y endanger
the p a t i e n t , h o s p i t a l s s t i l l prefer to r e l y on i n t e r n a l r e s o l u t i o n
procedures. Also, some paramedic coordinators feel that OEMs has an
unclear regulatory r o l e .
OEMS a u t h o r i t y - Since there i s no reporting requirement, DHS may not
be aware of a l l incidents where formal d i s c i p l i n a r y a c t i o n has been taken
by a h o s p i t a l against an EMT. As a r e s u l t , DHS may not be able to take
action against the EMT's c e r t i f i c a t i o n to keep the EMT from p r a c t i c i n g .
Both IEMTs and paramedics must have a base h o s p i t a l w i l l i n g to supervise
t h e i r work ( provide medical c o n t r o l ) . According to OEMs s t a f f , the most
severe d i s c i p l i n a r y a c t i o n a h o s p i t a l can take i s to remove an EMT's
medical control since only DHS can suspend or revoke thei r
c e r t i f i c a t i o n . Consequently, i t i s possible that an EMT who has had
medical control withdrawn can r e e s t a b l i s h i t at another h o s p i t a l as long
as h i s c e r t i f i c a t i o n i s v a l i d . Most paramedic c o o r d i n a t o r s s t a t e d that
they must r e l y on an informal communication system where they contact a
new EMT's previous h o s p i t a l p r i o r to h i r i n g , but also agreed that t h i s i s
no guarantee that p o t e n t i a l l y dangerous EMTs w i l l be kept from p r a c t i c i n g .
Other Boards Have Mandatory
Reporting Requirement
There are several medical l i c e n s i n g boards i n Arizona which have
s t a t u t o r y provisions r e q u i r i n g t h a t i n c i d e n t s of incompetence and
unprofessional conduct be reported. I f OEMs were able to implement such
a requirement, i t could enforce i t through review of ambulance transport
records.
Relevant s t a t u t e s - The Board of Medical Examiners and the Board of
Osteopathic Examiners, through A. R. S 6332- 1451, subsection A and 32- 1855
subsection A , r e s p e c t i v e l y , require physicians and medical i n s t i t u t i o n s
and associations to report any instances of doctors or osteopathic
physicians displaying unprofessional conduct or incompetence, alleged or
otherwise to the Board. The Board of Nursing, the Board of Physical
Therapy Examiners, and the J o i n t Board on the Regulation of Physician's
Assistants also have s i m i l a r s t a t u t o r y p r o v i s i o n s .
Statutes for the Board of Medical Examiners, the Board of Nursing, and
the Board of Osteopathic Examiners each contain a provision which makes
i t an act of unprofessional conduct for a member of the profession to
f a i l to provide such information, and that i n s t i t u t i o n s which f a i l to
provide s h a l l be reported to t h e i r l i c e n s i n g agency. The r e p o r t i n g
statutes for each Board mentioned above also s t a t e that any person or
i n s t i t u t i o n p r o v i d i n g i n f o r m a t i o n i n good f a i t h s h a l l not be held l i a b l e
for an action for c i v i l damages as a r e s u l t .
Enforcement - I f OEMs were able to implement a r e p o r t i n g requirement, a
possible means of enforcement i s already a v a i l a b l e . Base h o s p i t a l
paramedic coordinators r o u t i n e l y review a l l ambulance transport records
to ensure that the EMTs provided adequate treatment and that recognized
procedures were f o l lowed. I t i s from t h i s review that problematic cases
are i d e n t i f i e d .
Although OEMs s t a f f c u r r e n t l y do review these records, t h i s may only
occur once every two years i n conjunction w i t h the review done p r i o r to
renewing the base h o s p i t a l ' s c e r t i f i c a t i o n . More frequent review of these
same records could ensure that these cases are reported.
RECOWENDATION
The Legislature should consider amending the OEMs s t a t u t e s to include a
provision that would require a l l medical f a c i l i t y and EMS personnel to
report a l l instances of EMT incompetence and unprofessional conduct to
OEMs .
FINDING IV
THE STATE EXAMINATION FOR BASIC EMERGENCY MEDICAL
TECHNICIANS HAS NOT BEEN VALIDATED AND IS
NOT ADEQUATELY SECURED
The State c e r t i f y i n g examination f o r Basic EMT's does not meet n a t i o n a l
standards governing t e s t development and a d m i n i s t r a t i o n . The examination
has not been v a l i d a t e d to insure that t e s t items cover the c r i t i c a l
knowledge and ski I I areas necessary f o r safe p r a c t i c e . Test
a d m i n i s t r a t i o n does not meet standards because the same version of the
exam i s repeatedly given and i s not adequately secured. DHS should
consider using a v a l i d a t e d n a t i o n a l t e s t which i s a v a i l a b l e .
Testing I s Intended To Insure Competence
The O f f i c e of Emergency Medical Services administers examinations to
emergency medical t e c h n i c i a n s b e f o r e i s s u i n g t e c h n i c i a n s c e r t i f i c a t e s to
work. The purpose of these examinations i s t o insure t h a t t e c h n i c i a n s
possess the knowledge and s k i l l s necessary f o r safe p r a c t i c e . As noted
i n Finding 1 1 , EMT's can cause serious harm t o p a t i e n t s when they do not
f o l low proper procedures or make know ledgeab l e decisions and judgments.
Adequate t e s t i n g of Basic EMT's i s e s p e c i a l l y important because these
personnel, u n l i k e IEMT's and Paramedics, are not subject t o supervision
( medical c o n t r o l ) by base h o s p i t a l medical s t a f f .
Basic EMT's, which comprise the largest number ( 6,635) of EMT's
p r a c t i c i n g i n the f i e l d , are the only level of EMT's which are tested
using a State rather than n a t i o n a l exam for i n i t i a l c e r t i f i c a t i o n . OEMs
a n t i c i p a t e s spending almost $ 41 ,000 i n f i s c a l year 1988- 89 to administer
t h i s exam. Intermediate and Paramedic level EMT's take b o t h a w r i t t e n
and p r a c t i c a l examination prepared by the National R e g i s t r y , a n a t i o n a l
o r g a n i z a t i o n which has developed EMT examinations i n accordance w i t h
n a t i o n a l standards.
EM1 Exam Has
Not Been Validated
DHS cannot adequately assure that the BEMT exam assesses knowledge and
s k i l l s needed for safe p r a c t i c e . S t a t e law mandates the development o f a
v a l i d a t e d t e s t i n g procedure, yet t h i s has not occurred. Because the exam
was not developed i n accordance w i t h n a t i o n a l standards, DHS lacks
evidence supporting t h e exam's v a l i d i t y .
- Sta te and National Standards - State law, through A. R. S. $ 36- 2204.2,
requires a v a l i d a t e d t e s t i n g procedure for a l l EMT c l a s s i f i c a t i o n s .
Standards f o r developing, v a l i d a t i n g , and a d m i n i s t e r i n g l i c e n s i n g or
c e r t i f y i n g examinations have been developed by a j o i n t committee of the
American Educational Research Association, American Psychological
Association, and the National Council on Measurement i n Education. These
standards are designed to assure that l i c e n s i n g or c e r t i f y i n g
examinations measure the c r i t i c a l or important knowledge, s k i l l s , or
a b i l i t i e s needed to perform a job at a minimum level of competence deemed
necessary for the p u b l i c ' s p r o t e c t i o n .
Proper development of a c e r t i f y i n g examination requires a task analysis
p r i o r t o t e s t v a l i d a t i o n . Task analysis i d e n t i f i e s the c r i t i c a l s k i l l s
that characterize a given occupation. Through task a n a l y s i s , knowledge
and s k i l l s important to p u b l i c p r o t e c t i o n can be i d e n t i f i e d and t e s t
developers can determine exam content, the number of questions needed i n
a p a r t i c u l a r area and the r e l a t i v e importance or weight of questions or
groups of questions.
Examinations then need to be v a l i d a t e d t o determine i f , i n f a c t , they
adequately address and measure the c r i t i c a l areas i d e n t i f i e d by a task
a n a l y s i s . According to the American Psychological A s s o c i a t i o n , v a l i d i t y
i s the most important consideration i n evaluating a t e s t . An examination
which has not been properly v a l i d a t e d t o determine i f i t adequately
measures c r i t i c a l knowledge and s k i l l s could be subject to legal
challenge.
BEMT exam remains out of compliance - Although OEMs management
acknowledges the mandate f o r v a l i d a t e d t e s t i n g procedures, the Basic EMT
exam remains out o f s t a t u t o r y compliance. A task analysis was not done
during the development process, and exam content was not properly
validated. Instead, the exam was developed based on questions derived
from the U. S. Department of Transportation's Standard Curriculum for
Emergency Medical Technicians, as well as suggestions from t r a i n i n g
program coordinators and OEMs s t a f f . This f a i l u r e to follow development
standards would put DHS i n a weak p o s i t i o n to defend theexam's
v a l i d i t y . ( 1
A DHS i n t e r n who reviewed the exam i n A p r i l of 1986 found numerous
question d e f i c i e n c i e s . This analysis was due to concern about the high
f a i l u r e rate on a version of the exam which had been i n use for f i v e
months. Each question was reviewed for i t s a p p l i c a b i l i t y to the learning
objectives i n the BEMT course curriculum. This review recommended that
changes be made on 53 of the exam's 150 questions. These recommendations
ranged from simple wording changes t o d e l e t i n g or r e w r i t i n g whole
questions. Per OEMs management, the only changes made were on the ten
questions i d e n t i f i e d as having m u l t i p l e correct or wrong answers. The
other 43 recommended changes were not reviewed or implemented due to a
s t a f f i n g shortage at the time.
Exam I s Not Adequately
Secured
The BEMT exam also lacks proper a d m i n i s t r a t i o n and s e c u r i t y . The same
version of the exam i s administered i n each t e s t i n g session, and c o n t r o l s
over exam a c c e s s i b i l i t y and the a d m i n i s t r a t i o n process have been weak.
The current version of the BEMT exam was implemented i n December of 1985,
and the questions have not been changed since. Many applicants do not
( ' 1 The BEMT exam i s not the only exam given by the Department which has not been
v a l i d a t e d . DHS administers a pharmacology exam t o IEMT's as a supplement t o the
National Registry exam. Also, since t h e National R e g i s t r y Exam i s only f o r i n i t i a l
c e r t i f i c a t i o n , OEMs has developed i t s own r e c e r t i f i c a t i o n exam f o r IEMTS. Neither
exam was developed and v a l i d a t e d i n accordance w i t h standards.
pass on the f i r s t attempt, and each retake allows them a d d i t i o n a l
o p p o r t u n i t i e s to see the same exam questions. According to OEMs s t a f f ,
one applicant took the exam seven times before passing. Also, the exam
i s easy to memorize, since i t i s 150 m u l t i p l e choice questions, and
a p p l i c a n t s can take the exam numerous times. The OEMs O f f i c e Chief c i t e d
one instance of a t r a i n i n g program i n s t r u c t o r r e c o n s t r u c t i n g the exam
from questions memorized by students. The i n s t r u c t o r could then cover
these questions i n f u t u r e classes.
Also, exam s e c u r i t y i s weak. Exam copies stored i n the OEMs o f f i c e are
not locked, and OEMs s t a f f have s t a t e d t h a t anyone could o b t a i n access to
a copy of the exam. According to OEMs s t a f f , a t least one provider has a
copy of the exam. This was determined when OEMs s t a f f i n d i r e c t l y
obtained a copy of a p r a c t i c e exam which a c t u a l l y was an a l t e r e d version
o f the State exam.
, Compliance w i t h i n t e r n a l l y developed exam a d m i n i s t r a t i o n procedures has
also been inadequate. U n t i l July 1988 regional council s t a f f assisted
OEMS i n a d m i n i s t e r i n g t h e exam. OEMs s t a f f c i t e d some instances where
proper procedures were n o t f o l l o w e d , however. For example, one procedure
states that only a p p l i c a n t s w i t h an a u t h o r i z a t i o n l e t t e r from DHS w i l l be
allowed to take the exam, yet one a p p l i c a n t under c r i m i n a l i n v e s t i g a t i o n
by DHS was allowed to t e s t without a u t h o r i z a t i o n . According to OEMs
management, exams are c u r r e n t l y only administered by DHS s t a f f , so many
of these c o n t r o l problems should be e l i m i n a t e d .
National Exam Should
Be Considered
OEMs should consider u s i n g a v a l i d a t e d Basic EMT w r i t t e n exam from
another source such as the National R e g i s t r y . This exam i s properly
developed and v a l i d a t e d , and has good s e c u r i t y because d i f f e r e n t versions
a r e a v a i l a b l e . OEMs should also consider implementing a fee schedule to
cover exam a d m i n i s t r a t i v e costs.
The National Registry exam i s a v i a b l e o p t i o n because i t i s properly
developed and v a l i d a t e d and i s presently a v a i l a b l e f o r use. I t would
also enable OEMs to f u l f i l l i t s s t a t u t o r y mandate to p r o v i d e a v a l i d a t e d
t e s t i n g mechanism. This exam i s an e f f e c t i v e measure of Basic EMT
competence, because i t i s based on the U. S. Department of T r a n s p o r t a t i o n
curriculum(') f o r Basic EMTs which i s used by 48 states i n c l u d i n g
Ar i zona.
A main reason t h i s exam has not been used p r e v i o u s l y i s t h a t EMS
providers i n Arizona have opposed the $ 15 fee. Some large EMS providers
have stated that DHS should incur a l l c o s t s a s s o c i a t e d w i t h the EMT
c e r t i f i c a t i o n process. They f e e l t h a t the i m p o s i t i o n of a fee i s
u n j u s t i f i e d . However, taxpayer subsidies for i n d i v i d u a l s ' c e r t i f i c a t i o n s
may be inappropriate. EMS p r o v i d e r s o r t h e i r employees should bear the
costs of c e r t i f i c a t i o n . This i s the usual p r a c t i c e i n almost every other
instance i n v o l v i n g l i c e n s i n g / c e r t i f i c a t i o n of p r o f e s s i o n a l s .
I n implementing a fee f o r taking the National R e g i s t r y exam, OEMs should
e s t a b l i s h a fee at least high enough to cover the approximate $ 6,000
annual cost of a d m i n i s t e r i n g the w r i t t e n p o r t i o n o f the c e r t i f i c a t i o n
exam. ") Although a p p l i c a n t s pay a $ 15 fee, t h i s amount i s retained
by the R e g i s t r y . No reimbursement i s made to the s t a t e s o f f e r i n g the
exam for a d m i n i s t r a t i v e costs. According to the OEMS O f f i c e C h i e f , the
only way the National Registry exam would be a f e a s i b l e o p t i o n would be
i f OEMs d i d not incur any a d m i n i s t r a t i v e expense.
Reconmendations
1. The L e g i s l a t u r e should provide DHS w i t h s t a t u t o r y a u t h o r i t y t o impose
fees adequate to recover costs of examining and c e r t i f y i n g EMT
a p p l i c a n t s .
2. DHS should adopt the National R e g i s t r y ' s examination f o r Basic EMT's.
( ' ) The U. S. Department of Transportation ( DOT), through the National Highway T r a f f i c
Safety A d m i n i s t r a t i o n , developed EMT t r a i n i n g courses responsive t o the standards
established by the Highway Safety Act of 1966. These courses were intended t o
provide national guide1 ines f o r EMT t r a i n i n g . C u r r e n t l y , t h e DOT curriculum f o r
Basic EMTs i s used by 48 states, i n c l u d i n g Arizona.
(') According t o OEMs s t a f f , there are approximate1 y 2,000 applicants annually f o r
i n i t i a l c e r t i f i c a t i o n , f o r a per- capi t a cost of s l i g h t 1 y over $ 3.00. National
Registry also r e q u i r e s a p r a c t i c a l exam f o r Basic c e r t i f i c a t i o n and OEMs should
consider t h i s cost as w e l l , though no cost f i g u r e s are c u r r e n t l y a v a i l a b l e .
3. DHS should develop a fee schedule to cover the cost of t e s t
a d m i n i s t r a t i o n .
4. DHS should take steps to insure secure storage for exam copies stored
i n the OEMs o f f i c e and should also insure t h a t s e c u r i t y procedures
are followed when exams are administered i n the f i e l d .
AREAS FOR FURTHER AUDIT WORK
Would a l t e r n a t i v e s t o the current C e r t i f i c a t e o f Necessity ( CON) process
be more e f f e c t i v e ?
Currently, i n order t o p r o v i d e ambulance service an ambulance company
must obtain a C e r t i f i c a t e o f Necessity ( CON) from DHS. The CON
establishes the p r o v i d e r ' s operation area, allowable rates and charges,
and response times. A CON can be, and often i s , given to more than one
provider for coverage of one area. For example, DHS has granted CONS to
two providers i n the Tucson area and eight i n the Phoenix area. In
addition, a CON i s renewed p e r i o d i c a l l y , and no competition i s introduced
i n t o the process.
I n some instances, m u n i c i p a l i t i e s have contracted for a l l ambulance
service w i t h one of the companies which has a CON for the area. For
example, the C i t y of Tempe recently contracted w i t h one of i t s
State- authorized providers for a l l emergency transports. The C i t y o f
Phoenix has a s i m i l a r s i t u a t i o n , wherein i t s own f i r e department handles
over 90 percent of the emergency transports and the other
State- authorized providers p r i m a r i l y handle the nonemergency ambulance
t r a f f i c .
Further, some local systems encourage competition. For example, the
c i t i e s of San Diego, C a l i f o r n i a and F t . Wayne, Indiana and at least one
county i n F l o r i d a obtain t h e i r ambulance service through a bidding
process.
Further audit work i s needed to determine whether i t i s desirable and
feasible to a l l o w l o c a l governments to regulate at least the economic
p o r t i o n o f ambulance s e r v i c e , and whether competition i n the process
would be b e n e f i c i a l .
Should the State require that Basic EMTs operate under medical c o n t r o l ?
Basic EMTs are not required to be supervised by base h o s p i t a l physicians,
as are Intermediate EMTs and Paramedics. Several base h o s p i t a l emergency
s t a f f expressed concern over t h i s lack of medical supervision. According
to hospital as well as OEMs s t a f f , the need may be greater i n r u r a l areas
where Basic EMTs provide most s f the emergency treatment. Thus, i n rural
areas, people are being treated by entry- level EMTs who are not closely
superv i sed .
However, although base h o s p i t a l s t a f f were i n favor of medical control
over Basic EMTs, OEMs s t a f f stated that base h o s p i t a l s may be hesitant to
provide the c o n t r o l . Currently there are more than 6,000 Basic EMTs
Statewide, and the h o s p i t a l s reportedly may not want to take on t h i s
large a d d i t i o n a l workload.
Further audit work i s needed to determine whether medical c o n t r o l f o r
entry- level EMTs i s worth the a d d i t i o n a l resources i t would require to
provide the supervision. I f deemed necessary, f u r t h e r work would also be
needed to determine how the supervision should be c a r r i e d out.
Should DHS audit ambulance companies' records p r i o r t o granting r a t e
i nc rease22
In the past four years, DHS has granted 46 rate increases to ambulance
companies. Companies can receive increases i n any one of three
categories. Twenty- one of these companies received increases which
exceeded ten percent, while 14 of these companies received increases
which exceeded 50 percent. ( DHS has explained that even the large rate
increases can be j u s t i f i e d , depending upon the f i n a n c i a l condition of the
ambulance company and c h a r a c t e r i s t i c s of the community i n which i t
operates.) However, DHS does not audit the records t h a t p r o v i d e r s submit
to support the rate requests. As a r e s u l t , although some of the
increases may he appropriate, DHS may be allowing the ambulance companies
to charge consumers more than they should have to pay for ambulance
transport. The Arizona Corporation Commission ( ACC) audits a number of
u t i l i t y companies p r i o r to granting rate increases. In a d d i t i o n , at
least one other s t a t e ' s EMS o f f i c e audits some ambulance companies p r i o r
to increasing t h e i r rates. Further audit work i s needed to determine
whether a u d i t i n g ambulance companies' records i s needed and would be
b e n e f i c i a l .
Are ambulance inspections s u f f i c i e n t and adequate?
Currently DHS annually inspects 313 ambulances as part o f the
r e g i s t r a t i o n process. During our review, we noted some instances where
DHS conducted inspections a f t e r the u n i t ' s r e g i s t r a t i o n renewal date had
passed. DHS would simply allow the r e g i s t r a t i o n t o remain i n e f f e c t
u n t i l an inspection could be done. A d d i t i o n a l a u d i t work i s needed to
determine how and to what extent the ambulance inspection program should
be improved. Staggering r e g i s t r a t i o n renewals may be a workable
a l t e r n a t i v e .
I n a d d i t i o n , EMS may not be inspecting ambulances as thoroughly as do
some other s t a t e s . DHS inspectors check to make sure that each ambulance
has the required medical equipment on board, and t h a t l i g h t s , s i rens and
b a t t e r i e s are working. However, u n l i k e other s t a t e s , Arizona does not
thoroughly inspect ambulances for proper maintenance, nor does i t
r o u t i n e l y check the o p e r a b i l i t y of medical equipment kept on the
ambulances. A t l e a s t t h r e e o t h e r states provide maintenance inspections
through t h e i r Department of Motor Vehicles, which apparently have the
maintenance inspection equipment. Also, a t least one s t a t e inspects the
medical equipment f o r o p e r a b i l i t y . A d d i t i o n a l a u d i t work i s needed to
determine whether t h e i n s p e c t i o n program should be expanded to include
maintenance and medical equipment, who should conduct the v e h i c l e
maintenance inspections, and costs of any a d d i t i o n a l r e s p o n s i b i l i t i e s .
Is testing for recertification necessary for the Basic and Intermediate
EMT levels?
The current Rules and R e g u l a t i ~ n s require t h a t BEMTs and IEMTs pass an
exam to be recert i f ied. Paramedics are not requi red to t e s t to
recert i f y . Instead, they must only meet continuing education
requirements, have current c e r t i f i c a t i o n i n advanced cardiac l i f e
support, and o b t a i n a L e t t e r of Recommendation from t h e i r medical
d i r e c t o r . One reason t h a t paramedics are not required to t e s t i s that
they are under medical c o n t r o l by t h e i r base h o s p i t a l , so the q u a l i t y o f
t h e i r work i s constantly being reviewed. However, IEMTs are also under
medical c o n t r o l and they are required to t e s t . Also, DHS administers
approximately 3,000 r e c e r t i f i c a t i o n exams to BEMTs, while 28 other s t a t e s
do not require r e c e r t i f i c a t i o n t e s t i n g . Also, the National R e g i s t r y o n l y
requires continuing education for r e c e r t i f i c a t i o n a t t h e Basic l e v e l .
Further audit work i s needed to determine the e f f e c t i v e n e s s of
r e c e r t i f i c a t i o n t e s t i n g for BEMTs and IEMTs.
. - " a&-> ARIZONA DEPARTMENT OF HEALTH SERVICES
Office of the Director
ROSE MOFFORD, GOVERNOR
TED WILLIAMS, DIRECTOR
December 16, 1988
Mr. Douglas R. Norton
Auditor General
Office of the Auditor General
2700 North Central Avenue, Suite 700
Phoenix, Arizona 85004
Dear Mr. Norton:
Attached please find the Department of Health Services' response
to the performance audit of the Office of Emergency Medical
Services.
As we stated in our response we must, unfortunately, agree with
your findings. We appreciate your including in the report an
acknowledgment of the work we have done since August, 1987 to
improve the Office of Emergency Medical Services, and we have
emphasized these efforts in our response. We wish to assure the
Auditor General and the public that the Department is committed to
continuing the work begun to strengthen this office to ensure safe,
affordable pre- hospital care.
We would like to thank the auditors for their cooperation during
the time of transition in this Office and for the courtesy shown
DHS staff during the course of the audit.
Sincerely, ,
Ted Williams
Director
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The Department of Health Servrces as An Equal Opportunzty Affirmative Actron Employer.
@ State Health Building 1740 West Adams Street Phoenix, Arizona 85007
- A . L d
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I i.* l- ARIZONA DEPARTMENT OF HEALTH SERVICES
Office of the Director
ROSE MOFFORD, GOVERNOR a TED WILLIAMS, DIRECTOR
Response to the Performance Audit on the
Office of Emergency Medical Services
Overview
In general, the Department agrees with the report's conclusions and
recommendations and has already taken action to put these
recommendations into effect. The Department would like to reiterate
the ~ uditor's statement that " DHS management has recognized the
need for improvement in the Office of Emergency Medical Services
and made several changes since August 1987." The Department would
like to make the following observations in support of that
statement and in response to the findings:
1. Most of the audit refers to a system that no longer
exists.
2. The Department began a major reorganization of the Office
of Emergency Medical Services ( EMS) in August, 1987
before the audit began in February, 1988. Emphasis needs
to be given to the effects of this reorganization and the
concerted efforts being made by this Office to address
and correct its own problems.
3. The Office of EMS has functioned from its inception
without adequate resources.
Background
In 1982, the Division of Emergency Medical Services was created by
statute and placed into the Department of Health Services. The new
~ ivision is a combination of EMS components from the Corporation
omm mission, the Department of public Safety and the Department of
Health services. In 1983 The ~ ivision of Emergency Medical
Services was combined with the Division of Health Resources,
creatingthe Division of Emergency Medical services and Health Care
Facilities.
In early 1987 there were three Offices performing EMS functions in
the ~ ivision: the offices of Ambulance Licensure, Training and
certification, and Regional Coordination.
The office of Ambulance Licensure was staffed by four professional
and two support staff. One person inspected and licensed all
The Department of Health Services is An Equal Opportunity Affirmative Action Employer.
State Health Building 1740 West Adams Street Phoenix, Arizona 85007
ambulances in the state; one person performed the Certificate of
Necessity ( CON) program; one handled all contracts and Requests
for Proposal; and one served as Office Chief.
The Office of Training and Certification was staffed by three
professional and four support staff who manually processed all
application materials, testing materials, and test scoring and
reporting.
The Office of Regional Coordination was established to promote
development of EMS systems as well as Itfill gaps." Four staff
members represented the four regions of the state and were housed
in those regions.
In June, 1987 the Department began to identify problems, to
identify statutorily mandated functions that were not being
performed, and to reorganize the Office into a unit that would look
at EMS as a system rather than as separate, unrelated functions.
In August, 1987 the new structure was put in place. It consists
of one Office of EMS with an Office Chief and three regional teams
composed of a member of each of the former functional Offices. It
took one full month for staff orientation to the new structure and
cross training for all functions.
It is critical to this response to note that the EMS Office has
been changed from three independent, isolated offices to a single
unified Office of EMS. This Office is dedicated to developing
a system of EMS that operates along a continuum from incident
detection to the delivery of safe and competent pre- hospital care.
The Office has gone from a philosophy of virtually no regulation
in 1986 to one of strong regulation in 1988.
The actions taken to facilitate this implementation are:
1. A computer network was designed, developed and
implemented to streamline this paper intensive Office.
The network is in place and the certification process is
almost fully automated, making the process more efficient
and effective. Other functions of the Office are now
being automated to improve efficiency and utilization of
professional staff time.
2. A policies and procedures manual covering all major tasks
within the Office has been completed.
3. An audit of the regional councils was performed and the
decision was made to utilize state staff to provide
support services. Replacement of regional staff will
avoid duplication, improve performance of state- wide
programs, provide accountability and reduce costs. State
personnel will assume the regional council support on
January 1, 1989.
4. A task/ time analysis was completed and service
measurements developed which created a basis for
determining staffing requirements and preparing the
annual budget. It has clearly demonstrated that the
Office was functioning with less than half the staff
required.
5. Central files have been created which facilitates uniform
record keeping by eliminating duplicate files within the
office and at the regional level.
Response to Statement of Findings
DHS8s Emersenc~ Medical Services Office
Has Lost and Mishandled Com~ laints
Unfortunately, Division and Office management must agree with this
finding. The following action has been taken:
The policy and procedure manual, including the section
on complaint handling, is complete and operational. An
accurate log book has been maintained since January,
1988. Logging of complaints is handled by one person and
distributed to the proper regional manager for
investigation and substantiation.
The following will be implemented:
1. A " Compliance Unitw is being developed within the office.
The hiring of an investigator has been approved and
recruitment has been initiated. The unit will be
expanded if hiring of additional personnel is approved
in the 1989- 1990 budget.
2. ~ utomation of the complaint tracking process is now being
developed and should be completed during March, 1989.
3. All professional EMS staff will be trained in
investigations and file preparation, using a program
designed by DHS and the Attorney General's Office. This
training will begin January, 1989. The Assistant
Attorney General assigned to represent the EMS office is
currently providing advice to staff on investigative
procedure and proper preparation of case files.
DHS has not acted on serious complaints
against Emersency Medical Technicians and
ambulance companies
The Department agrees with this finding. Furthermore, it agrees
with both recommendations and has taken steps to implement them.
The regional staff and two investigators should be adequate to
investigate the substantiated complaints.
OEMs needs to institute a mandatory reportinq
requirement for all instances of EMT incompetence and
unprofessional conduct
The Department agrees with this finding and also agrees that base
hospitals should be required to report incompetence and
unprofessional conduct to ADHS. ADHS will seek voluntary
compliance while proposing statutory authority to implement this
recommendation.
The state examination for Basic Emersency Medical
~ echnicians has not been validated and is not
adequately secured
The Department agrees with this finding. Corrective action has
already been taken.
The office of EMS has purchased a computer program that contains
1,000 questions covering the entire content of the basic EMT course
curriculum. The questions and answers are derived from material
in all major textbooks utilizing United States Department of
ran sport at ion ( DOT) knowledge and skill objectives. Because it
is a new program, the questions are now being validated. The
program allows the user to create numerous examinations and
variations by selecting questions from one section or from any
combination of sections. The Office of EMS will have the
capability to change the test as often as it is administered. The
computer program will be accessible only to selected personnel and,
therefore, much more secure. This exam will be in use by January,
1989.
The Department further concurs with the recommendation to use the
National Registry Exam, unless the recently purchased exam proves
to be superior. Legislation will be introduced to give ADHS the
authority to collect a fee for certification. The fee will be set
to cover the cost of the National Registry or the current exam as
well as the cost of administering the exam.
Areas Recommended for Further Audit
1. Would alternatives to the current Certificate of Necessity
( CON) Drocess be more effective?
The Department does not believe this area needs further audit.
2. Should the State rewire that Basic EMTs o~ erateu nder medical
control?
The Department takes the position that all EMTs who provide
direct patient pre- hospital care should be under medical
control. This has been discussed by the EMS Council and will
be studied at length by the EMS Medical Director and the
~ edical Standards Committee of the EMS Council in the coming
year.
3. Should DHS audit ambulance com~ anies'
records prior to srantins rate increases?
This statement contains some misleading misinformation that
should be clarified before any recommendation can be made
regarding further audit work. The audit states that DHS
granted rate increases to 46 ambulance companies, and that of
this 46, " 14 of these companies received increases which
exceeded 50 percent." The report should also show that:
Four companies were run by local governments that
increased rates so that a greater portion of the cost of
providing ambulance service is paid for by those
utilizing the service.
One company asked for a rate increase because a
substantial subsidy had been withdrawn and even with the
rate increase the company went out of business.
Three companies were sustaining substantial operating
losses with rates set initially. These rates were set
on projected data, and the increase was based on actual
data.
Two ambulance companies went out of business even with
substantial rate increases.
One company received the rates of a defunct company and
applied for new rates.
Three companies were non- profit corporations ( volunteer)
that were established based upon initial revenue requests
that later proved to be inadequate.
Of these 14 requests, all were justified. Through the annual
financial reporting process, the Department can review actual
operating data and adjust the rates accordingly. It should
be noted that there are situations in which auditing is
needed. Additional staff have been requested in the FY 89- 90
budget to perform this audit function.
4. Are ambulance inspections sufficient and adewate?
The Department believes that ambulance inspections are
sufficient and adequate except for inspection of the
mechanical aspects of the vehicle.
The Department currently conducts inspections for health and
safety on 76 ambulance services and registers/ re- registers 320
ambulances annually, The Office of EMS has developed a
computer ambulance re- registration program which generates a
re- registration application to each ambulance company 60 days
prior to the expiration of the license. The provider is
required to identify the location of the vehicle and submit
his request for re- registration thirty days prior to the
expiration date of the registration of the vehicle to be
inspected.
An ambulance inspection handbook, as well as policies and
procedures to assist the inspectors in providing a more
thorough and consistent inspection, has been developed and
is operational.
Although current forms do not reflect that inspectors check
the operation of medical equipment and note evidence of poor
maintenance, new check lists, in preparation, will more
accurately reflect the actual inspection process.
The Department agrees that maintenance inspections of the
mechanical aspects of the vehicle should be done. If the
Department of Motor Vehicles cannot perform this service, as
recommended by the auditors, the other alternative would be
to have the Office of EMS assume this responsibility. To
adequately do this, maintenance facilities would need to be
provided around the state and mechanics trained to do the
mechanical inspections of ambulances.
5. Is testinq for recertification necessary
for the Basic and Intermediate EMT levels?
The Department takes the position that recertification exams
are necessary for the basic and intermediate EMT levels.
At the present time, the EMS Council, through its Education
committee, is in the process of developing standards for the
recertification of all levels of EMTs. The alternatives being
considered are: 1) testing only those EMTs not under medical
direction, and 2) testing all levels every two years.
Summary
The Department agrees with the findings and recommendations of this
report and wishes to reiterate that it has taken action to correct
the problems. While it is true that not all the problems have been
eliminated, the report justifiably reflects that the Department
recognized a need for change and has taken steps to rectify the
problems. These steps included hiring a new Assistant Director,
reorganizing the Office to consolidate three separate Offices and
appointing an Office Chief to be responsible for EMS. The
Department developed and implemented new policies and procedures
for a central filing system, designed and implemented a computer
network system for the certification process which is now
approximately 75% complete, and is designing an automated
complaint tracking system. The Department performed financial
audits of the regional councils amd replaced regional council staff
with state staff in order to eliminate duplication and reduce
expenses. The Department will open offices in Flagstaff and Havasu
in January, 1989 to better serve those regions. Department
management designed training programs on investigation and case
file preparation and worked with the Assistant Attorney General and
the Office of Staff Development and Training to have the program
ready for presentation in early January, 1989. Staff transitioned
from an Office doing paper reviews to an Office that is in the
ggfieldgdgo ing on- site inspections and follow- ups. Finally, the
staff now functions as a team. These accomplishments were not
made overnight nor without trauma. It was, and continues to be,
a difficult project but one to which the Department is fully
dedicated.