ii

Rural and Frontier EMS 

Agenda for the Future: 

A Service Chief’s Guide to Creating 

Community Support of Excellence in EMS

 

U.S. Department of Health and Human Services 

Health Resources and Services Administration 

Office of Rural Health Policy 
 iii

This document was prepared under HRSA contract # 250-03-0022, U.S. Department of Health 

and Human Services, Health Resources and Services Administration, Office of Rural Health 

Policy. 
Contents

Foreword................................................................................................................................v 

Introduction............................................................................................................................1 

What is the Rural and Frontier EMS Agenda for the Future? ...................................1 

Community Assessment and Planning...................................................................................5 

Introduction and Background ....................................................................................5 

Key Recommendations from the Rural & Frontier EMS Agenda for the Future .....6 

Specific Tasks ............................................................................................................6 

Integration and Regionalization.............................................................................................7 

Introduction and Background ....................................................................................7 

Key Recommendations from the Rural & Frontier EMS Agenda for the Future .....9 

Specific Tasks ............................................................................................................10 

Quality and Performance Improvement.................................................................................11 

Introduction and Background ....................................................................................11 

Resources for Quality Improvement Project Development.......................................13 

Key Recommendations from the Rural & Frontier EMS Agenda for the Future .....14 

Specific Tasks ............................................................................................................14 

Conclusion .............................................................................................................................15 

Contact Us:.................................................................................................................16 

APPENDIX A: About the Rural & Frontier EMS Agenda for the Future............................17 

APPENDIX B: REMSTTAC Stakeholders...........................................................................19 
Foreword 

The Rural and Frontier EMS Agenda for the 

Future, published in 2004, was a landmark 

document that focused attention on the 

issues specific to the survival and 

improvement of EMS in rural America. 

Much of what is included in the document is 

aimed at policy makers at various levels of 

government. However, it also contains many 

practical ideas and concepts that can, and 

should, be implemented at the local EMS 

agency level. 

This serves as a companion document to the 

report and identifies some of the tasks that 

can be started in almost any rural and 

frontier EMS agency. We recognize that 

taking on additional tasks as a volunteer 

overseeing a rural agency may seem 

impossible. However, the action items listed 

in each section are, in most cases, small 

steps that can be accomplished over time. 

We hope that each of you will choose at 

least one of these tasks to tackle in your 

community. By completing these activities 

you will make a difference to your agency, 

your community and your patients. 

Marcia K. Brand, Ph.D. 

Associate Administrator for Rural Health, 

HRSA 

Nels D. Sanddal, Director 

Rural Emergency Medical Services and 

Trauma Technical Assistance Center
 vi
 1

Rural and Frontier EMS Agenda for the Future: A Service Chief’s Guide to Creating 

Community Support of Excellence in EMS 

INTRODUCTION 

“Rural America is unique and requires unique solutions.” 

 -David Sniff, National Rural Health Association 

Ensuring access to high-quality EMS services is growing more and more difficult for 

EMS ambulance agencies in rural areas around the country. Many rural EMS agencies 

are finding that it is: 

• challenging to understand and successfully respond to changing 

reimbursement policies, regulation, and community needs, 

• hard to recruit and retain quality staff (paid or volunteer), 

• complicated to keep up with changing technology, 

• challenging to meet the needs of an increasingly elderly population, and 

• difficult to “make ends meet” financially. 

In order to succeed in the future, rural EMS agencies must galvanize community support, 

develop strong partnerships and collaboration, and utilize new systems to measure 

performance and enhance quality. Achieving any of these goals is difficult; succeeding 

in all three areas seems like an overwhelming task. However, there are resources to help 

rural EMS agencies address these challenges. One such resource is the recently 

published report, the Rural and Frontier EMS Agenda for the Future. This guide 

summarizes some of the key elements of the Rural and Frontier EMS Agenda for the 

Future, and describes the changing health care environment so that rural EMS services 

can best position themselves to succeed in the future. 

What is the Rural and Frontier EMS Agenda for the Future?

The Rural and Frontier EMS Agenda for the Future is a 2004 report that describes an 

optimal future for rural EMS and describes changes that would be required for rural EMS 

to achieve that vision. Several associations worked together to complete the report and 

invited hundreds of EMS professionals and other interested people to submit comments 

regarding the current rural EMS system, and to suggest important systems changes that 

must occur for rural EMS to remain viable. 

The partner organizations that decided to undertake the project were the National 

Association of State EMS Officials, the National Organization of State Offices of Rural 

Health, and the National Rural Health Association. With funding from the U.S. 

Department of Health and Human Services Health Resources and Services 

Administration, Office of Rural Health Policy, these organizations set up a Web site to 

accept comments from any interested parties and also sponsored a 1-day meeting that was 

attended by over 100 individuals who represented ambulance services, other health care 

providers, and numerous associations and government agencies. A final report was 
 2

published in October of 2004 (read more about the development of the “Agenda” 

Appendix A). 

The partners had several purposes when they decided to undertake this project. First, 

they wanted to lay out a policy agenda for political leaders and rural EMS advocates. 

They wanted to provide guidance to influence policy makers whose decisions can have 

an impact on the future of rural EMS. However, the partners also believed that the Rural 

and Frontier EMS Agenda for the Future could serve as a guide for local and State EMS 

agencies, and their communities, in developing realistic plans for the future based on 

available resources. Ultimately, sound local decision-making will ensure the ongoing 

success of EMS in any community. With that in mind, A Service Chief’s Guide to 

Creating Community Support of Excellence serves as a companion document to the 

Rural and Frontier EMS Agenda for the Future and is created specifically to provide 

information, tools and resources to rural EMS leaders and their partners. Specifically, 

this guide will help EMS agencies address issues around the topics of: 

1) Community Assessment and Planning. A deliberate planning process 

involving broad representation from the community (including representatives 

of health care, education, public safety, business, government, citizen 

consumers, and other “stakeholders”) should be used to guide system 

decisions in rural communities. EMS is generally poorly understood in rural 

areas. EMS agencies cannot afford to plan for the future without involving the 

community (which should help develop community support). The planning 

process should examine at the current situation, a “visioning” process to 

describe what the community would like EMS to become in the future, and an 

honest dialogue regarding the type of system the community is willing to 

support in the long term. Most rural and frontier EMS systems are currently 

under-funded. Expansion and upgrading of existing systems without 

solidifying community commitment to funding could result in deeper financial 

hardships. 

2) Integration and regionalization. Historically, these words have had a negative 

flavor in rural areas, but it is important that rural EMS providers embrace 

these concepts. Integration does not mean that a local EMS system has to 

become a part of a larger organization and lose its independence. But in 

today’s environment, EMS must collaborate closely with local health care 

systems, public health, and public safety. EMS agencies may also want to 

form closer connections with other “sectors” in the community. Regionally, 

EMS needs to think about its role in the continuum of health care delivery. 

Centers for Medicare and Medicaid Services and other Federal agencies have 

already begun demonstration programs to base reimbursement on quality. In 

rural areas, measures that demonstrate quality across the entire spectrum of 

care, including EMS, will be selected for “pay for performance” systems in 

the coming years. This includes such things as participation in programs that 

improve outcomes for such issues as trauma, cardiac, burns, and stroke. Being 

part of an organized and pre-planned system has measurable benefits to those 

in need of services. 
 3

3) Quality and Performance Improvement. As mentioned above, Medicare and 

other payors/purchasers of health care services are moving toward systems 

where payment is based, in part, on performance in accordance with 

standardized quality measures. Regulators may follow the trend in years to 

come, by requiring that regulated agencies demonstrate that quality 

improvement systems are in place. Patients deserve to be treated by 

organizations that are committed to reducing errors and providing the highest 

possible quality services. Quality Improvement and Performance 

Improvement (QI/PI) systems are dependent on processes to gather and 

analyze data and methods to use this information to improve systems 

performance. 

This guide provides information about existing resources and tools that are available to 

local EMS leaders who undertake community planning and establish strong QI/PI efforts. 

The information is designed to help keep rural EMS services viable next year and well 

into the future. To survive, however, there is another important role for rural EMS, and 

that is the role of advocacy. An unfortunate byproduct of the lack of understanding of 

rural EMS is that oftentimes it is overlooked when policy decisions are made, or poor 

policy decisions are made on behalf of rural services. It is important that rural EMS be a 

strong and vocal advocate, and to educate the general public and policy makers at a local, 

State, and national level about the importance of a quality EMS system in rural areas. In 

this guide you will find information that will help you, as a local EMS leader, use 

strategies and techniques to advocate on behalf of your system. 

The remainder of this guide is broken into the three general focus areas summarized 

above: community assessment and planning, integration and regionalization, and quality 

and performance improvement. Each of the three sections is further broken down into 

three discrete parts, an introduction and background statement, a list of specific key 

associated recommendations from the Rural and Frontier EMS Agenda for the Future

that support the section, and a brief list of specific action items that might be 

implemented to move a rural EMS system closer to the attainment of at least some of 

Rural and Frontier EMS Agenda for the Future’s recommendations. Many rural EMS 

agencies will have already completed some of the tasks. Target those tasks and activities 

that make the most sense for your service. There is also a brief guide to advocacy at the 

end of this document. Advocacy is the word used to describe involvement of an agency in 

the political process. To be successful you have to do more than simply go about your 

business and provide good service; it is also imperative that you work with decisionmakers to help them understand rural EMS needs and issues. This advocacy guide will 

provide some ideas about ways to get involved in the political process (see Appendix B). 

That process may seem intimidating or even mysterious to some. If you are among those, 

don’t worry. This guide will take away some of that mystery and show you some simple 

ways to get involved, and help position your service for success. 
 4

COMMUNITY ASSESSMENT AND PLANNING 

Introduction and Background

“...Despite the last 30 years of experience and intense media profile, EMS 

remains mostly a mystery to the public. They know we will show up 

when they call 9-1-1, but the public knows very little about who we are, 

how we are organized and funded, and quality in the system.” – Tom 

Judge, CCT-P, Executive Director, LifeFlight of Maine 

Comprehensive advanced life support (ALS) services are difficult to establish and 

maintain in systems with low call volumes, because of the high fixed costs associated 

with ALS services and the challenge of being able to recruit, retain, and adequately 

reimburse highly-trained paramedics. As a result, the more remote a rural area, the less 

likely one is to find advanced life support (ALS) levels of EMS available in that area. 

However, even in rural areas many residents may expect that ALS care is readily 

available. In areas where EMS is heavily dependent on volunteers, and services are 

limited to basic life support (BLS), the general public may be surprised to learn that 

paramedic care is unavailable. 

In rural areas, many of which have a limited (and perhaps shrinking) resource base, 

community support of EMS should not be taken for granted. If EMS is to sustain 

community support, it is critical that the community understand the challenges EMS 

faces. Rather than shying away from community scrutiny, EMS should help 

communities accurately understand the services they provide, other service options that 

exist, and the cost of the options. This education needs to start at a basic level. Indeed, 

many people outside of health care do not even realize that different types of EMTs 

(basic, intermediate, and paramedic) exist. The community needs to understand the costs 

of maintaining EMS in both financial and human resources so they can make an informed 

decision about the level of service that is possible. Rural EMS services should promote a 

community-based EMS assessment and planning process and encourage community 

decision makers to determine the type and level of EMS they desire and the means to 

fund the system. You need to ask, “How can we add value to our present system?” 

A number of community EMS assessment and planning programs have been developed 

for rural areas in the United States. Two State EMS offices have developed community 

technical assistance team processes, and in these States expert teams visit communities to 

assist in the process of community assessment. Another process was developed by a notfor-profit agency with funding support from the Federal Office of Rural Health Policy. 

The Critical Illness and Trauma Foundation (Bozeman, Montana) offers their “EMS 

Community Planning and Integration Guide” online at 

http://www.citmt.org/Training.htm#Community%20Planning. This process includes a 

system self-assessment as well as perception surveys conducted with a variety of 

community sectors (health care, public safety, school system, media, government, etc.). 

Regardless of the approach you decide on, you will probably need some outside help. 

Your EMS Office, State Office of Rural Health or the Rural EMS and Trauma Technical 
 5

Assistance Center (REMSTTAC) may be able to help you find resources to provide 

assistance with the assessment process. 

Key Recommendations from the Rural & Frontier EMS Agenda for the Future

• Develop a national template for community EMS system assessment and 

informed self-determination processes to help communities determine and be 

accountable for their own EMS type, level, and investment (Ch. 8). 

• Fund processes for community EMS system assessment and informed selfdetermination. Consider regional and statewide resources (e.g. aeromedical 

services) in implementing these processes (Ch. 8). 

• Foster the development of a culture of volunteerism and community service 

through local schools in partnership with community agencies (Ch. 5). 

• A national EMS service leadership and service management training model 

should be developed and shared with all State, territorial and tribal governments. 

This model should include successful practices in EMS volunteer and paid human 

resources management (Ch. 5). 

• Conduct an ongoing assessment by rural/frontier EMS agencies and local 

hospitals of their resources and needs and search for common educational 

opportunities (Ch. 7). 

• Emphasize optimal interdisciplinary care of the ill or injured patient, including 

complex event management such as cardiac arrest and multiple casualty incidents 

(Ch. 7). 

Specific Tasks

1. Establish a local planning group that consists of EMS stakeholders, local 

political/policy leaders, medical community leaders, and public health leaders to 

develop an EMS system development plan at the community level. This group 

can become the catalyst for the implementation of a focused effort to identify 

future directions in the development of your local EMS system. You may want to 

choose a facilitator for this group. Oftentimes you can find trained facilitators in 

your area. County extension agents are often a good resource for this activity, 

particularly if they utilize the tools available through REMSTTAC. 

2. Ensure that your agency is represented at regional and statewide activities in EMS 

system development. This would include attending key meetings, monitoring 

Internet information resources such as list serves, and maintaining an awareness 

of opportunities that may be helpful to your local efforts in EMS development and 

planning. 

3. Assign individual liaisons to key partners in the local EMS system. The liaisons 

should be responsible for developing relationships with those components of the 

community that can support your EMS mission. By having these liaison 

relationships in place, your partners can learn more about the needs of EMS as 

well as giving EMS providers an opportunity to understand the web of 

relationships necessary to support health care in rural communities. 
 6

INTEGRATION AND REGIONALIZATION 

Introduction and Background

“Rural and frontier EMS providers must be well integrated with their 

public safety partners in this era of domestic preparedness in order to 

operate more effectively in disaster situations. But EMS providers must 

learn to integrate as well with community health, medical, and nursing 

partners if they are to bring the level and type of care to the community 

that it expects and are to continue to operate at all. Our survival depends 

upon it.” – Kevin McGinnis, MPS, WEMT-P, Program Advisor, National 

Association of State EMS Officials and Crew Chief, Winthrop Ambulance 

Service (Maine) 

In many rural areas populations are aging. Older populations mean that the need for all 

types of health care services increases. However, at the same time many rural 

communities are finding it hard to maintain current health care services because of 

declining rates of reimbursement, challenges in recruiting and retaining health care 

professionals, and a declining tax base as a result of shrinking population. As other 

resources dwindle, communities may increasingly call on EMS providers not only for 

traditional emergency services but also for a range of informal care, evaluation, and 

advice. These services are often provided in “no transport” situations, which may be the 

reason that isolated communities often have “no transport” rates much higher than the 

State average. These locally developed solutions to fill a gap in the community’s health 

needs have been called “EMS-based community health services” or “community 

paramedicine.” In some cases these “no transport models” of care may impose additional 

burden on rural and frontier EMS systems due to loss of revenue. In other cases such care 

models may provide opportunities to bolster human resources by establishing paid 

positions at local hospitals. 

How can rural EMS respond to this growing demand for both traditional and nontraditional EMS services? Many experts believe the key to rural EMS’ survival and 

success will depend on the ability of EMS providers to successfully link with partners 

including nearby EMS providers, local public safety, and especially the health care 

system. 

EMS should be able to draw upon fire department, emergency management, law 

enforcement, and public works resources (as well as resources from nearby EMS) as 

needed, based on the presence of mutual aid agreements. If such agreements are not in 

place, EMS agencies should contact their State Bioterrorism Hospital Preparedness 

Program (BHPP) or their Department of Emergency Management for assistance. Each 

State has a BHPP, funded through the Health Resources and Services Administration, and 

each State program is tasked with providing technical assistance to local EMS to develop 

such mutual aid agreements. Information is available at 

http://www.hrsa.gov/bioterrorism/. 
 7

Rural and frontier EMS should also work closely with medical oversight to ensure that 

they are part of teams representing the continuum of care to enhance triage, transport and 

treatment decisions that make effective use of local resources and ensure a disposition in 

the patient’s best interest. Many States have State trauma programs and within those 

programs, regional trauma teams or councils exist that work to enhance trauma care in 

their regions. Other local and State teams are working to enhance the continuum of care 

for stroke, heart attack, and other acute medical conditions that require emergency 

treatment. Sources of information on these programs are State Quality Improvement 

Organizations (http://www.cms.hhs.gov/QualityImprovementOrgs/) or State FLEX 

programs (http://tasc.ruralhealth.hrsa.gov/). Strong medical oversight is a key part of the 

development of such initiatives. However, little formal training exists for rural 

practitioners who are often trained in family practice or general internal medicine, to 

become well versed in providing medical direction for EMS. Currently, a collaboration 

led by the Critical Illness and Trauma Foundation is migrating the NHTSA medical 

director training program to an interactive Web-based format 

(http://www.citmt.org/training.htm). 

Regional approaches to consider are many. The most common regional cooperatives are 

Quality Improvement-based systems. In Kansas, the State FLEX program has funded the 

development of three such regional QI initiatives. In each case, a regional EMS provider 

has worked with smaller EMS agencies in the area to develop a common run form and to 

collect and analyze run form data from these agencies. The regional agency then brings 

all participating EMS units together on a regular basis to share information, explore best 

practices in care among the sharing agencies, and promote adoption of these best 

practices region-wide. EMS should involve emergency department and other hospital 

personnel in this process, as they may have valuable insight into the quality of care based 

on their observations of EMS when they arrive with a transported patient. In some cases 

EMS services have partnered with local physicians, and together they have worked with 

specialists in regional referral centers to develop standard protocols among the specialists 

in the referral centers. 

EMS agencies in a region may also wish to form a collaboration to pursue a joint 

purchasing arrangement that will allow them to purchase equipment and supplies at lower 

prices, and to rotate stock regionally to ensure that supplies do not have to be discarded 

due to non-use prior to expiration dates. One example of such a buying co-op is the 

North Central EMS Cooperative (NCEMC), another network: the Western EMS Network 

(WEMSN) is forming to similarly serve western States. State EMS offices 

(www.nasemso.org) and State Offices of Rural Health (www.nosorh.org) are places to 

search for information on such programs. 

Formalized agreements between nearby EMS services may also allow the integration of 

paid staff into units that have essentially relied on volunteer service. It may seem like a 

stretch for small basic life support (BLS) units to consider moving to a model that 

includes paid staff. However, the nature of volunteerism is changing in rural America. It 

is becoming more difficult to recruit young volunteers who themselves are willing to 

spend time away from their jobs, families, and other pursuits to volunteer for the 
 8

demanding job of EMT. Finding volunteer staff to work during standard business hours 

can prove very difficult, as employers can be reticent to allow employees to leave work 

when they realize that long transports to a distant medical center may mean that an 

employee is away from the job for hours at a time. There are examples of services that 

have brought paid staff into their organizations and created ALS systems in environments 

that historically were based on BLS services. However, this usually entails integration of 

several local EMS units, a political and operational process that is, admittedly, very 

difficult to achieve. We are not suggesting that an ALS system is needed in each area. 

That decision should be part of the community planning process described in the first 

section and supported by historical EMS response data. A well-trained BLS system with 

strong relationships to area health care organizations may be the right solution for many 

rural areas, but even these systems will likely need to move toward a model with paid 

staff. 

This goal might also be accomplished through integration of EMS and a local hospital, 

another process that might sound intimidating...to both sides! Different cultures among 

EMS and hospitals has often meant that there is an important, yet uneasy, relationship 

between the two. However, integration can have important benefits. Integration may be 

defined as close collaboration or sharing of resources. Integration can provide services 

access to new resources. Integration provides EMTs the chance to work in other 

prehospital and in-hospital settings. Another potential benefit is the chance to generate 

new revenues for the ambulance service. For example, some EMS units owned and 

operated by Critical Access Hospitals receive cost-based reimbursement for Medicare 

and Medicaid patients. Analyses have shown that cost-based reimbursement for 

emergency services can result in significant additional Medicare and Medicaid revenue. 

For more information about cost-based reimbursement, contact your State FLEX 

program. State program contacts for the FLEX program can be found at 

http://tasc.ruralhealth.hrsa.gov/. 

Key Recommendations from the Rural & Frontier EMS Agenda for the Future

• Encourage EMS-based community health service program development through 

the funding of pilots, cataloguing of existing successful practices, exploration of 

opportunities for expanded EMS scopes of practice, and ongoing reimbursement 

for the provision of such services (Ch. 1) 

• Federal, State, and local programs addressing all-hazards planning, and 

addressing the specific needs of special rural populations, should include EMS as 

a categorical component. Statewide and border State networks of formal regional 

EMS mutual aid agreements, including EMS licensee recognition, should be 

established (Ch. 1). 

• The Indian Health Service should integrate tribal EMS-based community health 

service and Community Health Representative programming, and consider the use 

of both tribal and non-tribal sources of care (Ch. 1). 

• Facilitate the use of subscription services as a part of the overall funding of the 

EMS safety net infrastructure, in cooperation with State insurance authorities (Ch. 

4). 
 9

• Form, and fund through county, regional, State, or Federal tax dollars, 

rural/frontier EMS operational or service contracting networks in those areas 

where they provide economies of scale, improved access to EMS care, improved 

quality and/or increased tax payer value (Ch. 4). 

• Implement EMS based community health programs and services through an 

interdisciplinary approach involving EMS operational and medical oversight 

components and primary care professionals (Ch. 6) 

• Development of State/regional stockpiling, and sharing of expensive training 

devices such as mannequins and patient simulators (Ch. 7). 

• Among local, State, Federal, and national EMS and public health agencies (and 

other agencies with prevention roles), cooperatively develop and fund community 

health advocacy roles and prevention programs for rural/frontier EMS personnel 

that are mutually beneficial (Ch. 9). 

• Provide formal Emergency Medical Dispatch to every caller seeking EMS (Ch. 

10). 

• States should establish formal plans for roadside call-box, satellite, and/or cellular 

networks to effectively cover all rural/frontier primary roads (Ch. 10). 

• EMS leaders should continue to develop ongoing paths of communication with 

State and Federal telecommunications interoperability and Intelligent 

Transportation Systems industry planning entities (Ch. 11). 

• EMS-based community health services pilots and programs should have a 

physician supervised evaluation system (Ch. 14). 

Specific Tasks

1. Review and update existing mutual aid agreements with neighboring services. 

Consider including “administrative/planning” mutual aid in these agreements that 

will institutionalize an expectation of routine communication with neighboring 

services and institutions. By developing a culture of cooperation and 

communication, agencies concerned with providing health care in rural 

communities can develop into strong regional consortiums. 

2. Identify specific needs and opportunities within your own agency and look for 

resources outside of your agency that may be able to provide resources to address 

these needs. Approach these agencies and ask for their input and assistance. This 

can become the basis upon which strong regional relationships can be built. In 

most communities, resources exist that aren’t used due to the fact that someone 

just never asked. Be the one to ask! 

3. Invite local elected officials and policy makers to attend your organization’s 

meetings on a regular basis. Seek opportunities to provide reports of your 

ongoing activities and needs at county commission meetings, local service 

organizations, etc. 
 10

QUALITY AND PERFORMANCE IMPROVEMENT 

Introduction and Background

You have to remind yourself sometimes....your arrival at the end of the 

driveway is a significant event in the lives of those who call for help. It is 

not just another call. It is a moment likely to be incorporated into family 

lore as “the day the ambulance came.” 

You try to act accordingly. To meet the expectations. To simply – help. 

You won’t always live up to the hype. “What we’re going to do...” I was 

saying, when the woman on the couch interrupted me. 

“Oh, I know,” she said, “I’ve seen Paramedics [TV show].” This is like 

telling your Little Leaguer you expect him to yank a Randy Johnson 

fastball over the left-field wall. We are basic-level emergency medical 

technicians. We have skills, but they are basic. We can’t always match 

what you see on TV....- from Population 485, by Michael Perry (writer 

and volunteer firefighter/EMT) 

It is true that public expectations of EMS are high. Often times in rural areas, the 

expectations may be unrealistic. But EMS providers, whether individual 

prehospital care providers (EMT-B, EMT-I, EMT-P) or the service providers 

themselves, are all interested in meeting expectations, and in helping to the best of 

their abilities. Also, it must be stated that high quality prehospital care does not 

relate to the level of care provided (ALS & BLS). Basic life support services can 

provide high quality care. EMS providers do strive to continuously improve the 

quality of services they provide to their patients and to enhance their overall 

system performance. It is central to the mission of EMS to provide the best care 

possible. However, traditional methods used within health care and sometimes in 

EMS to enhance quality (often referred to as “quality assurance”) are limited in 

their ability to truly make advances in improving the quality of services delivered. 

It is thus important for EMS to begin to adopt new methods to enhance quality. It 

is something patients will expect and demand, and in the future, the ability of 

EMS providers to document the quality of care they provide may influence their 

levels of reimbursement. Purchasers of care, like the Medicare program, have 

already begun basing payments to some types of health care providers on the 

basis of “pay for performance.” In such systems, providers must demonstrate 

their involvement in Quality Improvement (QI) efforts, or even demonstrate 

actual improvement in quality on the basis of some predefined set of measures. 

QI systems can be simple or complex. If your system is just beginning a QI program, 

start simple. Determine several areas where you believe your system could show 

improvement. Select a clinical area, and perhaps also a non-clinical area (form 

completion, recruitment progress, billing efficiency, etc.) and discuss the issue. 

First, discuss how you can measure the issue. If you want to improve some aspect of 

timeliness, for example, describe how you can measure the current “baseline” level of 
 11

performance and how you can measure improvement. Then, set a target for performance 

that describes how much you want to improve. For instance, you might want to improve 

the time from when a dispatch call is received to when the ambulance leaves the station. 

If it currently takes 20 minutes and you think that could be improved, set a target for 

improvement, such as: “We will decrease the time from dispatch call to time the 

ambulance leaves the station by 30%”. Your goal would be to have a 16-minute response 

time. You then have to make plans on how you can improve your performance to reach 

your goal. Perhaps you have read about a process another ambulance service used to 

improve their response time, and you decide to try that approach. Or you could simply 

ask other area ambulance services for ideas. 

One way to generate these ideas is by creating a “benchmarking” system. This is 

accomplished when a group of health care providers agree to share information through a 

systematic process so that everyone in the group can see who does something particularly 

well. The group of providers agrees to measure the same process, and to share the 

resulting data amongst themselves. Providers that may be struggling with a particular 

activity can ask those services that seem to be doing well for advice and assistance, thus 

allowing everyone to benefit from this mutual effort. Several State Flex programs have 

used Federal funding to support the development of benchmarking systems. In Kansas, 

for instance, the Flex program provided start-up grants to three groups of ambulance 

services that came together to do benchmarking. In each instance, one ambulance service 

took the lead in discussions among a number of area EMS providers about creating a 

common run form, focusing on certain elements that were measured by the run form, and 

sharing the information among one another through reports and monthly meetings when 

the services got together to share lessons learned and “best practices.” These networks 

also provided computers to each ambulance service so that they could enter the data into 

a computer, which made the comparisons among the services easier to accomplish. 

Another place to get ideas on performance improvement is from hospitals where you 

transport patients. Have you ever sought input from Emergency Department staff in the 

hospitals where you transport? They might be a valuable source of information. State 

Rural Hospital Flexibility Program (FLEX) programs are encouraged to support this type 

of integration and collaboration, so you should contact your State FLEX program to see if 

they may have resources or assistance that could help you develop this type of process. 

Of course, once a service has gathered ideas on ways to improve a process, they should 

implement those changes. It is ideal to implement one change at a time so you can 

measure the impact of the change. Implement one change and then continue to evaluate 

the issue, and after 1 or 2 months determine if the change made a difference. If it did, 

you might be satisfied with that and move on to look at other measures. Or perhaps you 

are still not satisfied and think you could enhance performance even more. Perhaps you 

institute another change and once again measure progress in that area of concern. 

Don’t continue to evaluate the same parts of your service forever. Choose one or two 

areas and show that you can make improvements. Then move on to another area. Put 

together teams that can oversee the process. These teams can include internal staff, but 
 12

as we discussed above, consider other resources – other ambulance services, hospital 

personnel, perhaps even community members (who represent the patient perspective). 

Of course, it is critical to involve the service medical director in this process. 

Resources for QI Project Development

Of course, taking on QI projects takes time and resources. You may feel you don’t have 

sufficient staff to take on this added responsibility. If that is the case, please realize there 

are many resources available to help you move forward. As mentioned before, FLEX 

programs often have (or are aware of) resources that can help develop these projects. 

There are also organizations in each State, funded by the Medicare program, to help 

health care providers develop QI programs. These organizations are known as Quality 

Improvement Organizations, or QIOs (find your QIO online at 

http://www.cms.hhs.gov/QualityImprovementOrgs/). Each State QIO is different, so 

your QIO may, or may not, have resources that are pertinent to EMS. 

You may also be able to identify volunteers within your communities who can help. A 

great recruiting tool is to provide opportunities for area youth to learn about EMS. 

Would you consider asking the local high school if they would like to offer an 

internship(s) to a student to help your service develop a QI program? Approaching a 

larger ambulance service in the area to see if they would be interested in helping with 

program development is another way to not only establish a QI program, but promote 

cooperation and regionalization as well. 

Many hospitals have well developed QI programs. Do you believe an area hospital might 

be willing to help you? You might find assistance from a small local hospital, or perhaps 

a tertiary facility further away. You may feel that you don’t have a good working 

relationship with these facilities, but we urge you to take the step, to start talking with 

these hospitals. Caring for patients who arrive through the ER is of critical importance to 

hospitals, and they are very interested in working to ensure that the continuity of care 

from one provider to the next is as good as it can be. Your area hospitals, if they are like 

most, will be happy to begin talking with you about creating joint QI opportunities. For 

instance, a collaboration between area EMS, community hospitals and cardiac specialists 

in a referral center might come together to help determine how to improve the entire 

continuum of care for a heart attack patient who lives in your community, from the time 

he/she places a 9-1-1 call to the time they receive treatment in the tertiary facility. A 

project of this type was initiated by the Minneapolis Heart Hospital. Working with 

community ER physicians and area EMS providers, they were able to improve system 

“hand offs” and communication and significantly reduce the amount of time it took to get 

transported patients onto the operating table for life-saving angioplasty. 
 13

Key Recommendations from the Rural & Frontier EMS Agenda for the Future

• Make data that are collected through information systems at State and Federal 

levels available for community based assessment and research, and provide tools 

to promote community-based research (Ch. 2). 

• Compensate EMS medical directors for the EMS medical oversight services that 

are provided. The level of compensation should be equivalent to the level of 

compensation the physician would experience (for the equivalent hours) in their 

normal clinical practice (Ch. 6). 

• Require that EMS medical directors be physicians, but encourage the use of 

physician extenders and regionalized arrangements of medical oversight to 

increase the EMS medical oversight resources in rural/frontier areas (Ch. 6). 

• EMS medical directors must actively participate in local, regional, and State EMS 

program planning and implementation. States must seek out and include 

rural/frontier medical directors for these purposes (Ch. 6). 

• Encourage EMS-based community health service program development through 

the funding of pilots, cataloguing of existing successful practices, exploration of 

opportunities for expanded EMS scopes of practice, and ongoing reimbursement 

for the provision of such services (Ch. 1). 

• Implement EMS-based community health programs and services through an 

interdisciplinary approach involving EMS operational and medical oversight 

components and primary care professionals (Ch. 6). 

• EMS-based community health services pilots and programs should have a 

physician supervised evaluation system (Ch. 14). 

• Fund the availability of training and tool kits to encourage effective local 

service/system quality improvement processes (Ch. 14). 

• Implement and maintain a local EMS information system at every local EMS 

service/agency. Maintain data on every EMS event in a manner that is timely and 

able to drive the quality of the EMS system service and patient care delivery (Ch. 

13). 

• As needed, share costs and resources required to implement and maintain an EMS 

information system among multiple systems to achieve an economy of scale (Ch. 

13). 

• EMS systems must provide analyzed and descriptive information on service and 

patient care delivery that they provide to their EMS personnel, administration, and 

community (Ch. 13). 

• EMS-based community health services pilots and programs should have a 

physician supervised evaluation system (Ch. 14). 
 14

Specific Tasks

1. Contact your State/regional EMS office to locate data collection resources that 

may already be available to your agency. Many States are working to establish 

and enhance their statewide data collection systems and resources may be readily 

available that can provide an appropriate capability for your agency. 

2. Consider developing a relationship with the local high school or community 

college to gain assistance in developing a data gathering system that works for 

your community and area providers. Many institutions of this nature look for 

opportunities to place students in “real life” situations and provide local technical 

assistance in the development of data collection systems. 

3. Develop a “quality improvement” team within your service to identify areas of 

potential improvement in both patient care and administrative areas of service. 

Empower the team to look into all aspects of service operation and develop a plan 

to implement a quality improvement plan of action. 
 15

We hope that you have found this document useful and practical. Hopefully, it has 

stimulated your thinking about how your service might be improved or solidified, how 

you might better engage the public or how you might work with other agencies. We look 

forward to receiving your comments and thoughts on how we might improve this 

document in subsequent editions. 

Contact REMSTTAC: 

Thank you for using the Rural and Frontier EMS Agenda for the Future: A Service 

Chief’s Guide to Create Community Support of Excellence in EMS. We’re interested 

in your feedback on the use and utility of this product. If you have comments or 

suggestions for improvement, please contact us at: 

Health Resources and Services Administration, Office of Rural Health Policy 

5600 Fishers Lane, Room 9A-55 

Rockville, MD 20857 

Phone 301-443-0835 

Fax 301-443-2803 

http://ruralhealth.hrsa.gov/

REMSTTAC 

300 North Willson Avenue 

Suite 802-H 

Bozeman, MT 59715 

Phone 406-587-6370 

Toll Free 866-587-6370 

Fax 406-585-2741 

info@remsttac.org 

http://www.ruralhealth.hrsa.gov/ruralems
 16

APPENDIX A: ABOUT THE Rural and Frontier EMS Agenda for the Future

In 1996 the National Highway Traffic Safety Administration brought together a broad set 

of experts and advocates to create the EMS Agenda for the Future. This document was 

supposed to set out a broad vision for the future of EMS. However, because rural 

America presents such a unique set of challenges to the provision of Emergency Medical 

Services, the National Rural Health Association, the National Association of State EMS 

Directors, the National Organization of State Offices of Rural Health and the Federal 

Office of Rural Health Policy came together in 2003 and 2004 to target the national goals 

outlined in this report that were most critical to rural communities. These partner 

organizations were responsible for the publication of the Rural and Frontier EMS Agenda 

for the Future. 

Their goal was to inspire and inform a number of different audiences. For rural 

advocates it was to serve as a policy blueprint for the future. For political leaders, it was 

designed to outline what needs to be done, and what needs to be funded, to ensure that 

quality EMS care is available in even the most remote, frontier communities. And for 

rural communities nationwide, the partners hoped that the new document would serve as 

a tool for what communities could do with available resources and how they could plan 

to sustain and enhance EMS services in the future. 

The Rural and Frontier EMS Agenda for the Future was built on the same format as the 

1996 EMS Agenda for the Future. It proposed continued development of 14 key EMS 

attributes: 

• Integration of Health Services 

• EMS Research 

• Legislation and Regulation 

• System Finance 

• Human Resources 

• Medical Oversight 

• Education Systems 

• Public Education 

• Prevention 

• Public Access 

• Communication Systems 

• Clinical Care and Transportation Decisions/Resources 

• Information Systems 

• Evaluation 
 17

A process for developing the document began in 2003. Volunteer writing and editorial 

teams helped in the direction of a draft document that was posted to the NRHA web site 

in fall 2003. From January to June of 2004 over 235 individuals from over 100 

organizations provided comments about versions of the document that were routinely 

posted to the Web site. These included about 100 individuals including local ambulance 

directors, State EMS officials, State rural health officials, and a range of policy experts 

provided input during a 1-day session preceding the May 2005 National Rural Health 

Association Annual Rural Health Conference. The document was first released to the 

public in October 2004 at the annual meeting of the National Association of State EMS 

Directors (now the National Association of State EMS Officials). 

Fulfilling the vision identified in the Rural and Frontier EMS Agenda for the Future 

requires the application of significant Federal, States and local resources as well as 

committed leadership at all levels. Because significant policy and funding decisions at 

Federal and State levels are critical to future success of rural EMS, the Rural and 

Frontier EMS Agenda for the Future focused, in large part, on those policy makers. 

However, the project partners also recognize that action at the local level is just as 

important, if not more important, to the future of EMS in rural communities. We 

recognize that rural and frontier EMS providers are acutely aware of the challenges they 

face. As such, this new “Service Chief’s Guide” has been created in hopes of arming 

local EMS providers with information about possible future directions for rural EMS 

system development to ensure their survival, advancement, and growth. It is meant to 

serve as a companion document to the Rural and Frontier EMS Agenda for the Future, 

and we encourage rural EMS leaders to learn about and use that original document. It is 

available for free download at http://www.citmt.org/download/rfemsagenda.pdf 
 18

APPENDIX B: ACKNOWLEDGEMENTS 

This service chief’s guide was made possible by funds provided by ORHP and the Rural 

Emergency Medical Services and Trauma Technical Assistance Center (REMSTTAC) 

and the Kansas Department of Health and Environment. Special thanks for producing 

this guide go to Chris Tilden from the Kansas Department of Health and Environment, 

Office of Local and Rural Health and to REMSTTAC staff Nels Sanddal, Director; 

Heather Soucy, Program Support Specialist; Joe Hansen, Assistant Director and Teri 

Sanddal, Associate Director; and members of the Service Chief’s Guide Workgroup at 

REMSTTAC. 

Nels D. Sanddal, B.S., Co-chair 

Director 

Rural Emergency Medical Services and Trauma Technical Assistance Center 

Chris Tilden, PhD, Co-chair 

Interim Director 

Kansas Department of Health & Environment 

Contributors and Reviewers: 

Dennis Berens 

Director 

National Organization of State Offices 

of Rural Health 

Nebraska Office of Rural Health 

Dean Cole 

EMS/CISM Program Administrator 

Nebraska Health and Human Services 

System 

EMS Program and Public Health 

Assurance Division 

D. Randy Kuykendall, MLS, NREMT-P 

Chief, Emergency Medical and Trauma 

Services Section 

Colorado Department of Public Health 

and Environment 

Health Facilities and Emergency 

Medical Services Division 

Fergus Laughridge 

EMS Coordinator/ Program Manager 

Nevada State Health Division – EMS 

Bureau of Licensure and Certification 

Kevin K. McGinnis, MPS, EMT-P 

Program Advisor 

National Association of State EMS 

Directors 

Mary Sheridan 

Director 

State Offices of Rural Health 

Idaho Department of Health and Welfare 

Ron Seedorf 

Outreach Coordinator 

Colorado Rural Health Center 
 22

APPENDIX C: REMSTTAC STAKEHOLDERS GROUP 

Jane Ball, Executive Director 

EMSC National Resource Center 

Trauma-EMS Technical Assistance Center 

Eli Briggs, Policy and State Affairs Manager 

National Rural Health Association 

Government Affairs Office 

Bethany Cummings 

Rural Affairs Ad Hoc Committee 

National Association of EMS Physicians 

Drew Dawson, Chief, EMS Division 

National Highway Traffic Safety Administration 

Tom Esposito, Medical Director 

Rural EMS and Trauma Technical Assistance Center 

Loyola University Medical Center 

Blanca Fuertes, Past Project Officer 

U.S. Department of Health and Human Services 

Health Resources and Services Administration 

Office of Rural Health Policy 

Tommy Loyaconno, Representative 

National Association of Emergency Medical Technicians 

Christian L. Hanna, Rural Site Director 

Children’s Safety Network 

National Children's Center for Rural Agricultural Health and Safety 

Bob Heath, EMS Education Coordinator 

Nevada State Health Division 

Marilyn Jarvis, Assistant Director for Continuing Education 

Burns Telecommunications Center 

Montana State University 

Doug Kupas 

Rural Affairs Ad Hoc Committee 

National Association of EMS Physicians 

Fergus Laughridge, Program Manager 

Nevada State Health Division 

EMS Bureau of Licensure and Certification 
 23

Tami Lichtenberg, Program Manager 

Technical Assistance and Services Center 

Rural Health Resource Center 

Patrick Malone, Director 

Initiative for Rural Emergency Medical Services 

University of Vermont 

N. Clay Mann, Professor, Associate Director of Research 

Intermountain Injury Control Research Center 

University of Utah 

Evan Mayfield, CDC Public Health Advisor 

New York Department of Health 

Charity Moore, Research Assistant 

Cecil G. Sheps Center for Health Services Research 

University of North Carolina at Chapel Hill 

Carol Miller, Executive Director 

Frontier Education Center 

National Clearinghouse for Frontier Communities 

Daniel Patterson, AHRQ-NRSA Post-Doctoral Research Fellow 

Cecil G. Sheps Center for Health Services Research 

University of North Carolina at Chapel Hill 

Davis Patterson, Research Associate 

WWAMI Center for Health Workforce Studies 

University of Washington 

Ana Maria Puente, Project Officer 

U.S. Department of Health and Human Services 

Health Resources and Services Administration 

Office of Rural Health Policy 

Kristine Sande, Project Director 

Rural Assistance Center 

University of North Dakota Center for Rural Health 

Dan Summers, Director of Education 

Center for Rural Emergency Medicine 

West Virginia University 

Chris Tilden, Interim Director 

Kansas Department of Health and Environment 

Office of Local and Rural Health 
 24

Robert K. Waddell II, Secretary /Treasurer 

National Association of EMS Educators 

Bill White, President 

National Native American EMS Association 

Gary Wingrove, Program Development 

Technical Assistance and Services Center 

Rural Health Resource Center 

Jill Zabel, Healthcare Consulting 

Wipfli LLP