Rebuilding Place in the Urban Space

"A community’s physical form, rather than its land uses, is its most intrinsic and enduring characteristic." [Katz, EPA] This blog focuses on place and placemaking and all that makes it work--historic preservation, urban design, transportation, asset-based community development, arts & cultural development, commercial district revitalization, tourism & destination development, and quality of life advocacy--along with doses of civic engagement and good governance watchdogging.

Wednesday, February 10, 2016

DC EMS Medical Director/Assistant Fire Chief resigns with blistering resignation letter

In biting detail, the resignation letter describes the problems with the EMS program, and how they are embedded in organizational dysfunction and culture failures ("D.C. fire department's medical director resigns," Washington Post).  From the article:
The D.C. fire department’s medical director, hired last year to help reform an agency beset by failures in response times and patient care, is resigning, saying that her proposals have been blocked and that “people are dying needlessly because we are moving too slow.”

Jullette M. Saussy, ending her eight-month tenure, delivered a scathing indictment of the District’s new fire chief and what she calls his refusal to end a culture of indifference that she contends endangers residents’ lives.

“The situation is grim,” Saussy wrote in her Jan. 29 resignation letter to D.C. Mayor Muriel E. Bowser (D), a copy of which was obtained by The Washington Post. Saussy said that without an immediate change in leadership of paramedics and other first responders, the department “will continue to be plagued by serious — but fixable — issues that result in the continuous, unnecessary loss of life.”
The sad thing is that these problems date back decades.  See the past blog entries:

-- DC's fire department is in the same situation as WMATA in terms of the necessity of a redesign of culture and behavior through a human factors approach (2015)
-- The "recent" failures of the DC Fire Department are indicative of much deeper systems failures than people realize (2006)
-- Rationalizing fire and emergency services (2011)
-- Fire and emergency services (in DC) (2013)
-- DC "fire" department continued (2013)
-- Fire department issues in municipalities (2014)

And I am surprised that the letter indicates that the chief of the department is part of the problem too, since he hails from the Seattle Fire Department, which runs one of the more innovative and successful EMS programs in the US. From the article:
She directly attacks the chief, saying he bowed to union pressure to scuttle the assessment tests of emergency medical technicians, allows his firefighters and others to run “undisciplined and unchecked,” and did not put in properly trained supervisors to oversee crucial medical care.

She also criticized Dean’s plan to privatize ambulance service for routine medical calls to free up advanced care for critically injured patients, writing that it “is as unlikely to fix the situation as placing a Band-Aid on a gushing artery.”
EMS and the fire fighting service: A bad fit?  A big problem with the provision of EMS care within fire departments is how departments have shifted from "fighting fires" to mostly responding to EMS calls. Typically more than 80% of the calls to a "fire department" are related to medical needs and care. Some of these calls are absolute emergencies. The majority are not.

Source: DC FEMS performance statistics webpage.

But fire departments want to remain EMS providers because otherwise, the department wouldn't have much to do.

EMS services and frequent users.  Most EMS systems are overburdened providing care to frequent users, such as is described in two series of articles in the San Diego Union-Tribune, mentioned in the previous entry on providing services to the homeless.

The DC fire department is no exception, and my sense is that the fact that many of the calls are not emergencies breeds a sense of laissez-faire amongst the workers in that they tend to believe that most patients are alcoholics and that the situation isn't an emergency.

EMS and alcoholics.  More than 13 years ago, when I was involved in alcoholic beverage sales issues in the city, I was surprised to learn of the association between availability of alcoholic beverages typically purchased for consumption in the public space and crime and emergency health calls. The impetus in Seattle at that time for restricting the sales of "singles" in certain areas of the city was a response to such problems ("Restaurants and liquor licenses--How much is too much on H Street?"). From the 2004 Seattle Times article, "Seattle may extend alcohol-sale limits to much larger area":
An estimated 2,000 chronic street alcoholics live in King County, nearly all in the three downtown Seattle zip codes. The 20 worst offenders among them cost an estimated $2 million a year for police, medical, ambulance and transportation, according to the King County Department of Community and Human Services.

Treatment options are limited. There are only two involuntary treatment centers in the state, and chronic street alcoholics are usually poor candidates for the 227 publicly funded, voluntary treatment beds in King County.

City and county strategies on street alcoholics largely focus on cutting emergency-room and ambulance costs. A city-county agreement created the expanded, 60-bed Dutch Shisler Sobering Center, which provides a warm bed in which to sleep one off.

The city is also backing a novel housing idea, a 75-bed apartment complex at 1811 Eastlake Ave. that would allow chronic alcoholics to continue drinking, within certain restrictions.
Training, Organization, Management, Leadership.  But dealing mostly with nonemergency calls and a preponderance of alcoholics is only one element of the problem.  The other is the training of the paramedics, the way that the function of the agency is set up to be managed and organized, how it's operated, the resources that are provided, etc.

While I understand how integrating the use of private ambulances within the emergency care system can be seen as a stop gap measure, at the same time it does allow for the beginning of a reconfiguration and reformulation of how the city's EMS service works.

But Dr. Saussy's resignation and her description of the issues communicates that the problems are much deeper and the use of private ambulances isn't addressing deeper and more fundamental issues that are likely to remain unaddressed.

Government agencies and elected officials need to start thinking more deeply about risk management.  Lately, I have been thinking about systemic and systematic problems in government agencies--the frequent killing of African-Americans by police officers, the frequent killing of people with mental health problems by police officers, and what happened in Flint with the water system--from the standpoint of risk management.

For whatever reason, the accountability mechanisms are broken within these agencies, between these agencies and the executive branch, between government and the legislative branch and with elected officials.  So sure, officials in Michigan will be sued while the Republican Party tries to make this out as a problem created by Democratic Party elected representatives who had no control over the decision-making.

And in Chicago, year after year, the city government pays out millions of dollars in settlements and judgements for faulty police actions.  According to the Chicago Sun-Times ("City pays heavy price for police brutality"), even before the recent police killings in Chicago, on average the city pays out $51 million/year for "police brutality" lawsuits.

More recently, Chicago paid $5 million to the family of Laquan McDonald "Mitchell: $5 million settlement in Laquan McDonald case," CST") whose death was caught on video that took more than one year to release--it's widely believed the video was held back to reduce the fallout during the reelection campaign for Mayor Emanuel.

Monies paid out by government agencies are ultimately derived from "the taxpayers."  People like us.

The officials and employees who committed the actions are rarely held accountable.  Some do lose their jobs.  But they aren't the ones paying out the settlements.

At the same time, such high annual costs of settlements ought to be seen as an "indicator" of a more serious problem--one that should be addressed in a systematic way.

What needs to be addressed is the cause of the problem, hence the recommendation to take a human factors approach to reorganizing how the fire department is structured, how the emergency medical service is organized and who provides the service, and whether or not to separate the services.

In general, from a risk management approach, it seems clear that we ought to take much more seriously questions of organizational management, systems, hiring, and training as it relates to government actions.

Note that this is not a government vs. private sector performance issue.  Corporations are pretty much immune from actual accountability too.  Sure they pay fines when they do something particularly egregious, but ultimately few individuals are held accountable, especially people higher up in management.

The Michigan Republican Party published an infographic attempting to blame the Obama Administration for how the Flint Water Department under the emergency financial control of the state government controlled by Republican Governor Rick Snyder, failed to treat the water with a "chemical cocktail" designed to limit corrosion and the leaching of lead and other contaminants in the water system.  Instead of focusing on "who did what," the infographic ascribes blame/responsibility in terms of how much money which government has directed to the problem so far. The reality is that the Michigan State Government is fully responsible, although the EPA should have acted sooner and stepped in to force the local and state government to respond properly and act. (That's another issue, of government agencies and deference. Sometimes you have to step up and act, quickly.)

As long as governance is made out to be ideological, performance of government agencies will continue to suffer and diminish in quality.

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At 9:00 AM, Anonymous charlie said...

Risk management and incentives.

Yep, we need a split in EMS and fire response. No easy way to do that.

Incentives -- take the money out of their pensions. Would work with firefighters.

It is also a example of the problem you identified with bikeshare. We keep extending government programs past the point of success. You need to re-architecture social services every ten years or so.

At 9:11 AM, Blogger Richard Layman said...

In college, I came across a psychology book called _Too much invested to quit_.

.... I've been meaning to write spurred by a NYT Magazine article on the misuse of the term "perfect storm" to excuse mostly what are systemic failures like the killing of African-Americans by police officers (albeit not helped by people committing crimes and putting themselves in situations involving armed police officers). The article also discusses Enron, but again, you had a utility situation set up as a monopoly with regular profits split up between distribution and power generation and external power producers and moving from long term to short term contracts with lots of opportunity for price escalation.

That's not a perfect storm, it's setting up the system for manipulation.

Anyway, the other article I was thinking about was an HBR article, "The Experience Trap," about how one reason that systems don't change in the face of problems/mistakes is out of the belief that "mistakes happen" regardless so "what's the use".

At 9:17 AM, Blogger Richard Layman said...

with re-architecture "every ten years" in some respects I'd say that's a bit too rote, but still a good point.

One of the problems with program architecture is that it is usually set up for "one size fits all."

E.g., I had a discussion with an ANC commissioner about snow removal. He's in Capitol Hill. I said in the core you need a focus on walking infrastructure. He said they try to make that point but it gets in the way of "One City" beliefs.

I said that's a slogan, not reality. The reality is we need differentiated program infrastructure and service delivery systems based on the spatial and demographic conditions present.

E.g., with the sustainable mobility "platform" or "product service system" I was mentioning in a GGW comment thread.

It can work really well in the center city. It works less well/doesn't work at all the farther you move from the center city.

It doesn't work well if you don't have a transit network. Etc.

In short, transit-biking as efficient transportation supporting a sustainable mobility lifestyle works well only in a few places in the US.

Part of the animus about transit is that we aren't "One Nation" and people in the non-Sustainable mobility supportive areas don't acknowledge the need for differentiated policy, practice, and funding.

Similarly, the people in the SM supportive areas aren't articulate in defining differences and saying fine, drive all you want, outside of SM areas...

At 9:36 AM, Anonymous charlie said...

yes, I've been doing the same to "black swan" for years now.

and I've calling your "scale" granular. One point of agreement I think we have is that cities don't scale out very well.

The gates people love scale.


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