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.