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Changing the Paradigm of the Emergency Medical Services


Can the Emergency Medical Services Evolve to Meet the Needs of Today?

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The emergency medical services (EMS) provide a means of rapid treatment and transportation to definitive care for those people who suffer immediate life-threatening injuries or illnesses (Department of Transportation, National Highway Traffic Safety Administration, n.d.; Mayer, 1980). There are a number of models across the country and the world that are seeking to redefine EMS in a way that is more meaningful in both of its missions, public safety and public health (Washko, 2012). However, financial constraints and overzealous regulations serve only to pigeon-hole EMS into the decade of its birth and refinement, the 1970s, by restricting incentive and growth and limiting the efficacy of directed research and its application towards the much needed restructuring of EMS.

In this brief literature review, I will examine the roots and context of EMS, its mission and current application, as well as possibilities for research, growth, and development. It is important to recognize that EMS is a grand resource for both public safety and public health, especially in light of the growing body of legislation that officials are using to redefine the current health care system within the United States. As we continue to develop EMS, other nations will look to us as they have in the past to adopt and adapt our system for use throughout the world.

A Brief History of Contemporary EMS

There were many forms of organized out-of-hospital medical aid provided throughout history from the biblical good Samaritan to the triage and extrication from the battlefields of the Roman conquests and the Napoleonic wars through the U.S. Civil War and every major war and conflict in U.S. history; however, it was not until the advent of combined mouth-to-mouth resuscitation and closed chest massage (what we know today as cardiopulmonary resuscitation, or CPR), enhanced 9-1-1 for use by the public in summoning emergency services, and the release of a 1966 white paper prepared by the Committee on Trauma and Committee on Shock of the National Academy of Sciences, National Research Council, that we have the EMS system that we are familiar with today (Department of Transportation, National Highway Traffic Safety Administration, 1996). It was about this time that the Department of Transportation (DOT) was given purview over EMS at the national level with the passage of the National Highway Safety Act of 1966.

During the 1970s, EMS had transitioned from mostly untrained funeral home drivers to providers trained by emergency physicians to treat many of the life-threatening scenarios that prevent people from seeking medical attention at hospitals, such as traumatic injuries, cardiac arrest, and many breathing problems. Since this time, there have been a number of concerted efforts and official recommendations by the DOT to augment and improve the delivery model of EMS throughout the country (Department of Transportation, National Highway Traffic Safety Administration, n.d., 1996, 2008). As early as 1996, the DOT published the vision of the future of EMS:

Emergency medical services (EMS) of the future will be community-based health management that is fully integrated with the overall health care system. It will have the ability to identify and modify illness and injury risks, provide acute illness and injury care and follow-up, and contribute to treatment of chronic conditions and community health monitoring. This new entity will be developed from redistribution of existing health care resources and will be integrated with other health care providers and public health and public safety agencies. It will improve community health and result in more appropriate use of acute health care resources. EMS will remain the public’s emergency medical safety net. (Department of Transportation, National Highway Traffic Safety Administration, 1996, p. iii)

Even as today’s emergency rooms, operating suites, and trauma centers throughout the world are overflowing capacity with an increasingly deficient workforce, EMS is expected to answer the call for help as the front-line of a fractured and inefficient health care system (Kellermann, 2006; Mason, Wardrope, & Perrin, 2003; O’Meara et al., 2006; Washko, 2012).

Hampered Efforts

EMS is known throughout the United States as rapid responders in times of medical and traumatic emergencies; however, ever-increasingly, EMS is being used as the front-line alternative to primary care for the non-emergent uninsured and under-insured patient population (Heightman & McCallion, 2011; Washko, 2012). There is a limited number of ambulances, EMTs, and paramedics available at any given moment, which is subject to financial constraints, and non-emergent use of these resources prevents their availability for when a true emergency arises. Secondary to the mission of providing care to the public, EMS is also needed to provide services for fire department and police department operations, such as firefighter rehabilitation at fire scenes and tactical medicine in concert with bomb squads, S.W.A.T. teams, and hazardous materials teams.

EMS resources are costly, and overburdened systems are negatively affected when these resources are misused, especially by those who are unwilling or unable to pay for the services.

Financial Impact

According to the DOT (2008) EMS workforce report, employers reported difficulties in retaining EMTs and paramedics partly due to the inability to raise wages or provide better fringe benefits. The report goes on to show that EMTs and paramedics suffer a wage disparity when compared to other similar public safety ($12.54/hr vs. firefighters: $26.82/hr; police officers: $22.25/hr) and health care workers (licensed vocational nurses and licensed practical nurses: $16.94/hr; respiratory therapists: $21.70/hr; registered nurses: $26.28/hr). In the five years leading up to 2005, the average wage for EMTs and paramedics grew only by $0.29/hr. It is important to note that these numbers do not take cross-trained firefighters and police officers into consideration.

Furthering the concern of wages, as the DOT (2008) report shows, is the lack of growth potential within EMS as most systems lack the ability to provide a meaningful career ladder to the EMTs and paramedics in their employ. These circumstances together create the scenario that EMS is an underpaid dead-end job causing high attrition as most EMTs and paramedics either suffer from burnout, culminated psychological stress from the job, or use the profession as a stepping stone into other health care fields, such as nursing, respiratory therapy, or physician-level medicine.

The DOT (2008) report provides evidence that transport-based reimbursement policies are likely to blame for the unusually low profit margin in EMS (Heightman & McCallion, 2011). The Medicare and Medicaid programs, as well as many private insurers, require documentation that the transport of a patient be medically necessary before they will pay; however, the Medicare and Medicaid reimbursement rates are very low and do not cover the cost of EMS operations. To complicate the matter, EMS providers are mandated by law to provide care to the public regardless of their insurance status or ability to pay (Heightman & McCallion, 2011). EMS is subsidized by either taxes or insurance reimbursement or some combination of the two.

Broad Mission

In addition to providing for the mundane care and transportation of the ill and injured and performing ancillary duties for the police and fire departments as noted above, EMS is tasked with disaster preparedness – preparing for the major incident that is highly unlikely to occur but would be devastating to lives and infrastructure if it does. That is if the EMT or paramedic is employed for an emergency service. Many of the EMTs and paramedics, today, are employed by private ambulance services who transport non-emergent patients to and from skilled nursing facilities and doctors’ offices. The multitude of these EMTs and paramedics are not considered when planning for emergency response schemes.

I consider EMS to be the caulking used to fill many of the fractures and gaps in today’s health care system. If it occurs outside of the hospital, then EMS will take responsibility, yet, they seldom get paid for their actions.

Proposed Solutions

There has been much talk over the past few years regarding the efficacy and efficiency of EMS, and all agree that the current definitive model is inefficient with, at best, questionable efficacy. Washko (2012) describes in detail the number of EMS schemes and their shortfalls. In his article, Washko is correct in stating that transport-based reimbursement policies fail to reward the greater EMS community for their willingness to take on further responsibility within the two scopes of operation: public health and public safety.

Wingrove and Laine (2008) explore the opportunity for training and equipping the most experienced paramedics for a public health centered role delivering community-based care. These community-based paramedics are described as augmenting the traditional emergency responder role with opportunities to direct patients to more appropriate care, such as doctor’s offices and urgent care centers instead of hospital emergency departments when appropriate to their condition. This model was researched recently in Australia with good results, and is now a recommended career path both there and in the United Kingdom (Mason, Wardrope, and Perrin, 2006; O’Meara et al., 2012). In the U.S., EMS professionals feel a responsibility to participate in disease and injury prevention efforts, and research on models that utilize specially-trained paramedics to perform home safety inspections, hazard mitigation, and reduce the risks of injuries to children have proven effective (Hawkins, Brice, & Overby, 2007; Lerner, Fernandez, & Shah, 2009). Hennepin Technical College, in Minnesota, now offers certification in Community Paramedic training when the recommended curriculum is provided by an accredited college, according to Wingrove and Laine.

Other, more immediate (but, arguably, less meaningful) solutions, as Washko (2012) describes, are incorporating operational tactics that better utilize ambulances by attempting to predict call volumes and locations based on historical data, the high-performance model. This, however, creates high-call volume, less resource driven scenarios with ambulances idling on street corners awaiting the next call. As mentioned earlier, attrition is a significant concern in EMS and these tactics are demanding on providers physically and psychologically leading to high incidences of burnout and injury (Department of Transportation, National Highway Traffic Safety Administration, n.d., 2008).


The standard operational benchmarks of EMS – response times and mortality and morbidity of cardiac arrest – are antiquated measures and typically distract policymakers when they are considering financial incentives for EMS (Heightman & McCallion, 2011; Washko, 2012). EMS needs to evolve with the changing health care system, and I feel that it is poised, specifically, to help address disparities in health and health care. Using the community-based paramedic model of health care delivery, we can address many public health concerns, provide for public safety, and still maintain the traditional role of emergency responder. The community-based paramedic model will provide an acceptable alternative to the options that lie ahead.

The economics of health care is a reality that must be considered by every EMS operation when approaching growth and change. As long as EMS can fill the gaps in the current health care system, it will be worth the money required to subsidize a robust, well-trained, and well-equipped contingent of emergency medical professionals. In the meantime, though, EMS agencies will have to seek more efficient models that maximize reimbursement while minimizing costs.


Committee on Trauma & Committee on Shock, Division of Medical Sciences, National Academy of Sciences, National Research Council. (1966). Accidental Death and Disability: The Neglected Disease of Modern Society. Washington, D.C.: Author.

Department of Transportation, National Highway Traffic Safety Administration. (n.d.). A leadership guide to quality improvement for emergency medical services (EMS) systems (Contract DTNH 22-95-C-05107). Retrieved from http://www.nhtsa.gov/people/injury/ems/Leaderguide/index.html

Department of Transportation, National Highway Traffic Safety Administration. (1996). Emergency medical services: agenda for the future (DOT HS 808441 – NTS-42). Retrieved from http://www.nremt.org/nremt/downloads/EMS%20Agenda%20for%20the%20Future.pdf

Department of Transportation, National Highway Traffic Safety Administration. (2008). EMS workforce for the 21st century: a national assessment. Retrieved from http://secure.naemse.org/services/EMSWorkforceReport.pdf

Hawkins, E. R., Brice, J. H., & Overby, B. A. (2007). Welcome to the World: Findings from an emergency medical services pediatric injury prevention program. Pediatric Emergency Care, 23(11), 790-795. doi:10.1097/PEC.0b013e318159ffd9

Heightman, A. J. & McCallion, T. (2011). Management lessons from Pinnacle: Key messages given to EMS leaders at the 2011 conference. Journal of EMS, 36(10), 50-54.

Kellermann, A. L. (2006). Crisis in the emergency department. New England Journal of Medicine, 355(13), 1300-1303. doi:10.1056/NEJMp068194

Lerner, E. B., Fernandez, A. R., & Shah, M. N. (2009). Do emergency medical services professionals think they should participate in disease prevention? Prehospital Emergency Care, 13(1), 64-70. doi:10.1080/10903120802471915

Mason, S., Wardrope, J., & Perrin, J. (2003). Developing a community paramedic practitioner intermediate care support scheme for older people with minor conditions. Emergency Medicine Journal, 20(2), 196-198. doi:10.1136/emj.20.2.196

Mayer, J. D. (1980). Response time and its significance in in medical emergencies. Geographical Review, 70(1), 79-87. Retrieved from http://www.ircp.info/Portals/22/Downloads/Performance/Response%20Time%20and%20Its%20Significance%20in%20Medical%20Emergencies.pdf

National Traffic and Motor Vehicle Safety Act of 1966, Pub. L. No. 89-563, 80 Stat. 718 (1966).

O’Meara, P., Walker, J., Stirling, C., Pedler, D., Tourle, V., Davis, K., … Wray, D. (2006, March). The rural and regional paramedic: moving beyond emergency response (Report to The Council of Ambulance Authorities, Inc.). Retrieved from http://www.ircp.info/Portals/22/Downloads/Expanded%20Role/The%20Rural%20and%20Regional%20Paramedic%20Moving%20Beyond%20Emergency%20Response.pdf

Washko, J. D. (2012). Rethinking delivery models: EMS industry may shift deployment methods. Journal of EMS, 37(7), 32-36.

Wingrove, G. & Laine, D. (2008). Community paramedic: A new expanded EMS model. Domain3, 32-37. Retrieved from http://www.ircp.info/Portals/22/Downloads/Expanded%20Role/NAEMSE%20Community%20Paramedic%20Article.pdf

Paying for Health Care, Today and Tomorrow

Before delving into the substance of this discussion, I must say that my personal beliefs are contradictory to many globalized health care efforts. Penner (2005) discusses some benefits of discussing and comparing health care economics between various nations. However, as we combine efforts to target specific health concerns across the globe, we lose the ability to innovate, promote evidence-based discussion, and promote the sovereignty of each country involved in the global effort. This globalization of health care deteriorates the ability to compare and contrast best practices of various countries. Unfortunately, most of the published works promote an insidious form of social justice and do not address how globalization efforts reduce the sovereignty of nations and people. Huynen, Martens, and Hilderdink (2005) support this deterioration by promoting a foundation for a global governance structure that would lead to better dissemination and control of globalization efforts.

Campbell and Gupta (2009) directly compare some claims that the U.K. National Health System (NHS) has worse health outcomes than the traditional U.S. model. Though Campbell and Gupta provide evidence disparaging many of these claims, they also seem to provide some insight as to the woes the NHS has recently faced and are working to correct. Under a system promoted by Huynen, Martens, and Hilderdink (2005), we would ultimately lose the comparison between nations as to best practices. The U.S. is currently debating the value of nationalizing health care, and similar arguments are arising based on the inability for interstate comparisons of effective and efficient delivery of health care among the various states.


Campbell, D. & Gupta, G. (2009, August 11). Is public healthcare in the UK as sick as rightwing America claims? The Guardian. Retrieved from http://www.guardian.co.uk/society/2009/aug/11/nhs-sick-healthcare-reform

Huynen, M. M. T. E., Martens, P., & Hilderink, H. B. M. (2005). The health impacts of globalisation: a conceptual framework. Globalization and Health, 1, 1-14. doi:10.1186/1744-8603-1-14

Penner, S. J. (2004). Introduction to health care economics & financial management: fundamental concepts with practical applications. Philadelphia, PA: Lippincott Williams & Wilkins.

Budget Forecasting Models

Forecasting, according to Menifield (2009), is an important component of budget preparation and analysis. Using the Putnam police department (Putnam, CT) as an example, I will show how forecasting can benefit the budget process.

The Putnam police department is a small local department that relies heavily on public support. In order to forecast the economic condition that provide insight to the budgetary needs of the department, I would normally suggest using simple time-series forecast model. Due to the wavering economy over the last few years, however, I would start to consider using a multiple regression model that could take into account decreases in property taxes, real inflation, and the poor business environment for many of the small businesses that contribute a sizable portion of the tax base (Spencer, 2009). Menifield (2009) suggests that many localities can get by using the simpler, non-multivariate analysis, though as I point out, economic trends should be considered, lately.

The Putnam police department has annual purchases very typical of other similar sized departments and the single capital program (for the K-9 division) is being paid for by grants and donations. It is these donations that promote the need for additional fiscal responsibility; the public may be less willing in the future to offset major purchases through donations if property taxes rise significantly.


Menifield, C. E. (2009). The basics of public budgeting and financial management: a handbook for academics and practitioners. Lanham, MD: University Press of America.

Spencer, M. (2009, January 5). Current economic situation vs. the Great Depression: Striking comparisons with the current economic situation to the Great Depression. WTVY.com. Retrieved from http://www.wtvy.com/home/headlines/29813759.html

Government Budgets

Every line item of a government budget must be an expenditure necessary to achieving the goals of the organization (Menifield, 2009). The governmental budgetary process provides transparency to the economic demands of the organization allowing for oversight by the people directly and by committees of elected officials dedicated to fiscal responsibility. It is this fiscal responsibility that ensures government spending is controlled and necessary for the purposes of government.

As Menifield (2009) points out, there are four dominant areas of concern, typically, when addressing governmental impact: political, tax, demographic, and administrative. Within each of these areas of concerns, aspects of efficiency, effectiveness, and equity must be addressed. While political concerns are more about the soundness of the overall plan, other concerns are more focused on specific aspects of the plan, such as who will be impacted and how

The budget process is the government’s means of allocating funds to departments within its jurisdiction in order to perform efficiently and effectively. The transparency of this process allows the people to offer criticism and promote their values and views on the process. This is important to ensure that people understand the necessity of each expenditure.

Though there are few people that pay attention to every aspect of the budget process, there are programs, usually expensive ones, that empassion people towards action in the way of participation in the process. Politicians should envision and anticipate many of the questions and concerns that the public might have for any program that they are seeking to funding. By being prepared, politicians will serve their constituency well by allaying fears and providing information.


Menifield, C. E. (2009). The basics of public budgeting and financial management: A handbook for academics and practitioners. Lanham, MD: University Press of America.

Political and Technical Budget Strategies

When preparing an agency or department budget, two strategies may be employed, usually in combination: political budgeting and technical budgeting (Menifield, 2009). While most budgets are defended politically, the technical budgeting stategy is most useful when defending mandatory and base expenditures of a legally mandated service, such as a police or fire department (Menifield, 2009). New programs, especially those viewed largely as ancillary, or “nice to have,” would be largely defended using a more polital than technical strategy.

Menifield (2009) explains the technical budgeting strategy as “[concentrating] on the numbers or budgetary facts [and] split into two categories: mandatory, [sic] and discretionary spending” (p. 43) with base expenditures “to maintain the same level of service” (p. 44) identified for each. Efficiency and productivity are foci of the technical budgeting strategy. The political budgeting strategy, according to Menifield (2009), is used to “sell” a program based more on its merits or public demand than on mandate or efficiency and productivity.

In the emergency medical services, since its provision is usually not a legal requirement of the government, it would make sense to defend the budget politically if the service was started within the last few years; however, a more technical budget in continuing years might help to buttress the perceptions of the public that it is actually a needed service. Continuing to defend an emergency medical services budget with a more political strategy could make it actually appear less important and subject to tighter budget controls. Additionally, as the emergency medical service is the only public safety entity that routinely charges user fees, the structure of a technical budget would plainly show revenue offsetting expenditures, making it less likely to suffer cuts. Again, both strategies would be used proportionally to their need.


Menifield, C. E. (2009). The basics of public budgeting and financial management: A handbook for academics and practitioners. Lanham, MD: University Press of America.

Mind Your Own Business: Health Care Economics

Regardless of funding levels or overhead, health care must be provided ethically. The goal of the health care industry is to improve health, and unlike other industries, this market is driven not by choice but by need. Other markets perform, according to Friedman and Friedman (1980) and Smith (1910), only when mutual benefit can be achieved, that is, without external force, coercion, or unnatural limitation. Penner (2004) presents the economy of health care representative of many of the ideals that were accepted at the turn of this century. However, the current state of health care economics is the result of the unnatural force of these ideals in attempting to mold the market against natural market pressures, as described in detail and warned against by Friedman and Friedman and Smith.

Health care demand is based on need. Within that need, demand is reflective of pricing. For example, patients do not elect coronary bypass surgery, but if needed, the demand could be reflected by pricing constraints realized in negotiations of hospitals and insurance carriers. In this case, the patient may be transferred to a center that has negotiated reduced rates with the carrier for coronary bypass procedures. Ergo, health care demand is reflective of patient need and is variable only in the context of insurance pricing. It is within this negotiation that the aspects of quality, access, and cost are accounted. Government policy, however, has a negative and downward effect on these negotiations. If health care institutions are perceived to be able to provide the same services at discounted prices for government payors, then the institution should be able to provide these same services to private payors for the same or similar cost. This cost adjustment conversely affects quality and access.

Penner (2004) makes a logically flawed argument in respect to regulation arguing that increases in skilled nursing facility (SNF) safety regulations created a demand for more nursing assistants; however, this is an increased input to be provided by the SNF, not an output to be demanded by the patient. The cost will be borne by the private insurance payor, ultimately, and not the regulatory agency or the patient, which increases premiums decreasing access to private health insurance. Regulations negatively impact the relationship between supply/demand, quality, access, and cost. This is not to say that safety should not be a concern, as it is one of the few areas that I agree should be regulated, though, minimally.

Penner (2004) goes on to state “one role of government is to intervene in cases of market failure” (p. 21), using the pharmaceutical industry as an example. Unfortunately, with the focus on the new and significant health care and health insurance legislation and regulation, many academic discussions surrounding health care economics are now outdated and trivial. Without entertaining a constitutional debate, recently, governmental involvement has shown to have a negative effect on the health care industry actually causing market failures instead of alleviating them. Recent over-regulation by government on the pharmaceutical industry has resulted in a significant and dangerous shortage of life-saving emergency medications (Malcolm, 2012). This economic constraint will lead to higher demands of other, inferior, medications and increase the price, effectually increasing cost and decreasing both access and quality. This effect is also seen in the emergency medical services when states fix the price that can charged to users leaving the municipal taxpayer to face tax increases or decreases in access to emergency services and the quality of the services delivered (American Ambulance Association, 2008). Over-regulating an industry without regard to survivability is inefficient and unethical, limiting access and quality while increasing costs.

Insurance companies have sought to minimize their exposure to the rising costs of health care (Penner, 2004). By developing common sense incentives, insurers can advocate for their customers financially while expressing desire for optimal outcomes. By maximizing consumer and provider choice, these incentives can be used as natural pressures within the market to improve upon cost, quality, and access (Penner, 2004). This realization, according to Penner (2004), resulted in the emergence of the health maintenance organization (HMO) — the first widely accepted form of managed care. Unfortunately, HMOs faced scrutiny in the 1990’s and later augmented business models to reflect newer preferred provider organizations (PPO) and point-of-service (POS) plans. PPO and POS plans were created to promote the more inexpensive use of general providers and those providers that have negotiated fees. Unfortunately, Penner writes, the pressures of these PPO and POS plans on the consumer limit choice within the market; however, the consumer still has a choice of insurance carrier, which minimizes the pressure faced within each plan. This freedom is not expressed in governmental plans, such as Medicare and Medicaid.

As health care costs rise, the writings of Friedman and Friedman (1980) and Smith (1910) would suppose that we lessen regulation within the industry, allow new and novel approaches to insurance paradigms, and create an environment with as little unnatural market pressures as possible in order to allow natural market pressures to ensure equitable cost, access, and quality through competition


American Ambulance Association. (2008). EMS structured for quality: Best practices in designing, managing and contracting for emergency ambulance service. Retrieved from fitchassoc.com/download/Guidebook-April08-V2.pdf

Friedman, M. & Friedman, R. D. (1980). Free to choose: a personal statement. Retrieved from http://books.google.com/

Malcolm, A. (2012, January 4). Vast web of federal regulation causing drug shortages. Investor’s Business Daily. Retrieved from http://news.investors.com/article/596775/201201041859/big-government-behind-drug-shortages.htm

Penner, S. J. (2004). Introduction to health care economics & financial management: Fundamental concepts with practical applications. Philadelphia, PA: Lippincott Williams & Wilkins.

Smith, A. (1910/1957). The wealth of nations (Vol. 1). Retrieved from http://books.google.com/

Private vs. Public Budgets

Budgeting is an important concept that is pertinent to any organization. According to Menifield (2009), budgeting is a financial planning function that creates accountability for the funds made available to meet or work towards some goal. In the private sector, budgets create the bottom line, or the amount needed to earn making a profit. In the public sector, however, budgets reflect the accountability and stewardship of tax revenue and its application towards maintaining and improving infrastructure. Although Menifield focuses on public budgets and compares them to private-for-profit business models, many not-for-profit corporations and other philanthropic ventures use budgets to account for funding and spending without focusing so much on profit, much like public budgets (Maddox, 1999). Not-for-profit corporations still need to focus on maximizing funding and reinvesting gains, though — a difference of public budgeting (Maddox, 1999; Penner, 2004). Most important, a budget provides a sense of direction for the organization and should reflect the stated vision and values.

Menifield (2009) describes the primary difference of public versus private budgeting as public budgets are prepared based on organizational needs and the funding for the budget is directed through tax revenue. Private organizations, according to Menifield, do not have the luxury of compulsory funding enjoyed by public organizations and must generate revenue through a prospective business model that maximizes income while minimizing expenditures. Both types of budgeting have intrisic responsibilities inherent to the process, which, if ignored, could result in severe penalties to those responsible.

Additionally, there are functions of government which are served by private contractors. Employing this concept would be rationalized, planned, and tracked by utilizing both private and public budgets — the contractor would utilize an internal budget reflective of private organizations, and the contracting governmental entity would use its public budget to plan and track the contract. Whereas typical criminal justice agencies, such as local police departments, judicial systems, et al., rely on public budgeting, the recent use of private contractors to manage some federal prisons reflect this use of private-public budgeting (Austin & Coventry, 2001; Nelson, 2005).

Budgeting is a form of financial planning. A budget also serves as an important document that can be used to focus an organization towards specific goals and provides overall accountability in financial management.


Austin, J., Coventry, G. (2001). Emerging issues on privatized prisons (NCJ No. 181249). Retrieved from http://www.ncjrs.gov/pdffiles1/bja/181249.pdf

Maddox, D. C. (1999). Budgeting for not-for-profit organizations. Retrieved from http://books.google.com/

Menifield, C. E. (2009). The basics of public budgeting and financial management. Lanham, MD: University Press of America.

Nelson, J. (2005). Competition in corrections: Comparing public and private sector operations (IPR No. 11647 [Revised]). Retrieved from http://www.bop.gov/news/research_projects/published_reports/pub_vs_priv/cnanelson.pdf

Prior Proper Planning …

… Prevents Poor Performance

I am in the midst of planning an ad hoc merger of a number of local emergency medical service agencies into a single regional provider to reduce overall costs while maximizing revenue, improve training and the delivery of care, and to streamline the operational processes that support our providers in the field. Unfortunately, I have found that there are many obstacles that need to be dealt with at every step before moving on to the next. My research has certainly opened my eyes to developing a useful approach to these problems.

Planning “[provides] the appropriate focus and direction for … organizations” (Zuckerman, 2006, p. 3). Without planning, organizations risk stagnation and obsolescence. For any organization to succeed (and continue to do so), the strategy needs to focus both on the contemporary traditional needs as well as those anticipated in the future, but this focus needs to be comprehensive. Bartling (1997) writes of 25 different pitfalls any health care organization might face when considering strategic planning. These 25 pitfalls are just some of the issues I hope to avoid.

One of the largest difficulties in planning for emergency medical systems, however, is the sense of ‘fiefdom’, or an assertion of organizational ownership — in a truly feudal sense. A fiefdom is a literal power trip. In this area, there are 10 towns with an average of two ambulances each, and each department’s administration will fight tooth and nail to keep the organization from outgrowing them. What is interesting about the area is that many of the members of one department work for at least two of the other departments, also. This is because the pay is so meager they have to work as many hours as possible, and there is no chance of working more than 32 hours at any one service in any given week. The pay is low as is the quality of care. This needs to change, but how do I create an amalgumated organization from the bits and pieces that I have to work with? Add to that my lack of formal authority in this process. My vision is to reduce the number of ambulances by staffing eight ambulances at all times and tactically positioning them around the region. This alone would create 48 well-paid jobs, using the same 40 people who currently job share across organizational lines.

In reviewing the available resources, I have learned that there is no particular process or flow-chart pathway to effective planning (Bartling, 1997; Begun & Kaissi, 2005; Zuckerman, 2006). Critical forward thinking is needed, instead. Some of the particular issues that Bartling (1997) discusses and I foresee might be particular to my planning process are: inadequate planning, short-sightedness, underestimating the complexity of the process, post-merger angst, analysis paralysis, and lack of evaluative criteria, to name a few. Politics plays a large role in many of these issues I mention.

Inadequate planning, short-sightedness, and a lack of evaluative criteria are closely related. I see in the present that the system does not work as well as it should (short-sightedness), and I want to develop a plan that can be implemented immediately (probably suffering inadequate planning). This would leave me with a fragmented system devoid of vision and, therefore, crippled from improving (lacking that evaluative criteria). These are pitfalls that I need to avoid. These issues would give rise to the others dooming my effort to failure and, possibly, leaving the system in even worse shape than it began.

Perhaps, my only chance of fulfilling this process is to first perform a limited situational assessment by identifying the mission, vision, and values of all of the stakeholders and show how a streamlined process can better fulfill their visions (Casciani, 2012). By gaining stakeholder support, I might better leverage my idea against those who fear change.


Bartling, A. (1997). 25 pitfalls of strategic planning. Healthcare Executive, 12(5), 20–23.

Begun, J. & Kaissi, A. (2005). An exploratory study of healthcare strategic planning in two metropolitan areas. Journal of Healthcare Management, 50(4), 264–274.

Casciani, S. J. (2012). Strategic planning. In S. B. Buckbinder & N. H. Shanks (Eds.), Introduction to healthcare management (Custom ed.; pp. 3-23). Sudbury, MA: Jones & Bartlett.

Zuckerman, A. (2006). Advancing the state of the art in healthcare strategic planning. Frontiers of Health Services Management, 23(2), 3–15.

Future Threats

Aside from hoax attacks, where credible threats occur based on purposeful counter-intelligence efforts of terrorists, I suspect large-scale events to be the modus operandi of terrorists in the next decade. According to LaFree, Yang, and Crenshaw (2009), anti-U.S. terrorists have ample intent on attacking the U.S. on our soil; however, this would be a huge and logistically complicated undertaking. For this reason, any future organized act of terror on U.S. soil will be designed to be significant, causing extreme loss of life or toppling a significant structure or both.

Biologic weapons would be the choice for terrorists who wished to inflict harm to the greatest amount of people, though releasing biologic material lacks the sudden impact usually sought, and weaponized biologics are not easily grown or economical (Levitin, 2005). Chemical weapons are typically easier and cheaper to manufacture, though they lack effectiveness and tend to merely create a scare of equivalent magnitude of a hoax (Levitin, 2005). Aside from basic explosives, this leaves the radiologic threat, a threat that I believe, coupled with a significant target, will cause devastating effects not unlike 9/11.

A dirty bomb is a conventional explosive used to disseminate radiologic materials over an area. I foresee a coordinated attack on the financial districts of the U.S. using dirty bombs. The bombs would, first, cause physical destruction to the buildings causing immediate disruption of the financial sector of the U.S. economy, along with a large death toll. Second, the radiation dispersed over the area would cause difficulty in cleaning up the area, inhibiting recovery and further impacting the financial markets.

A law enforcement response to such an attack would certainly be large in scale. The local police department would be first to respond, along with state police, then the WMD Coordinator at the local FBI field office would be apprised of the situation. As responders start arriving on scene, personal radiation detectors would start to tone indicating the release of radiologic material. This further information would prompt the WMD Dictorate in Washington, D.C., to order a full asset response by the FBI and other federal terrorism partners (e.g. the Joint Terrorism Task Force). The response to this type of incident should be trained on in cooperative exercises involving all levels of law enforcement. Additionally, personal radiation detectors (and other detectors) should, at a minimum, be placed in police vehicles for early warning of environments immediately dangerous to life and health. Adequate training, equipment, and preparation are the only ways in which to prepare for responding to large-scale terrorist attacks.


LaFree, G., Yang, S., & Crenshaw, M. (2009). Trajectories of terrorism: Attack patterns of foreign groups that have targeted the United States, 1970-2004. Criminology & Public Policy, 8(3), 445-473. doi:10.1111/j.1745-9133.2009.00570.x

Levitin, H. W. (2005). Debunking myths: How law enforcement can help diffuse the public’s fear. On the Beat. Retrieved from http://www.adl.org/learn/columns/Levitin.asp

Fear of Terrorism

As terrorism becomes more prevalent within a society, concerns about the psychological effects are brought to the forefront. The psychological effects of terrorism, in general, should have an impact on the ability of law enforcement and the public to interface appropriately. A recent study by Bleich, Gelkopf, and Solomon (2003) of the psychological effects of terrorism on the public in Israel showed surprisingly low levels of post-traumatic stress disorder symptoms despite high incidences of direct exposure to terror events. This study demonstrated that, although up to a third of the respondents acknowledged a “limited sense of safety and substantial distress [they] reported adapting to the situation without substantial mental health symptoms and impairment, and most sought various ways of coping with terrorism and its ongoing threats [, possibly linked to] processes of adaptation and accommodation” (p. 619). The study found that the most effective and widely used coping mechanism was checking on the well-being of friends and family. As people tend to cope well with trauma, attitudes towards protective measures seem to acquiesce for the common good, and this can be assistive to law enforcement.

One of the protective measures people tend to adopt that would help law enforcement is a sense of hypervigilance (Bleich, Gelkopf, & Solomon, 2003). Hypervigilance allows the people to be more attentive to things out of the ordinary (e.g. unattended packages, suspicious loitering, anxious mannerisms of others, et al.). This promotes a line of communication with law enforcement not only regarding terrorism but for other criminal activity, also.

Another protective measure, which goes towards acquiescence, is the ability of the people, in general, to accept an increased presence of law enforcement in their daily lives. When faced with a proximal event, the bulk of the citizenship contend that it is, indeed, a function of government to protect the masses from further harm, and these citizens tend to accept limits on personal liberty for perceived increases in security (Klein, 2007). This is a double-edged sword, however. People tend to want to return to a normal state of affairs (Bleich, Gelkopf, & Solomon, 2003). Though an increased police presence is initially welcomed and embraced, the people will eventually resent the loss of liberty and require law enforcement presence to recede. How this occurs will either enhance or detract from the ongoing relationship with law enforcement. An example of this is easy to see when considering both local law enforcement and the federal effort of the Transportation Security Administration (TSA). Local law enforcement seems to have decreased their presence, at least in my area, and are respectfully viewed as helpful, whereas the TSA, an agency that continues to irrationally impede on liberty, is viewed negatively by the traveling public.

Law enforcement is a service-based industry where the public is the customer. Police need to understand both the rights and the fears of the people in order to maintain the appropriate level of service, which waxes and wanes.


Bleich, A., Gelkopf, M, & Solomon, Z. (2003). Exposure to terrorism, stress-related mental health symptoms, and coping behaviors among a nationally representative sample in Israel. Journal of the American Medical Association, 290(5), 612-620.

Klein, L. (2007). Civil liberties and national security in the post 9-11 era: State power and the impact of the USA Patriot Act. Conference Papers – American Sociological Association, 1-8.