LOS ANGELES COUNTY
CITIZENS ECONOMY AND EFFICIENCY COMMITTEE

ROOM 743 HALL 0F ADMINISTRATION 500 TEMPLE / LOS ANGELES, CALIF0RNIA 90012 / 625-3611, EXT 64605



REPORT ON THE
COMMITTEE ON EMERGENCY MEDICAL CARE


February 1975

Report by the Task Force on Commissions and Committees

Dr. Robert J. Downey, Chairman
Anne S. Collins
theodore S. Flier
Mrs. Ray Kidd
Joseph A. Lederman
William S. Mortensen
Earl J. Sachs
Dr. Warren H. Schmidt
George Shellenberger


Other Commission Members

Maurice Rene Chez, Chairman
Muriel Pfaelzer Bodek
Catherine Graeffe Burke
John D. Byork
Rudolph A. Cervantes
Jerry Epstein
Milton C. Gordon
Leo A. Majich
Robert Ruchti, II
Larkin Teasley
Bryan Walker


Commission Staff

Burke Roche, Executive Secretary
John J. Campbell, Staff Specialist
Maxlynn Larsen, Secretary to Commission

 

PREFACE

At the meeting on December 3, 1974) the Board of Supervisors asked the Economy and Efficiency Commission to review proposals for strengthening the Committee on Emergency Medical Care and to report to the Board on December 17, 1974. The request followed eighteen months of debate among members of the committee, the Board of Supervisors, and other interested parties over the role and composition of the committee. This debate reflected a concern over the inability of the committee to function effectively.

We submitted a progress report on December 17 which contained two recommendations:

1. That the Board again include in the County's current legislative program an amendment to the Health and Safety Code, Section 1756, to provide that the Committee on Emergency Medical Care will act in an advisory capacity to the Board of Supervisors and to the Department of Health Services.

2. That the Board request the individual members of each committee or commission with a role related to the provision of emergency medical services to support the passage of such legislation in the form approved by the Board in 1974.

We explained that the present State law requires the Committee on Emergency Medical Care to report annually to State health agencies on emergency medical care services. The law is silent, however, as to whether the committee should also act in an advisory capacity to the Board of Supervisors and the Department of Health Services. The County Counsel has interpreted this silence to mean that the committee cannot act in an advisory capacity to either the Board or the department.

The 1974 bill passed in the State Senate but was amended and failed in the Assembly. Therefore, to correct the present ambiguous situation, we recommend that the County again initiate the same legislation and that all commissions and committees concerned with health care support the legislation. The Board of Supervisors approved the recommendations in our December report, and the County is now in the process of implementing them. (For copies of the current law and the proposed amendment, see Appendices B and C.)

This report contains our final conclusions and recommendations on the Committee on Emergency Medical Care. They are based upon over 70 interviews and meetings with members of the Committee on Emergency Medical Care and with other participants in or experts on the County's emergency care system, including County officials. (See Appendix D for a list of persons interviewed.) We thank them for their suggestions and assistance in the preparation of this report. The conclusions and recommendations, however, are solely the responsibility of the task force. in addition, we have reviewed a substantial number of reports, legal documents, committee minutes, and similar material associated with the operation of the Committee on Emergency Medical Care and related committees.



TABLE OF CONTENTS

Preface

I. Summary of Recommendations

II. Controversy Over the Role and Composition of the Committee

III. Role of the Committee

IV. Responsibilities of the Committee

V. Principles of Operation

VI. Composition and Method of Appointment of Committee Members

VII. Relationship to the Paramedic Committee

VIII. Communications with Other Groups


APPENDIX A - Legal Background

APPENDIX B - Health and Safety Code 1755 (Available with Hard Copy)

APPENDIX C - Letter from Los Angeles County Counsel, January 3, 1974, RE: Proposed Legislation
(Available with Hard Copy)

APPENDIX D - Persons Interviewed (Available with Hard Copy)




I. SUMMARY OF RECOMMENDATIONS

This section summarizes the task force recommendations on the Committee on Emergency Medical Care. A full discussion of the reasoning which led to the recommendations is contained in the body of the report beginning with Section II, page 4.

The report contains six recommendations on the following subjects: (1) Role of the Committee, (2) List of Responsibilities, (3) Principles of Operation, (4) Composition and Method of Appointment of Committee Members, (5) Relationship to the Paramedic Committee, and (6> Communications with Other Groups. The recommendations should be implemented by incorporating them in an amendment to the Administrative Code (Ordinance No. 4099).

Recommendation 1.

The role of the committee should be purely advisory and evaluative. It should have no regulatory or managerial responsibilities.

Recommendation 2.

The principal duties of the committee should be:

1. To act in an advisory capacity to the Board of Supervisors and the Department of Health Services regarding County policies, programs, and standards for emergency medical care services throughout the County.

2. To conduct a continuous evaluation of the impact and quality of emergency medical care services throughout the County.

3. To conduct studies of particular elements of the emergency medical care system as requested by the State, the County or other public or private agency, or on its own initiative.

4. To report its findings, conclusions, and recommendations to the Board of Supervisors at least every six months.

5. To report annually its observations and recommendations to the concerned State agencies, as required by State law.

6. To recommend to the Board of Supervisors an annual budget for the committee, including the number and classification of staff personnel.

(For additional duties, see Section IV, pages 11-12.)

Recommendation 3

To insure the greatest possible independence and objectivity for the committee, it should operate on the following principles.

1. Members should not be in a position to augment their income or promote their special interests through membership on the committee.

2. County employees should not serve on the committee.

3. The committee should report directly to the Board of Supervisors.

4. The committee should appoint its own staff, as authorized by the Board of Supervisors.

5. Terms of membership should be two years, with no limit on number of terms.

6. The committee should adopt a set of formal bylaws for its own operation consistent with ordinance provisions.

Recommendation 4

The committee should consist of the following members who should be appointed in the following manner:

The committee will consist of eleven members. All members will be appointed by the Board of Supervisors. All will be residents of Los Angeles County. Five members will be physicians actively engaged in acute or emergency medicine. They will be nominated by certain medical societies or associations involved in emergency care. The six other members will also be nominated by a specified sponsoring group.

The Board may reject the nomination of any of the sponsoring groups and ask for a new name to be submitted. If the Board wishes, it may also request more than one name for nomination by any group. We caution, however, that this latter procedure could embroil the Board in troublesome and time-consuming controversy and lobbying over the appointment of any individual.

The members and nominating group should be:

1. An emergency medical care physician nominated by the California Chapter of the American College of Emergency Physicians.

2. An orthopedic, general, or neurological surgeon nominated by the Los Angeles Surgical Society.

3. A cardiologist nominated by the American Heart Association, Greater Los Angeles Affiliate.

4. A psychiatrist nominated by the Southern California Psychiatric Society.

5. A physician nominated by the Los Angeles County Medical Association.

6. A registered nurse with experience in emergency medical care nominated by the California Nurses Association.

7. A hospital administrator nominated by the Hospital Council of Southern California.

8. A systems specialist experienced in communications, transportation or education systems nominated by the Western Section of the Operations Research Society of America.

9. A systems specialist experienced in management or financial systems nominated by the Southern California Chapter of the Institute of Management Sciences.

10. A public representative familiar with emergency medical care nominated by the Los Angeles County Federation of Labor, AFL-CIO.

11. A public representative familiar with emergency medical care nominated by the League of California Cities, Southern California Chapter.

Recommendation 5

The County Paramedic Committee should continue to serve as advisory to the Director of the Department of Health Services in matters relating to the training and certification of mobile intensive care paramedics.

Recommendation 6.

The Paramedic Committee, the Emergency Preparedness Committee, and all other County committees and commissions whose actions could affect emergency medical systems should transmit to the Committee on Emergency Medical Care copies of all minutes, testimony and associated records of their findings and actions.

II. CONTROVERSY OVER THE ROLE AND COMPOSITION OF THE COMMITTEE

In the course of our study several people, including members of the Committee on Emergency Medical Care, have stated that the primary reason why the committee is not functioning effectively is personality conflicts. While it is evident from transcripts and tapes of committee meetings that some personal animosity has obstructed the committee's work, our conclusion is that the principal problem is a lack in present legislation of a clear specification of what the committee should do or the basic p6licies and principles by which it should operate. (See Appendices A, B, and C.) This gap has left room for the intrusion of personal, emotional, and ideological disputes, which have recently dominated committee meetings.

Personal and ideological differences, however, exist on all committees. Nevertheless, committees can and do function effectively when they are given a specific mandate. Thus, the real problem affecting the Committee on Emergency Medical Care is the lack of definition of the committee's proper responsibilities and method of operation.

Recently, two groups on the committee have submitted conflicting proposals to the Board of Supervisors to change the committee's composition. These proposals - referred to as the majority and minority proposals - are a current manifestation of the committee's lack of a concrete mission. Both proposals agree that the committee should be reconstituted, but base their recommendations for membership on different criteria. In this section we review the current composition of the committee and the majority and minority proposals.

Current Composition

State law requires the Board of Supervisors of each County to establish and to determine the composition and membership of a Committee on Emergency Medical Care. Currently, the committee in Los Angeles County consists of eleven members appointed by the Board consisting of five physicians and six non-physician members as follows:

Director of Health Services or his designee

Deputy Director, Community Health Services

A representative of the Sheriff

A nominee of the County Medical Association

A nominee of the American Heart Association

A nominee of the Hospital Council of Southern California

A nominee of the County Federation of Labor, AFL-CIO

A nominee of the Southern California Ambulance Association

A nurse and two doctors appointed directly by the Board of Supervisors

Minority Proposal

In June, 1974, three of the physicians on the committee submitted a report to Supervisor Hahn recommending a reconstitution of the committee. "We believe," the letter stated, "that the purpose of the Los Angeles County Committee on Emergency Medical Care, to act as an independent advisory body to the Board of Supervisors, has been thwarted. Substantial differences exist on the Committee between public and private members. Governmental employees, who already have normal direct access to the County Board, control the Committee. During the past year, the major function of the Committee has been to rubber stamp and there is no prospect that this will change.

They proposed to enlarge the committee to twelve members consisting of six physicians and six non-physicians. Three physicians would be nominated by the County Medical Association, the American Heart Association, and the American College of Emergency Physicians. The other three physicians would be appointed directly by the Board of Supervisors from specialties related to emergency medicine, such as orthopedics, chest surgery, and neurosurgery.

The number of County employees would be reduced to one - a nominee of the Department of Health Services. Two non-physician members would be nominated, as they are now, by the Hospital Council and the Ambulance Association. The nurse would be nominated by the Emergency Department Nurses Association, and the two other non-physician members would be appointed directly by the Board from fields related to emergency medical services, such as communications, bio-engineering and health education.

Significantly, this proposal does not include public members. The representative of the County Federation of Labor, now considered to be a public member, would be replaced by a physician. Clearly, the minority proposal emphasizes expertise as the principal criterion of membership.

Majority Proposal

The Board referred the minority proposal back to the committee for its recommendations. At a regular meeting in November, 1974, the committee debated various proposals for composition of the committee and voted 5-4 to recommend a different reconstitution of the committee. This proposal was incorporated in a report submitted to the Board of Supervisors in November.

Commenting on the committee history, the report stated, "In fulfilling its obligations, the Committee has contributed much advice, direction, and leadership to the County Emergency Medical Care Program, helping it to become one of the finest programs in the Country today." However, the report continued, "Despite this progress, new concerns have emerged over the past year which have made clear the need for re-evaluation of key committee elements, particularly its composition and structure."

The majority proposal similarly emphasized the need for expertise, but it also attempted to balance this requirement with the need as the report states, for "citizen participation and political responsiveness." The proposal makes three changes from the present composition. It replaces one of the two representatives of the Department of Health Services by a representative of the Forester and Fire Warden; it requires one of the physicians appointed directly by the Board to be a member of the American College of Emergency Physicians; and it specifies that the nurse must be actively involved in emergency service.

Board Action

At the Board of Supervisors' meeting on December 3, the Board considered both this proposal and the previous proposal by the three physicians, which was resubmitted as a minority report. Since the Economy and Efficiency Commission had already initiated a study of all health related committees and commissions, the Board referred this entire matter, including its own discussions over the past twelve month8, to our commission. The task force analysis and recommendations follow.

III. ROLE OF THE COMMITTEE

As we have noted, nowhere in the present legislation is there a clear specification of what the committee should do and how it should operate. First of all, in order to determine the responsibilities which appropriately should be assigned to it, the fundamental nature of its operation should be defined. The key question, we believe, is should the committee be limited to a purely advisory role or should certain: regulatory or managerial duties be assigned to it, such as the approval of emergency aid program contracts between the County and designated community hospitals?

This absence of an officially prescribed role, we believe, is a major reason why the committee itself for the pa8t two years has had difficulty in agreeing upon its proper responsibilities. The manner of operation of the committee, we believe, should be prescribed in the Administrative Code (Ordinance No. 4099). The Code currently contains no mention of the committee.

Recommendation 1.

The Administrative Code should be amended to cover the operation of the Committee on Emergency Medical Care. The amendment should prescribe that the role of the committee be purely advisory and evaluative. It 8hould have no regulatory or managerial responsibilities.

Discussion - Responsibility for providing emergency medical care services throughout Los Angeles County is divided among a number of public and private agencies, one of which is Los Angeles County. These agencies are consequently responsible for the management of these services.

The Board of Supervisors is responsible for the governance and regulation of all health services in the County and delegates this responsibility specifically to the Health Services Department. The role of the Committee on Emergency Medical Care should be to advise the Board, the Department of Health Services, and other public and private agencies which provide emergency services on the impact and quality of these services. Such a role is consistent with the current State law and we believe would make the committee most useful to the County. In order to advise the County responsibly, the committee must conduct a continuing evaluation of the services being provided. This will require establishing criteria on which it will base its evaluation. If the committee were assigned a regulatory or managerial role, it would be placed in the position of evaluating its own decisions. Therefore, we believe that the committee:

(1) Should not engage in managerial direction of personnel engaged in the field.

(2) Should not act as a regulatory body with its decisions binding upon those who participate in hearings before the committee, as, for example, hearings to review County contracts with private hospitals for emergency care or with private ambulance companies.

(3) Should not act as a mandatory review board to approve or reject plans, policies and procedures required to be submitted to it by private and public agencies.

We do not intend that these injunctions should discourage or prohibit the County or any other agency from requesting the committee to review and comment on its plans for new programs or policies or specific hospital or ambulance contracts. Such review may be quite helpful, particularly on complex or controversial issues. We would specifically recommend this practice to the Department of Health Services to assist it in making difficult decisions and to secure the committee's support for presentations before the Board of Supervisors. In the past, the Board has generally required such review, and we recommend it continue this practice.

As we have said, however, to give the committee more than advisory and evaluative responsibilities places it in the ambivalent position of advising on and evaluating its own decisions and actions. We, therefore, recommend against assigning it any regulatory or managerial duties.

IV. RESPONSIBILITIES OF THE COMMITTEE

We have emphasized in the previous section that the ordinance should provide that the committee's role is solely advisory and evaluative. It follows that its responsibilities should include only tasks designed to implement this role.

Recommendation 2.

The amendment to the Administrative Code should prescribe the following duties for the committee. These duties are based upon the principles enunciated in the previous section.

1. To act in an advisory capacity to the Board of Supervisors and the Department of Health Services regarding County policies, programs, and standards for emergency medical care services throughout the County.

2. To establish appropriate criteria for evaluation and to conduct a continuous evaluation on the basis of these criteria of the impact and quality of emergency medical care services throughout the county.

3. To conduct studies of particular elements of the emergency medical care system as requested by the State, the County or other public or private agency, or on its own initiative. To delineate problems and deficiencies and to recommend appropriate solutions.

4. To acquire and analyze the information necessary for measuring the impact and the quality of emergency medical care services.

5. To report its findings, conclusions, and recommendations to the Board of Supervisors at least every six months.

6. To review and comment on plans and proposals for emergency medical care services prepared by the County. To perform the same function for any public or private agency when so requested.

7. To review and to report annually, as required by State law, to the Advisory Health Council, the State Department, and the areawide comprehensive health planning agency for its area, its observations and covering ambulance services, emergency medical care and first aid practices in the County.

8. To recommend to the Board of Supervisors an annual budget for the committee, including the number and classification of staff personnel.

9. To appoint such staff as authorized by the Board of Supervisors and to direct staff activities in support of committee objectives.

10. To recommend, when the need arises, that the Board of Supervisors contract with consultant specialists to augment committee staff temporarily in the performance of committee duties.

Discussion - Conducting a useful evaluation will require establishing criteria to define how the system is expected to perform, collecting information describing how it actually does perform, and analyzing the relationships between actual performance and alternative methods of providing service. This will require, for example, comparing mortality rates, disability rates, and other information on outcome or prognosis with standards set for various types of emergencies. It will require analyzing alternative uses of such resources as personnel, equipment and facilities and determining the effect of various choices on outcome and prognosis. Such analysis will result in recommendations to improve patient prognoses, cost effectiveness of system elements, and geographic distribution of emergency facilities.

To assure appropriate action on these recommendations, as well as to keep the Board of Supervisors informed on committee activities and progress, we believe the committee should report to the Board at least every six months.

Our concept of committee responsibilities excludes certain tasks because they are either managerial in nature or because they conflict with the advisory and evaluative role of the committee. Specifically the concept excludes:

1. Mandatory review of the performance of physicians or other individuals working in emergency care.

2. Approval and denial of contracts of any kind. This does not exclude, however, review and comment by the committee when so requested.

3. Managerial direction or coordination of system elements.

The responsibilities we recommend for the committee may be construed as requiring a substantial investment in staff and support activities. While we recommend that the committee determine its own budgetary needs, for Board approval, it should be noted that the committee will be able to use existing information systems, already published studies and reports, and the testimony and advice of experts in the field. Consequently, we believe the committee will be able to fulfill its responsibilities without substantial permanent investment in information systems and research staff. Occasionally, needed information or expert testimony may not be available. In such cases, we recommend that the committee request the Board to contract with outside consultants on a temporary basis to augment the permanent staff.

To conclude, personal and ideological differences may be present on any committee regardless of its composition and membership. Committees can work effectively, however, if they have a specific mandate. Given such a mandate, personal and ideological differences may enhance rather than obstruct the committee's performance. We firmly believe, therefore, that if the Committee on Emergency Medical Care concentrates its efforts on fulfilling the role defined here, its current difficulties will be substantially diminished if not eliminated altogether.

V. PRINCIPLES OF OPERATION

In Section II we pointed out that nowhere in the present legislation is there a clear specification of the committee's role and responsibilities. In addition, current legislation fails to provide any guidance on the basic policies and principles by which the committee should operate. Such policies and principles should be based upon the committee's fundamental role. They should govern such matters as what circumstances should disqualify an individual from serving on the committee, what should be its organizational relationship to the Board of Supervisors and the Department of Health Services, what should be the term of membership, and what rules should the committee adopt to conduct its internal business.

Recommendation 3.

The amendment to the Administrative Code should prescribe the following principles of operation to insure that the committee will operate with the greatest possible independence and objectivity in performing its advisory and evaluative responsibilities.

1. Members should not be in a position to augment their income through membership on the committee.

Discussion - Consequently, no member should be a provider of such specialty services as emergency education and training or the manufacture or selling of emergency medical equipment, where his membership on the committee would offer an opportunity for profit. This concept would exclude owners of hospitals, emergency facilities, ambulance companies, and medical equipment companies. It would also exclude consultants and contractors in communications, transportation, education and similar specialties who are actively involved in emergency medical care. We do not mean, however, that the committee should not consult with such specialists when the need arises.

We have conferred on this matter with the present members of the Committee on Emergency Medical Care and all concur with the principle. This includes Mr. J. Walter Schaeffer, currently a member of the committee, who owns Schaeffer's Ambulance Service, Inc. Mr. Schaeffer observed that while such associations provide 8pecial expertise to the committee, they also offer an opportunity for special interest influence. He agrees, therefore, that with the reconstitution of the committee, the owner of an ambulance company or other enterprise directly associated with emergency medical care should not serve as a member.

Too strict an interpretation of conflict of interest, however, could result in excluding all expertise from the committee - such persons as physicians e~gaged in emergency medical care, hospital administrators, systems specialists, and similar individuals.

One could raise the question, for example, whether a hospital administrator or a physician who directs the emergency care room of a community hospital under contract with the County is placed in a conflict of interest position which should also exclude his membership on the committee. The task force does not think so.

In this case, the possibility of direct profit appears remote, whereas the expertise of such a person could be extremely valuable to the committee. Therefore, we believe that while there may be some borderline cases where possible self-interest should be weighed, we do not recommend exclusion of member- ship on the committee unless there appears to be a clear opportunity for abuse of the position.

2. County employees should not serve on the committee.

Discussion - Presently, three County officials serve as members of the committee. They are the Director of Health Services, or his designee; the Deputy Director, Community Health Services; and a representative of the Sheriff's Department. These officials are responsible for the management and operation of various portions of emergency medical care provided by the County. They also perform regulatory duties governing the provision of such services by both public and private agencies throughout the County. Their membership on the committee places them in the position of evaluating their own managerial decisions and actions. It is difficult for them, therefore, to act in a completely independent or objective manner on these matters. In addition, their membership on the committee tends to place the committee's independence and objectivity under question. We, therefore, recommend as a basic operating policy that no County employee should serve on the committee. We have conferred with Harry Huftord, Chief Administrative Officer, and Liston Witherill, Director of Health Services, on this principle. They concur with our reasoning.

This policy should not result in divorcing the committee from the valuable and necessary expertise and advice which County employees can provide to it. This type of expertise can be sought through interviews and meetings with County officials whenever the need occurs. This is the policy which our own commission follows. We recommend it to the Committee on Emergency Medical Care.

3. The committee should report directly to the Board of Supervisors.

Discussion - As mandated by State law, the committee is established by the Board of Supervisors, and its composition is determined by the Board. It should, therefore, report to the Board, acting in the advisory capacity which we have recommended. This should not preclude it from advising and assisting the Department of Health Services or other public or private agency. However, its independent stature will be most effectively maintained if the ordinance clearly stipulates that the committee reports directly to the Board of Supervisors and is not subject to the direction of any other County agency. The ordinance should also prescribe that the committee's budget and the number and classification of its staff personnel should be determined by the Board of Supervisors on recommendation of the committee, without administrative direction by the Department of Health Services.

Currently, the budget and staff of the committee is assigned to the Department of Health Services. If the committee reports directly to the Board, would it not be appropriate to transfer its budget and staff to the Department of the Board of Supervisors?

The task force's answer to this question is "no". While the committee should operate free of undue influence by the Department of Health Services, its function, nevertheless, is wholly involved in and limited to the area of health services. The cost of operation of health services in County government can only be readily ascertained if all activities associated with health services are contained within its budget. This is a standard accounting principle. Thus, we believe that the recommended arrangement will effectively support the independence of the committee and at the same time satisfy appropriate budgeting procedures.

4. The committee should appoint its own staff, as authorized by the Board of Supervisors.

Discussion - if the committee is to operate with appropriate independence, it follows that it should appoint its own principal staff personnel. The committee followed this practice in appointing its present staff director, using standard civil service procedures. In the future the committee may wish to employ its staff using a contract procedure independent of the civil service system and the County's administrative hierarchy. We believe the choice of procedure should be left to the discretion of the committee.

To further insure the committee's independence it should adopt formal ground rules governing staff operations and activities. These rules should cover the reporting relationship of the staff to the committee chairman and committee members and appropriate controls on civic, political and voluntary activities. The present committee adopted such rules in June of 1974. We recommend the same procedure for the reconstituted committee.

5. The ordinance should prescribe two-year terms for members.

Discussion - Neither the State law requiring establishment of the committee nor the Board orders cover4ng its membership mention terms of office. Both the majority and minority reports recommend overlapping four-year terms for members.

We do not agree. We believe a two-year term provides a better balance between the advantages of tenure and the advantages of adding new members from time to time.

A four-year term, we believe, exposes the committee to a too rigid and locked-in membership. It is true that if members lose interest or cannot devote sufficient time to committee responsibilities, they will generally resign and can therefore be replaced. If, however, an inappropriate appointment is made, the member, who is not qualified for service on the committee, may resist any suggestion to resign as a personal affront. There is then no easy remedy, and the quality of the committee work will suffer.

We, therefore, recommend an appointment procedure similar to that used for many County commissions, including the Capital Projects Appeals Board, the Architectural Evaluation Board, the Narcotics and Dangerous Drugs Commission, and the Economy and Efficiency Commission.

Members of these commissions serve for one or two-year terms. However, there is nothing to prevent reappointment of a member who has been serving well. At the same time, the procedure provides the opportunity for the Board or a nominating agency to introduce changes when needed. We believe this procedure provides an effective balance between the need for tenure and experience and the need for new points of view.

For the Committee on Emergency Medical Care, we recommend a two-year term. The procedure we recommend for nomination of members requires action by external agencies, which will require some lead time. Therefore, the two-year term seems appropriate. We 8hould also point out that there is no need to make the terms overlapping, since we would not expect the whole committee to be replaced after any two-year period.

6. The committee should adopt a set of formal bylaws for its own operation consistent with ordinance provisions.

Discussion - The committee has experienced considerable conflict over interpretation of procedures for nomination and election of officers and over the manner of submitting majority and minority reports to the Board of Supervisors. The procedures in these areas should be clearly spelled out in committee bylaws. The rules should cover nomination and election procedures for officers, terms of office, rules of order for meetings, and other basic committee operating procedures.

VI. COMPOSITION AND METHOD OF APPOINTMENT
OF COMMITTEE MEMBERS

To determine an appropriate membership for the Committee on Emergency Medical Care, the task force developed certain key criteria for selection. These criteria are designed to insure that the committee will operate with the greatest possible independence and objectivity and that it will effectively perform the work required of it.

In Section V on principles of operation we discussed two of these criteria. These were (1) that members should not be in a position to augment their income or promote their special interests through membership on the committee, and (2) County employees should not be members of the committee. Both these criteria were designed to augment the independence and objectivity of the committee. Thus all members will be public members in the sense that they will not have a direct financial interest in the system or otherwise be able to use their membership inappropriately to advance their own special interests.

The following additional criteria are designed primarily to insure that the committee will effectively perform the responsibilities which we have recommended be assigned to it.

1. The method of appointment should be such that the Board of Supervisors can be confident that the members will possess the expertise and experience required.

2. The committee must have credibility and prestige in the communities that will be affected by its actions.

3. To keep the committee workable, it should not contain more than eleven members. Five members should be physicians actively engaged in acute or emergency medicine; four members should be professionals in fields closely associated with the delivery of emergency medical care; two members should be public members familiar with the field of emergency care. We believe this composition provides an appropriate balance between medical and non-medical expertise.

4. All members should be capable of contributing to the evaluation of the system as a whole.

5. The specialty of each physician should enable him or her to provide knowledge for evaluation of some aspect of nearly every type of emergency.

6. Each non-physician member should have a profession or vocation which will be relevant to at least one component of the system.

Recommendation 4.

The amendment to the Administrative Code should prescribe the following composition and appointment procedure for the committee.

All members will be appointed by the Board of Supervisors. All will be residents of Los Angeles County. The five physicians will be actively engaged in acute or emergency medicine. They will be nominated by certain medical societies or associations involved in emergency care. The six other members will also be nominated by a specified sponsoring group.

The Board of course will be free to reject the nomination of any of the sponsoring groups and ask for a new name to be submitted. In addition, if the Board wishes, it may request more than one name for nomination by any of the groups. We should caution the Board, however, that this latter procedure could embroil it in troublesome and time-consuming controversy and lobbying over the appointment of any individual.

1.An emergency medical care physician nominated by the California Chapter of the American College of Emergency Physicians.

2. An orthopedic, general, or neurological surgeon nominated by the Los Angeles Surgical Society.

3. A cardiologist nominated by the American Heart Association, Greater Los Angeles Affiliate.

4. A psychiatrist nominated by the Southern California Psychiatric Society.

5. A physician nominated by the Los Angeles County Medical Association.

6. A registered nurse with experience in emergency medical care nominated by the California Nurses Association.

7. A hospital administrator nominated by the Hospital Council of Southern California.

8. A systems specialist experienced in communications, transportation or education systems nominated by the Western Section of the Operations Research Society of America.

9. A systems specialist experienced in management or financial systems nominated by the Southern California Chapter of the Institute of Management Sciences.

10. A public representative familiar with emergency medical care nominated by the Los Angeles County Federation of Labor, AFL-CIO.

11. A public representative familiar with emergency medical care nominated by the League of California Cities, Southern California Chapter.

Discussion - In establishing a method of appointing members to the committee and determining what expertise and experience will best serve the purposes of the committee, there are certain key criteria, as we have noted, which should be kept in mind. In some cases these criteria conflict with each other. For example, if the members are to work together effectively, the committee should be kept small in order to facilitate communications and to promote orderly and efficient decision-making. This requirement, however, forces a compromise with the requirement for a variety of medical and non-medical expertise relevant to evaluating the system. Emergency medical care obviously involves medicine, but it also involves systems of communication, transportation, education, finance, and management.

On the other hand, to attempt to provide every facet of this expertise on one committee would force its enlargement to completely unworkable proportions. Thus, in the composition we recommend, the specialties of the five physicians do not include all of the medical specialties associated with emergency medical care. To include all pertinent specialties would require at least ten physicians. Similarly, the non-physician members do not include all relevant non-medical specialties. To include these would require the addition of at least four more systems specialists as well as perhaps two lawyers. The result would be a committee of over twenty people, which we believe is too large to be workable, given the purpose of this committee.

With regard to expertise, medical and non-medical, we should stress that the purpose of this committee is not to tell doctors or anyone else in the system how to do their jobs. For example, the contribution of a medical specialty is not to help the committee determine the appropriate treatment in specific cases, but rather to assist the committee in interpreting information, establishing and using appropriate performance standards, and developing recommendations to improve the system for all types of emergencies.

Therefore, one criterion, as we noted above, is that each physician should be engaged in a specialty which is relevant in almost all emergency cases. Another criterion is that the physicians should enhance the credibility and prestige of the committee in the medical community.

Several physicians whom we have interviewed disagree with one or more of the specialties we have selected, arguing that the committee should include a critical care physician. Others recommend a pediatrician, or an anesthesiologist, or a pulmonary specialist. While these specialties may be associated with the treatment required in many specific emergencies and would not to our knowledge diminish the credibility of the committee, we believe our selection best meets the criteria we have established.

In determining these criteria and selecting specialties, the task force has consulted authorities in emergency medicine, as well as members of the Committee on Emergency Medical Care. Most have pointed out that it is not p05sible to obtain unanimous agreement on all details involved in selecting physician specialties, without enlarging the committee beyond bounds. Thus, any proposed combination of 11 members, including five physicians, will be controversial.

For example, we have been asked why we selected a psychiatrist rather than a critical care physician. A critical care physician is in an excellent position to evaluate emergency medical care, since many emergency patients go into critical care after they have been through the emergency response system. In addition, in-hospital emergencies often occur, and should be considered in the context of emergency medicine.

On the other hand, others with whom we consulted have strongly affirmed the value of including a psychiatrist - including Dr. George C. Griffith, a former member of the committee and long recognized as a leader in the field of emergency medicine, and Dr. John E. Affeldt, Medical Director of the Department of Health Services. They stress the need for incorporating response to and treatment of emergencies resulting from mental or emotional disorders into the total emergency medical care system. Currently, response and treatment of such emergencies operate independently of the rest of the system. Since they are not an integral part of the system, they tend to be overlooked by the committee.

In addition, regardless of the type of emergency, emotional trauma of some kind usually is involved. We recommend, therefore, the inclusion of a psychiatrist both to insure that psychiatric emergencies are given proper attention and to provide the committee with a resource to comment on the emotional implications of all types of emergencies.

As we have said, any selection of five physicians is bound to create some disagreement. However, the selection we have made is based on extensive consultation with many physicians and other authorities as well as our own review and analysis. We believe it best meets the criteria we have established for committee membership.

Concerning the non-physician members we have encountered no objection to the recommendations for a registered nurse, a hospital administrator and the two systems specialists. Some persons interviewed, however, questioned the choice of the County Federation of Labor and the League of California Cities as being the most appropriate sources for nominating the public members. Our reasoning is that the membership of each organization includes a broad cross section of the public and each has a legitimate interest in the system, one from the point of view of organized labor and the other from the point of view of public agency management. No one with whom we talked was able to suggest a preferable alternative. Our conclusion, therefore, is that the two organizations provide the most balanced method available for nomination of public members.

VII. RELATIONSHIP TO THE PARAMEDIC COMMITTEE

In a Board motion in November, 1973, Supervisor Schabarum proposed an ordinance to provide "that the membership of the Emergency Medical Care Committee shall constitute the membership of the Paramedic Committee." His suggestion was based on the concept that there should be only one committee of the County dealing with emergency medical care. The Paramedic Committee would be a subcommittee for the purpose of advising the department head on certification and training. After considerable discussion in which Supervisor Hahn voiced strong opposition to the proposal, the Board continued the question of consolidating the two committees until December, 1974.

In December, 1974, in a memorandum addressed to the Board, the Director of the Department of Health Services recommended that "the County Paramedic Committee continue to serve in its advisory capacity to the Director of Health Services directly in the highly specialized areas of training and certification of paramedics." At its meeting on December 17, 1974, the Board referred this recommendation to the Economy and Efficiency Commission.

There are two alternatives to the recommendation of the Director of Health Services. The first, as proposed by Supervisor Schabarum, is to consolidate the Paramedic Committee with the Committee on Emergency Medical Care. The second, as proposed by some members of the Committee on Emergency Medical Care and others, is to abolish the Paramedic Committee altogether and substitute department personnel to perform its functions.

As a matter of overall policy, efforts to consolidate related functions or to delete obsolete functions are certainly worth considering. The Economy and Efficiency Commission has traditionally favored such efforts when it is demonstrable that they would improve the effectiveness or efficiency of services. However, each situation is different and must be evaluated on its own merits. In this case our analysis does not support either proposal. We therefore concur with the recommendation of the Director of the Department of Health Services.

Recommendation 5.

The County Paramedic Committee should continue to serve as advisory to the Director of the Department of Health Services "in matters relating to the training and certification of mobile intensive care paramedics." (Administrative Code, Article LXX)

Discussion - In the case of the Paramedic Committee, the central fact is that the Director of the Department of Health Services - who is responsible for the emergency medical care system - has formally requested the Board of Supervisors, in a letter dated November 21, 1974, to continue the Paramedic Committee in its present role. It is his belief that as a layman, he needs the advice of the committee to support his responsibility as the certifying officer for paramedics. If the department head believes he needs such an advisory committee in a specialized area for which he is responsible, we can see no reason to prevent him from having one. The effect of taking away a committee that management wants is to weaken management, not strengthen it.

The argument to abolish the Paramedic Committee is based in part on a belief that the department has internal resources to do the same job. While it is true that the department commands extensive medical resources capable of advising the director, this argument ignores the major reason why the department director has requested continuation of the committee as an external resource. The advice of department employees would lack credibility in the general community. That is, coercion to protect the director could be alleged when employees are involved; it could not when the advice comes from an outside independent source.

In addition, abolishing or consolidating the Paramedic Committee would not increase efficiency and could increase costs.

First, it would not increase efficiency, as the proponents claim, because there is no duplication of effort involved That is, there is no agency other than the Paramedic Committee operating as an outside source to provide advice on training and certification to the Director of Health Services, as the certifying officer. The Committee on Emergency Medical Care does not now provide such advice, and we believe that it should not.

Consolidating the two committees would merge two incompatible functions. The Paramedic Committee exists solely to assist the department in the effective operation of a part of the emergency care system - namely, the establishment of proper standards for the training and functioning of paramedics and the certification of individuals. The Committee on Emergency Medical Care has the much broader role of evaluating the system of care as a whole and advising the County on the correction of major deficiencies. Thus, for this committee to assume the role of the Paramedic Committee would place it in the position of evaluating its own decisions. There may, of course, be deficiencies in the County's paramedic program, as well as in the County's governance of training and curriculum. One responsibility of the Committee on Emergency Medical Care should be to determine if deficiencies exist and to recommend corrective action to those responsible, including the Paramedic Committee.

Second, to assign the functions of the Paramedic Committee to another committee or the department could increase costs. Currently, the County obtains highly specialized services from the Paramedic Committee at no cost, since membership is voluntary and staff support services, office space and supplies are donated by Daniel Freeman Hospital. These staff and secretarial services cost approximately $15,000 a year.

Strong pragmatic reasons also exist to maintain the Paramedic Committee for the time that it is needed - that is, while pilot programs are being developed and implemented. The major objective, prior to any consideration of consolidation, should be to reconstitute the Committee on Emergency Medical Care and to insure that it is functioning properly. Doing so, will include amending the State law to enable the Committee on Emergency Medical Care to act in an advisory capacity to the Board of Supervisors and to the department. Until this is done, consolidating the two committees would be illegal.

Moreover, initiating any action that could be viewed as an attempt to reduce the effectiveness of the Paramedic Committee, regardless of how mistaken such a view may be, would almost certainly dilute any efforts to get the Committee on Emergency Medical Care working properly and could even jeopardize the legislation needed to make it advisory.

In summary, we recommend that the Paramedic Committee continue to function as it has been, separate from the department and the Committee on Emergency Medical Care. In a future report, we plan to examine the composition and functions of the Paramedic Committee. In this report, we are addressing only those issues that are directly concerned with enabling the Committee on Emergency Medical Care to function as a useful resource for the County.

VIII. COMMUNICATIONS WITH OTHER GROUPS

Recommendation 6.

The amendment to the Administrative Code should require the Paramedic Committee, the Emergence Preparedness Committee, and all other County committees and commissions whose actions could affect emergency medical systems to transmit to the Committee on emergency Medical Care copies of all minutes, testimony and associated records of their findings and actions.

Discussion - Our recommendation to continue the Paramedic Committee as an autonomous group does not mean that it should operate in opposition to the Committee on Emergency Medical Care. On the contrary, if the latter is to do its job, it will have to keep informed of the decisions and actions of the Paramedic Committee and all other County committees related to emergency operations. It can do so only if the other committees cooperate fully with a formal system of communication requiring systematic transmittal of their pertinent records to the committee.

Interlocking membership facilitates some forms of communication, but it is not sufficient to guarantee that the Committee on Emergency Medical Care will receive complete and timely information. Any individual serving on both committees could miss an occasional meeting, thus creating a gap in communication. Moreover, such an individual's judgment of what is important will always influence the contents of a report summarizing committee proceedings. Therefore, we think that a formal and systematic method of keeping the Committee on Emergency Medical Care fully informed of the actions of related groups is mandatory.

APPENDIX A

Legal Background

As we have noted, a major problem hindering the effective operation of the Committee on Emergency Medical Care is that the legislation relating to the committee does not clearly define how the committee should operate. The legislation consists of a State law and three Board orders.

State Legislation

The State law (Chapter 9, Articles I and II of the Health and Safety Code) requires that each county, or groups of counties, will establish such a committee and determine its membership. It goes on to state that the committee will review ambulance services, emergency medical care, and first aid practices in the county, and at least annually report its observations and recommendations to the Advisory Health Council, the state department, and the areawide comprehensive health planning agency. The article concludes that the committee "shall submit its observations and recommendations to the county board or boards of supervisors which it serves for comment only." As stated in the introduction, the law does not specify the committee's responsibility to act in an advisory capacity to the Board of Supervisors or the Department of Health Services. Hence, the need for an amendment to make this responsibility clear. (See Appendices B and C for the text of the law and the proposed amendment.)

County Board Orders

The three Board orders (No. 146, July 2, 1968; No. 128, August 15, 1972; and No. 113, May 8, 1973) are similarly vague on how the committee should operate. The first establishes the committee with a membership of five people. The second expands the membership to eight. (The Board later expanded this number to eleven without revising the Board order.) The third requires that all matters dealing with emergency medical care be referred to the committee and calls for an appointment of a representative from each supervisorial office to act as liaison to the committee.