Is ‘SSM’ Still a ‘Bad Idea’?

Ideas often take time to saturate a market. Even if the idea is generally recognized as a good one, complete with compelling evidence, change can still take time.  As a current example, how many agencies still have a protocol for complete spinal immobilization on a long spine board for “any fall” or “significant impact”?  On that very point, Dr. Ryan Jacobsen puts forth a lengthy argument in this recording of a  presentation at a NAEMSP conference.  The process of acceptance can be even worse yet if the idea has been controversial – as in the case of “System Status Management” introduced by Jack Stout in 1983. This distinction means it takes longer still in order for it to receive a “fair hearing” even if the evidence now shows a positive impact. In an ideal world, the best ideas would always be automatically and universally adopted, but that simply isn’t how the world works.  And for any professional industry it is a good thing that ideas are properly “vetted”over time to determine what is truly “best” before wholesale adoption or, in the case of “bad ideas”, that they are discarded only when a fair reading of the evidence discredits them.

CycleDynamicsGartner, Inc. of Stamford, Connecticut, has built both a reputation as an information technology research and advisory firm and a booming business of annually publishing their signature “hype cycle” graphs by industry segment.  For those unfamiliar with these charts, the basic structure starts with a technology trigger near the origin of time and is visibility followed by a quick rise to the “peak of inflated expectations” that is often driven by a combination of unrealistic claims by proponents and the hopes of users desperate to believe those claims.  The exaggerated peak of hype is inevitably followed by a crash of popularity into the so-called “trough of disillusionment.”  Many ideas just die here and drop off the curve, but for others, a more realistic set of expectations develop as ‘believers’ (the “early adopters” according to Everett Rogers’ “Diffusion of innovations”) begin to experience measurable benefits and serves to push the idea (sometimes with changes) up the “slope of enlightenment.” This gradual advance passes an important point of inflection on the performance “S” curve known as the “attitude confirmation” identified by Joon Shin.  The next landmark is crossing a social “chasm” identified by Geoffrey Moore at another critical inflection point called the “attitude plateau.”  Once an idea successfully crosses the chasm, it plateaus as a generally recognized productivity concept for that industry. Some ideas fly quickly along these curves passing other older ideas that seem to just plod along at a much slower pace.

So, is “SSM” still on the curve? And if so, where is it?  We must first realize that ideas evolve and sometimes morph into other names (just as “Emergency Medical Services” is known by some as “Mobile Integrated Healthcare” now.)  One apparent synonym for “SSM” is a broader idea of “dynamic deployment.”  If we look at the literature and practices of emergency ambulatory services, we find that the underlying concept is still quite popular despite attempts of detractors to further discredit or simply ignore it.  One such potentially damning article was written by Bryan Bledsoe back in 2003 after a crash of industry expectations for the idea.  This could easily be explained as the time that SSM passed its own pivot point where its value was questioned in the trough of disillusionment. (Some may also claim that hypothermia treatments for cardiac patients was also recently in this trough.)

Computing performance has increased dramatically since the 1980’s (or even the early 2000’s) and algorithms are discovering patterns in many human activities.  Demographic data show socioeconomic clustering that leads to similar health issues and traffic patterns with road designs that see more accidents than they should. These patterns are proving to be key in forecasting demand for EMS services. Automated Vehicle Location systems allow far better tracking than ever before and traffic patterns are being used to calculate more realistic routes. These are some of the advances that help explain the numerous agencies that are significantly improving response performance and making use of resources. Where field providers take an active part is developing strategies, there are also reductions in post moves, unloaded miles driven, and better disbursement of work loads.  The efficiency gained by its use in mainstream agencies beyond the initial public utility model organizations seem to vindicate Stout’s early vision and research as the concept moves up the slope of enlightenment toward the plateau of general acceptance.

Ideas are not static entities, so our understanding must continue to evolve and incorporate new thoughts.  As the iconic American social commentator, Will Rogers once said, “even if you’re on the right track, you’ll get run over if you just sit there.”  So, to honestly argue an idea, proponents of either side must continue to evolve their understanding and witness the current thought and evidence of an idea.  There is little point in continuing to attack past grievances which have been addressed while ignoring the mounting evidence out of sheer disbelief.  If “SSM” is not a “good idea’ yet, it is certainly moving in that direction all the while being shaped by those who are concerned over the future of EMS (or MIH.)

14 Comments

  • Skip Kirkwood says:

    There are various ways of implementing the combination of “dynamic deployment” and “peak load staffing” that first appeared in the early 1980s.

    Leaving crews stranded on a nasty street-corner for 12 hours is not the right way to do it. Unless, of course, you want unhappy medics, high turnover, and poor customer service.

    Try “station-based” dynamic deployment. It will cost a bit more in real estate, but be worth it if you value your staff.

  • Sean Brooks says:

    Agree with Skip — sitting in an ambulance for 12h at a go isn’t the way to develop a compassionate workforce.

    If ambulance response time standards are relaxed — either through better phone triage or through depending on other first responders — the area covered by a single post increases geometrically. More to the point, an ambulance can cover more than twice the area in 12 minutes than it can in 8 minutes. A system with half the posts can more easily afford to build fixed, comfortable, safe facilities for its personnel.

  • Nothanks says:

    SSM is great! Just ask all the happy and healthy medics who have retired from systems with SSM…

  • Medic 78 says:

    SSM does not work as well with 911 as it does with private services that have scheduled trips. Skip hit the nail on the head. I work for an agency that runs 3 units per shift. One on each end and one in the middle of our coverage area. If the unit in the center of the area goes out on a call they would rather waste fuel and make a truck go to the center rather than divide the area in half. Sometimes the book smart paper pushers are not common sense smart.

  • OKCPARAMEDIC says:

    I disagree. I am in a large urban EMS system that has 30-45 units on duty at a time. We also have mandatory response times to meet.

    No one in healthcare has expendable financing due to lower and lower insurance payments and reimbursement. In larger systems, we can not build 40 stations to make crews happy.

    There are ways to ease the stress of crews who have to be in units 12 hours a day. Post them in areas with food, drink, and clean facilities. Provide them with good comfortable units with working climate controls and leg room.

    I just doubt that the fuel savings will amount to anything close to enough to justify static station posting in the larger response areas.

    • BH says:

      The problem is OKC, I can almost guarantee that not one of your performance standards have any basis in medicine. Using response times as justification for abusing your crews with a questionable-at-best deployment strategy is the hallmark of bad management.

  • ABQ Medic says:

    SSM has really gone well for the local 911 private company. They base raises on response times and it is a management v/s employee system. It worked so well and crews enjoyed it so much that 40 of them quit in one month. Luckily for this company two colleges keep pumping out field fodder for them.

  • Roger Thayne says:

    SSM was always a very good idea. However, few EMS services actually fully understood it and implemented it completely. In essence, it is about ensuring that your system has sufficient resources in the best location to meet the expected demand to allow you to save the maximum lives at less cost. It should never have been about keeping crews in ambulances and not providing response posts with good facilities. Staffordshire UK was the only publicly provided SSM system in UK and operated effectively from 1994 to 2006 until it was absorbed into a regional EMS system covering the West Midlands and a population of 5M.
    Since this merger costs have risen, productivity has fallen to pre SSM days and life saving has halved.
    The key element of SSM is TQM.
    The problem is that doing SSM properly is very hard work so most EMS operators cannot be bothered, particularly if they are publicly funded. I am not aware of any other EMS system that saves so many more lives than the traditional systems.
    Someone should erect a statue to Jack Stout. He gave EMS a brilliant system.

  • David says:

    If it’s such a great idea why hasn’t Fire Dept embraced it?

  • mdquik84 says:

    When I worked in a system that implemented the SSM plan it shaved off about 1 minute of response time. This system had 3 units available. Medics were pressured by upper mgmnt of a 20min for medical and 10min for trauma(the same as in the EMT books). Some medics couldn’t handle the pressure and were missing key assessments to get out of the residence. One was a breathing/unresponsive pt. The medic loaded him in the unit only to find out it was his BG that was low. The medic could have got a signed refusal. The SSM needs some tweaking.

  • Julia Harris says:

    I refuse to work for a system that does SSM. I did ride time in one of these county systems, and it was exhausting. I love running calls. I would like to work in a busier system but not at the cost of getting stuck in a truck for hours on end. I’ve done this in non-emergent jobs and I HATED it. If you are unlucky enough to have a partner you don’t click with that’s a special circle of hell!! These places always have huge turnover and bad morale. Keep EMS out of fire and require them to be competent first responders. Communities spend millions on those Big Red Trucks and due to ISO requirements they rarely have more than a 5 mile radius for response. Give me a good partner, a good truck with updated functioning equipment, and a comfortable place to hang out between calls and I’ll be your most loyal and happy medic!!

  • Paul says:

    I think that the majority of you that talk about a unit sitting on a dirty street corner for 12 hrs at a time don’t realize that if they are doing that, the system doesn’t need SSM.

    • Brad says:

      EXACTLY, SSM or DD suck, and are going to end alot of medics careers early, due to the sole fact that you can only sit in a truck for so long before developing the whole long grocery list of health issues that all of our pt’s have. But I digress because anyone who argues for this crap has already drank the kool-aid and it’s just a waste of my time. Thanks Fitch your time here was marvlus.

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