The Wake County EMS system has gained national recognition for delivering clinically excellent emergency medical care to its patients. The system has been profiled in numerous articles, and its medical director was the NAEMT's Medical Director of the Year in 2006. It has received thousands of requests for advice on the implementation of its ICE (Induced Cooling by EMS) post-resuscitation hypothermia protocol. But when I was asked how the system's infrastructure supports and encourages clinical excellence, I had to pause for some time and consult with colleagues inside and outside the system. What do we do, if anything, that is different than what happens in every other EMS organization? After a while, a few common elements emerged. There's really no magic—just focus on a consistent purpose.

     As senior EMS officers, we are charged to lead, manage and administer. We lead people, we manage processes, and we administer in accordance with the kinds of rules and processes that are present in any large organization. Although Wake County EMS is a good-sized EMS organization (132 line staff, seven officers, two clerical support staff), we are a small part of Wake County government, which has more than 5,000 employees. The county's EMS Division handles 38,000 calls a year, while the entire system (the EMS Division plus six contract agencies) exceeds 60,000.

     One of the unique aspects of the Wake County EMS system is that service delivery levels are set by policy, given clinical and budgetary guidance. While the revenue from transport billing is an important element of the financial management process, the operating budget has been effectively decoupled from the revenue stream. What that means is that county commissioners and the county manager set the service level expectations and provide funding to support the delivery of service. Revenue from ambulance transport billing does not establish the service level any more than it does for law enforcement, the libraries or other essential public services. That's a big positive: There's no expectation that EMS transports pay for the cost of daily EMS operations. The county's finance department is expected to maximize the revenue stream through effective billing and collections. While we've not faced budget cuts in recent years, we must present a strong business case, driven by sound data, for any increase to our annual budget. Like everyone else, we've had to learn to do more with less. Evidence of this is seen when comparing our requests for additional resources to cope with growth in the county (we add more than 30,000 new residents a year) to what we've actually received: We've been granted about half of what we've sought. Accordingly, our system-wide unit-hour utilization has been steadily rising over the last four years.