Annual EMSC Grantee Meeting

State Partnership Representatives

Jumpstarting Your Performance Measure Activities

Part II: Measures 67 and 68

June 20 – 22, 2006

DIANA: We're going to go ahead and get started because we're running late. If you will open up your books to performance measures. Jennifer very nicely provided you with the overview slides that she's going to use. My slides are basically the questions that you all had that you submitted to us. And Mike does not have templates today. This is our final time to get together to ask questions, to discuss challenges that you all have or concerns.

So we're not going to go any further right now, other than to let Jennifer go ahead and get started with the overview.

JENNIFER: Thank you for everyone's patience. Sorry for the change in rooms. As Diana said, this is part two of jump‑starting your performance measures. Yesterday we reviewed performance measure 66, and today we'll be reviewing measure 67 and 68.

All right. Performance measure 67 is also a different measure, similar to measure 66. The measure reads the adoption of requirements by the state or territory for pediatric emergency education for the recertification of paramedics. You'll notice that the measure doesn't actually specify or require states or territories to have a minimum number of hours or courses that are devoted or dedicated to pediatric education. What's important here is that the state or territory has adopted some type of either courses or hours dedicated to pediatric education.

The goal for this measure is that the states have until 2011 to adopt these requirements. And there are some important definitions that we want to review today for this measure. The first is for the term "adoption." This is defined as the requirements having been formally put into place in the EMS rules and regulations at either the state, territory level or county regional level. And it must apply to all paramedics in a state or the territory.

So what that means is if you do decide to have these requirements put into place at the county or regional level, it must apply to all counties and regions in your state or territory in order for you to meet the measure.

Requirements is another term in this measure, and that's defined as formal written recommendations and guidelines for pediatric emergency care education as part of the recertification of paramedics. You'll notice that we don't specify specific curricular or courses that a state or territory has to adopt. We really left it up to the discretion of each state or territory. And the implementation manual for the definition of this term, we provided some sample courses. So PALS, APPLES. We've also noted that CPR courses do not, are excluded. Other than that, we don't provide any specifications in terms of actual courses or curricula.

And the next term is recertification. That's defined as the process of reregistering and fulfilling requirements for the certification or licensure to continue practicing as a paramedic in the state. We know that some states and territories may actually not have paramedics. In which case, and the electronic handbook, you'll be able to have an option of not applicable, which would be I don't have paramedics in my state so therefore this measure isn't applicable to me.

I'm going to turn it over now to Mike and Diana for any discussion items for this measure.

DIANA: The only discussion point that we actually, that was brought to our attention was the questions that were asked. Can the program consider including in the EMSC five‑year plan a requirement for EMTBs and EMTIs to also have pediatric training and recertification.

That was a statement that one of the states had sent to us. And after discussion we firmly believe that the five‑year plan's not connected directly to the performance measures. If you're referring to the performance measures, at this time there's so many inconsistencies between the states as far as EMTBs and EMTIs to mandate a specific set of guidelines.

So if you in your state are dealing with EMTIs and EMTBs and you want those requirements, then by all means you have our blessings to move forward and do that. But it is not a requirement. And because you can do that on your own state level. Okay?

That was one of the comments that was raised. The other comment that was specifically brought forward, if a state uses the national registry guidelines for paramedic testing and recertification, how should this be addressed? And from our perspective, the national registry guidelines should be sufficient as long as there's a pediatric component is included in the recertification training.

Okay?

JENNIFER: Are there any other questions people have about this measure? Okay. Easy enough.

On to performance measure No. 68. Unlike Measure 66 and 67, this is not a get‑for measure, but instead an EMSC program measure. The measure reads: The degree to which the state or territory has established permanence of EMSC and the state territory EMS system. There's actually not a specific target for this overarching measure, but there are targets for each of the four sub measures.

And the four sub measures are those elements define what permanence means.

I'll now go specifically and discuss each of these four sub measures. The first is 68‑A. Which reads the establishment of an EMSC advisory committee within the state or territory. The states and territories have until 2006 to establish their EMSC advisory committees. And establishment is defined by two different elements. You might remember that when this measure first came out, there were actually three different elements for establishment. We've decided to take out the element where the EMSC advisory committee is mandated within your state or territory.

So now there are two remaining elements. One ‑‑ everyone is happy about that? All right.

The first element is that the committee must be composed of 14 individuals. I'll go ahead and just quickly read through those 14. It's state EMSC administrator ‑‑

UNKNOWN SPEAKER: (Inaudible).

JENNIFER: Sure. The change. The change is that when you first saw this measure, when we first introduced the measure, there were three elements, I guess to this measure, three elements that defined establishment. One of them was that the EMSC advisory committee had to be mandated, and your state EMS rules and regulations. And that has now been deleted from the measure. So that's no longer a requirement that you have to do that in order to meet the measure.

UNKNOWN SPEAKER: I know it's hard but (inaudible).

JENNIFER: No, that's a good point. We thought that because the goal was by 2006, that was an unrealistic time frame for many states. However, it's definitely ‑‑ we still encourage all the states and territories to try and attempt to mandate it by 2011.

UNKNOWN SPEAKER: Some states have a cap on their advisory council, their division slash (inaudible) states EMS council. And that's why we ‑‑ so (inaudible) I am on the subcommittee of my advisory council or task force, but I can't (inaudible).

UNKNOWN SPEAKER: In our state (inaudible).

DIANA: So you're breathing better Doreen?

(Laughter)

UNKNOWN SPEAKER: Dan, is it mandated in Massachusetts?

UNKNOWN SPEAKER: Is it now, no. But I work very hard to get it. I'll tell you it's now mandated and I'm now crawling into that state system for the first time in ten years. And I get to go back and tell them it's not mandated.

JENNIFER: You don't have ‑‑ (inaudible).

(Laughter)

UNKNOWN SPEAKER: EMSC (inaudible).

UNKNOWN SPEAKER: I hear what you said. I know some states have (inaudible) just I just wish there was some way to get around it so that ultimately some way it could be mandated.

DIANA: I think you can tell them that ultimately the program would like to have the committee mandated, and some of the states will have difficulty meeting that requirement but ultimately, yes, it would be nice because it provides permanence.

UNKNOWN SPEAKER: (Inaudible).

DIANA: Ignore it. Well, somehow I kind of guess that was an answer.

UNKNOWN SPEAKER: I mean if the due date on this measure had been 2011, probably would have been kept in. But because it's this year, because we know some states and territories will get hung up on that we took (inaudible) we felt the advisory was crucial in helping with the rest of the measures and developing a strategy to tackle the rest of the measures. So that's why that's ‑‑

UNKNOWN SPEAKER: I would suggest maybe a neutral or midway alternative. I understand getting a mandate because it's '06 but at least in the mid‑Atlantic where our state has it codified it's a standard. But we have states within the mid Atlantic that you all within the federal government does not use some term that is stronger than ‑‑ I mean a mandate that's stronger than something else very (inaudible) groups are defined. So EMSC advisory task groups, whatever. If you can look at language for 2011, I really think there are states that would benefit from having some more input back in before 2011. That others may not agree with me.

We're moving ‑‑ (multiple voices).

UNKNOWN SPEAKER: The federal dollar or something attached to it is going to hamper the progress in other states.

DIANA: I think that's a great suggestion, Cindy, what we'll do is we'll take it back to the program and we'll discuss it further at this stage.

UNKNOWN SPEAKER: (Inaudible) what happens if I can't get it up and running? I assume by '06 means end of '06?

JENNIFER: February 28.

UNKNOWN SPEAKER: We have advisory groups saying in February. I don't expect it to take that long but Massachusetts ‑‑

DIANA: And you'll ‑‑ it's a full year.

JENNIFER: February 28, 2007. And I would think even if a state hasn't accomplished that by then, you should still strive to do it even past that date if you aren't able to do it by February 28th, even though that's the target or the goal. It doesn't mean come March 1st all right okay we're done with that.

UNKNOWN SPEAKER: Don't give up on it if it's not accomplished by 2006. It's a crucial thing.

UNKNOWN SPEAKER: I think what you need to keep in mind that's a requirement of your current grant to have an advisory committee meet during the first year of your grant. Okay. So it's a performance measure but it's a requirement of your grant. You all made the commitment. So just keep that in mind at the same time.

DIANA: Yeah, and the requirement you may not have all 14 members meeting, but you've got a committee that's meeting that you have identified as your advisory committee and that you're continuing to work to get it totally together as defined by the performance measure by February, the end of February of next year.

UNKNOWN SPEAKER: (Inaudible).

DIANA: Yeah. It's fiscal.

JENNIFER: I was going to quickly name the 14 individuals that must comprise your advisory committee.

UNKNOWN SPEAKER: We have one more question right here.

JENNIFER: I'm sorry.

UNKNOWN SPEAKER: (Inaudible).

(Laughter)

UNKNOWN SPEAKER: What does it count as an advisory meeting, do all 14 members (inaudible) the committee. Does it count as an advisory committee (inaudible).

JENNIFER: Yes.

DIANA: Because my guess is even with all 14 people identified and committed they're not all going to make it to every meeting. And you as an advisory group are going to have to decide what is a quorum to make decisions and how ‑‑ if you find out you're down to six people for your regularly scheduled date, maybe it makes sense to change the date. Maybe it makes sense to look at teleconferencing. You know, there's other ways of doing it. As long as you're getting some face‑to‑face meetings in together in that.

But I would find it a rare occasion that you're going to get all 14 there for every meeting. It would be nice, but I'd be surprised. And if you find out there's consistent people who are not coming, then you'd want to know, well, maybe we need to change that number.

JENNIFER: Another question?

UNKNOWN SPEAKER: When you say a quorum, are you saying that (inaudible) bylaws?

DIANA: No, however your operational capacity ‑‑ it's your committee to provide guidance to your program. So however you all, you know, some states like to have everything very specific that only those defined 14 members can vote. It's a public meeting but only those 14 can provide the actual votes.

UNKNOWN SPEAKER: (Inaudible).

DIANA: Yes. It's your committee.

UNKNOWN SPEAKER: Thank you.

JENNIFER: I'm going to quickly go through the list of 14. State EMS administrator, state EMS medical director. EMSC grant principal investigate for. EMSC grant manager. A family representative with state level leadership experience and a national organization such as Family Voices, highway traffic safety administrator, pediatrician with state level leadership in AEP. Emergency physician with state level leadership in ACEP. Emergency nurse with state level leadership in E&A. EMT with state level leadership in AN EMT. School nurse with state level leadership experience. EMS data specialist. State trauma manager and state hospital association representative.

We know it's an extensive list. However, you can have more than one person fill one of these positions as appropriate. And it would still count as meeting the measure.

I think Diana, you had a couple of ‑‑

DIANA: Well, actually, this entire measure hopefully you all made it to the breakout session yesterday where they talked about advisory committees and we encouraged Jane and she very nicely agreed to come and join us today to see if there were questions specific ‑‑ other questions related to the advisory committee, our challenges you're having that we need to address here. And if you're having a challenge with a specific group, maybe you don't know who your AAP chair is for your state, then my comment would be have you contacted the National Resource Center, because we sometimes, the TA folks, we know who our partner is through the program and we can contact and get a name for you in your state.

So don't ‑‑ just because you don't know who an individual is, don't stop there, because there's lots of other different avenues. Are there other challenges some of you are having? Go for it.

UNKNOWN SPEAKER: So we currently are (inaudible) and the grants (inaudible) but all of the measures aren't EMS trauma systems (inaudible) and they ‑‑ there is a mandate, a state mandate for (inaudible) and there is pediatric. Not all of these (inaudible) so are you saying we must have a separate council that has all of these representatives or (inaudible).

UNKNOWN SPEAKER: When we look at performance measures (inaudible) we're (inaudible) how many representatives have. We want you to identify and (inaudible) pediatric subcommittee or (inaudible) it's a separate committee. But keep looking for those other representatives that are on the list that you added to your group over time. (Inaudible) we have no inkling (inaudible) to be signed by the Governor and we have no (inaudible) at all. Then I would work with your EMS office. There may be a way for you to have people come in as ex‑officio people to participate as an interim step until maybe there's a way to get this changed or to get the membership list expanded through the Governor.

UNKNOWN SPEAKER: (Inaudible) I don't have all the (inaudible) list (inaudible).

JENNIFER: You'll have an opportunity, as Jane just mentioned there's a scale where you can tell where you are along that process of getting all 14. I'm just looking at the scale right now. For example, if you have, you know, one to three, you fall on .1 on the scale. If you have 4 to 6, it's.2. So you can indicate on the scale where you are. Unfortunately, yes, at that point in time you would be no for that particular measure, but you have an opportunity to let us know where you are along the way. What progress, where you are, what progress you've made.

UNKNOWN SPEAKER: Is that (inaudible) available through electronic handbook? Because currently when you go in the electronic handbook (inaudible) that I've been able to say there are three boxes. When you go to score, there's no way to enter the score.

JENNIFER: These are going to be like additional data collection forms that you'll have to submit along, during the continuation application process. That would be in addition to what's in the electronic handbook now.

UNKNOWN SPEAKER: We shouldn't be able to put a score for that measure in yet. Okay.

UNKNOWN SPEAKER: (Inaudible) EMS association (inaudible) EMT about four years ago. Do we have to have (inaudible).

UNKNOWN SPEAKER: It can be ‑‑ we want someone in a leadership role in EMS association. Not necessarily an EMT. Because we do know that (inaudible) presentation across the country.

UNKNOWN SPEAKER: Diane (inaudible).

DIANA: No, no, not the chair.

UNKNOWN SPEAKER: I mean the chair of.

DIANA: The state chair.

UNKNOWN SPEAKER: It has to be the state chair?

DIANA: No. It does not have to be. But typically what happens is you contact the state chair to get the representative so that there's a direct feedback. I'm sorry if I gave that impression.

UNKNOWN SPEAKER: EMT requirement, if you have a state association EMT, not an EMT state. We certainly have in the board, have practicing EMTs who could sit on the board, be part of this subcommittee for fulfilling this requirement (inaudible).

UNKNOWN SPEAKER: We've got nobody really at a state or national level that could represent that?

UNKNOWN SPEAKER: Correct. Although, as I say, within our statute there would be a composition of our advisory board list of practicing EMTs as a part of our state advisory board, committees that work off the state advisory board for which we have EMS committee, if you look at the central, practicing EMT, we could fulfill that obligation with the state or national connection would be (inaudible).

UNKNOWN SPEAKER: I would suggest having someone practicing EMS professional who is, you know, respected by other EMS providers in the state and then when you do your supporting documentation, just explain the variance.

UNKNOWN SPEAKER: We don't have a state trauma coordinator. Isn't an M and A or should I look for somebody that's sort of like a trauma surgeon or somebody that (inaudible) trauma.

DIANA: Where does trauma fall in your state? Are you developing ‑‑ you've got ‑‑

UNKNOWN SPEAKER: It's state EMS. There's no (inaudible) for.

DIANA: Do you have a trauma committee?

UNKNOWN SPEAKER: What?

DIANA: Do you have a trauma committee?

UNKNOWN SPEAKER: No.

DIANA: No?

Who over ‑‑ do they go out and do trauma center designation, collect trauma data.

UNKNOWN SPEAKER: The state doesn't but EMS and (inaudible).

DIANA: But the state's not doing anything?

UNKNOWN SPEAKER: No. (Inaudible).

(Laughter)
(multiple voices)

UNKNOWN SPEAKER: But that's part of our ‑‑ (multiple discussions).

DIANA: Because there are not state trauma managers in many states right now, especially with lapse in funding, do you feel that we would be appropriate in suggesting that the individual or where the trauma program falls, that perhaps they be assigned someone to come or they themselves? In many states it's the EMS office so the same person would be representing trauma, I guess.

>> I think we need to take this question back to Dan.

UNKNOWN SPEAKER: Another suggestion would be if you have an active society of controversial group in your state, some states the group trial coordinators get together through the auspices of the society of common nursing, and one of those members obviously has to go back to Dan, but that would be another source of finding a trauma manager at one of your hospitals who is committed to being organized at the state level.

DIANA: Thanks, Cindy, good idea. Unfortunately, STN is not as strong as we would like across the country, so we'll just see.

Great questions. Yeah, things that we'll have to take back. So you're picking up some of the issues that directly impact each of your states. Are there other things in reference to the advisory committee's specific challenges that you're already anticipating?

UNKNOWN SPEAKER: I just had a question when they're holding the EMS board meeting after this; is that correct. So are the performance measures, I mean is there a presentation on the (inaudible) directors, correct? So are the performance measures ‑‑ I mean is there a verification (inaudible) and.

UNKNOWN SPEAKER: Dan is giving an update. I don't think that ‑‑

UNKNOWN SPEAKER: EMS officials have been given an update on performance measures. They got this update last fall when they had their annual meeting. And they're very much engaged with you. So we feel like they have been informed. We're trying to make sure that the state medical directors get information. That was the reason for the webcast. Planning to try to reach them. So we have been working with the key partners that we've identified as trying to give representation to their stakeholder groups, your advisory committees. But you know if you're finding an issue in your state, someone doesn't seem to understand, please let us know, because we will reach out and try to help you to get the representation.

UNKNOWN SPEAKER: (Inaudible) meeting here a couple of weeks ago the new group, and there's a couple of (inaudible) pretty adamant that (inaudible) and we try to educate them as much as we can on those, that's why I was asking you an update as Mike was referring to.

UNKNOWN SPEAKER: Why don't you talk with us and we'll try to develop a strategy with the EMS officials, because maybe through their regional outreach they can help provide some reinforcement of some of the support that the EMS officials have given the support measures.

DIANA: Janette, you may want to actually talk to Dan Manns, who is going to give an update there. And make sure you get one of his cards so your person can perhaps call Dan who is a good person.

UNKNOWN SPEAKER: There's several states EMS directors (inaudible) there's quite a few of them that (inaudible) (inaudible) states.

DIANA: Hmm. Okay. That's a great concern, and I'm glad you brought it up, because it's something we'll need to take back to the program. And I think since we've got Dan here, he'll be helpful. But we need to think about a new plan for those directors, because there's several of them as Katrina said. And we obviously didn't integrate that into the performance measures.

Okay. Any other questions or concerns regarding advisory committee or challenges? Okay. You want to go on to 68 B.

JENNIFER: 68‑B is the incorporation of pediatric representation on the state or territory EMS board. States have until 2007 to meet this measure. A couple of important definitions. One is for the term "incorporation. What we mean by that is the existence of a formal designated voting position for pediatric representative on the EMS board, which is mandated in this state territory EMS statutes, rules or regulations. So for this measure, the mandate component that we have kept in this measure.

UNKNOWN SPEAKER: (Inaudible) definitions. (Inaudible).

DIANA: Actually, that was one of the questions that came from some of the grantees, Canon EMS advisory committee serve as the EMS board, and in talking with Dan and amongst ourselves, the decision was made that the structure, the EMS oversight is up to each state to ‑‑ and/or territory. If you're referring specifically to the EMSC advisory committee, they are there to organize EMSC grant initiatives.

UNKNOWN SPEAKER: (Inaudible).

DIANA: And does pit dictate who those members are at this time and point?

UNKNOWN SPEAKER: (Inaudible) and that would be a direction that you (inaudible) trying to get the (inaudible) member, maybe it's not (inaudible) but at least get representation (inaudible). So communication.

JENNIFER: It's the previous measure and the data collection form it's an opportunity to kind of say where you are. There's like a scale or continuum where you can indicate where you are since we know it's going to take some time for a lot of grantees to completely fully meet this measure.

UNKNOWN SPEAKER: (Inaudible).

DIANA: I would suggest that you go back to try and just work on developing your EMSC advisory board at this time. Because I don't think after what you've shared with me that you're going to get it back kind of up and running right away. So work with your EMSC advisory board to see how you can best implement your performance measures and initiatives.

JENNIFER: Any other questions for measure 68‑B?

DIANA: Question over here.

UNKNOWN SPEAKER: I think I'm still stuck with the lady back there, if in fact we had instituted a liaison to the EMS board but it absolutely is not possible even though it's going to rules or regulars to go through in less than two years, then we still have to put no we haven't met that measure?

DIANA: Uh‑huh. You have not met the measure but you can note and comment that you've been working on it and that you've had a pediatric lie a son meeting with the board who has been able to share pediatric needs to the committee and many states have had to go that route over the years. And if, believe me if the peds person keeps speaking up then eventually the rules and regulations get changed to incorporate that person.

UNKNOWN SPEAKER: I think what I'm hearing her say, it's where I'm confused, is the same decision making in which we took out the mandated advisory board, because you cannot put it through might apply to this. Because you took out the 2006 because you do not have time to mandate it. It's almost the same thing. So I'd just ask that they look at that because it's simply not possible to put it through in a year in probably many states.

DIANA: Yeah, I think the mandated part is going to be difficult in a lot of these especially in the first years. If the date gets extended to 2011 or whatever that gives you plenty of time to work on it. Yes.

JENNIFER: We'll take that back to Dan.

Measure 68‑C is the establishment of a one full‑time equivalent EMSC manager that's dedicated solely to the EMSC program. The original measure had another component to this measure. It had, required that the EMSC manager position to be fully funded by state or territory funds. You'll be happy to know that that's now been deleted from this measure.

There was ‑‑

DIANA: The smiles.

JENNIFER: There was a requirement that the EMSC manager had to be fully funded with state or territory funds in the original measure and now that part has been deleted.

UNKNOWN SPEAKER: (Inaudible)?

JENNIFER: Sure.

UNKNOWN SPEAKER: (Inaudible).

JENNIFER: That piece of it. So it still has to be a one full‑time equivalent EMSC manager whose time is dedicated solely to the program. But that FT does not have to be fully funded by state or territory funds. So that's ‑‑ does not have to be.

UNKNOWN SPEAKER: (Inaudible).

JENNIFER: It doesn't have been to be funded by all state territory funds. Because before we had wanted it to be a position that was fully funded with state dollars, state or territory dollars.

UNKNOWN SPEAKER: (Inaudible).

JENNIFER: No. No, there's no requirement for that. We encourage.

UNKNOWN SPEAKER: Some of the grantees, some of you all (inaudible) states ‑‑ we thought it would be a great thing by 2011 to (inaudible) even if it's paid by EMSC dollars (inaudible).

JENNIFER: We still encourage all states and territories to try to do that. I know Melea in Florida, that's happened. So if you have any questions, ask Melia how they got it done.

And solely means, the term "solely and the measure means 100 percent of the EMSC manager's time is devoted to the EMSC program.

DIANA: How many of you are 100 percent EMSC right now? 100 percent EMSC.

UNKNOWN SPEAKER: On paper?

UNKNOWN SPEAKER: On paper?

(Laughter)

DIANA: Yeah. And I think what we're seeing here, there's a lot of hands that did not go up. So our desire is to have somebody who can really focus in on EMSC, provide guidance to your advisory committee, work on initiatives, make sure that the pediatric issues are addressed at various levels at lots of different committees and if you're not doing that full time it's hard to do that obviously. So ‑‑

JENNIFER: And you do have until 2011 to meet this measure. So five years.

Okay. Moving on to 68‑D. The measure reads: The integration of EMSC priorities into existing EMS or hospital healthcare facilities statutes or regulations.

States have until 2011 to meet this measure, and there are actually six EMS priorities.

The six priorities actually are performance measures, the four sub measures for 66, or, excuse me, there's five sub measures for 66, and then measure 67. Those are the six EMSC priorities. So I'll go through those really quickly since we went through 66 yesterday and 67 earlier today.

The first EMSC priority is that prehospital provider agencies have on‑line and off line pediatric medical direction for BLS and ALS providers. That's measure 66‑A. The second EMS priority is that prehospital provider agencies have the essential pediatric equipment and supplies as outlined in the AEP ACEP joint guidelines for both BLS and ALS ambulances. That's performance measure 66 B. The third priority is the existence of a statewide territorial or regional standardized system that recognizes hospitals that are able to stabilize and/or manage pediatric emergencies. That's performance measure No. 66‑C.

The fourth and fifth EMS priorities actually map on to the new performance measures for 66 D and E. I'm not sure ‑‑ I think most of you were at the breakout session yesterday when I mentioned that the performance measure 66‑D for this year does not separate out guidelines and agreements, interfacility guidelines and agreements. But beginning fiscal year 2007, they will be broken out. So that's where the fourth and fifth priorities are the new 66‑D and E where the interfacility agreements and guidelines are broken out to two separate measures.

And then the last EMSC priority is performance measure 67, which is the adoption of requirements for pediatric emergency education for the recertification of paramedics.

I think there were some questions from grantees concerning this measure. Or maybe not.

DIANA: Okay. We got several comments in reference to 68‑D, in reference to the EDAP. And many of the EMSC coordinators, not many, several, have come up to us and asked specifically that hospitals are not, do not necessarily want to comply with requests for changes to their policies and procedures. How do we get them to want to change policies and procedures as far as having interfacility transfer agreements and interfacility guidelines?

And in reference to that, one of the things, if you look at your membership for your advisory committee, one of those memberships was the representative from the hospital association for your state. That particular person can be very influential in helping hospitals understand that they need to have these in place. The other place that I would suggest that you seriously consider is many states have hospital licensure departments. They need to be partners you need to seek them out. That would be if you've got that department, I would go to them and find out what actually do they require of hospitals, because they may very well have a requirement for if you cannot provide care for burn patients, you must have an interfacility transfer agreement with a facility who can.

And I think you'll find out that more hospitals have interfacility transfer agreements in place. They may not actually have defined protocols or guidelines in place as to when to do that. But departments of hospital licensure and then your hospital association rep will probably be able to help you with some of that.

Have others of you thought of other avenues to go when looking at interfacility transfer agreements and trying to determine whose got them and who doesn't and how to work with hospitals to change, since, you're right, you do not have direct control over them.

Yes. Go ahead. Did you have ‑‑

UNKNOWN SPEAKER: (Inaudible).

DIANA: Okay. Two more good suggestions. Look at, if you've got trauma centers designated in your state, you will find out that they probably already have agreements in place to get patients moved into them. And then the other place that has been identified, if you have critical access hospitals in your state, it is the requirement that they have to have interfacility transfer agreements. So that would be another place that you could look to see who has got agreements with someone else.