concentrated in those few hospitals where the volume of cases makes it feasible to maintain such coverage. Hospitals throughout the county would pay a “subscription fee” to support the cost of on-call coverage at designated hospitals. The fee would be set at a level below what it would cost to have hospitals manage their on-call coverage individually.

Accountability

The initiative includes the development of a countywide quality assurance program under which all hospitals would submit certain data elements for assessment. It is unclear at this time how far this system would go toward public disclosure of system performance.

NEED FOR A DEMONSTRATION PROGRAM

States and regions face a variety of situations, and no one approach to building emergency care systems will achieve the goals discussed in this chapter. There is, for example, substantial variation across states and regions in the level of development of trauma systems; the effectiveness of state EMS offices and regional EMS councils; and the degree of coordination and integration among fire departments, EMS, hospitals, trauma centers, and emergency management. The baseline conditions and needs also vary. For example, rural areas face very different problems from those of urban areas, and an approach that works for one may be counterproductive for the other.

In addition to these varying needs and conditions, the problems involved are too complex for the committee to prescribe an a priori solution. A number of different avenues should be explored and evaluated to determine what does and does not work. Over time and over a number of controlled initiatives, such a process should yield important insights about what works and under what conditions. These insights can provide best-practice models that can be widely adopted to advance the nation toward the committee’s vision.

The process described here is one that can be supported effectively through federal demonstration projects. Such an approach can provide funding critical to project success; guidance for design and implementation; waivers from federal laws that might otherwise impede the process; and standardized, independent evaluations of projects and overall national assessment of the program. At the same time, the demonstration approach allows for significant variations according to state and regional needs and conditions within a set of clearly defined parameters. The IOM report Fostering Rapid Advances in Health Care: Learning from System Demonstrations articulated the benefits of the demonstration approach: “There is



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