In 1966 the federal government identified the horrendous quality of emergency care rendered to Americans. Seven years later, New York State responded with a law that set out lofty, but vague, goals for improving emergency care. Implementing statewide policies requires many choices: goals, technical theories, using an existing agency or building a new one, as well as evaluation criteria. Unfortunately, New York chose organization design and implementation methods that were inadequate to the task, not evaluated and pre-destined to fail. This work examines the Rochester Region within New York State. It reveals that, even today, the Rochester Region does not meet national quality standards on a consistent basis. This work explains why the State “system architecture” for EMS in New York was a design that was not effective and easily thwarted. The progress in EMS service that did occur was made despite State policy rather than because of it. This work should be useful to public managers, emergency managers, policy makers and legislators, as well as students of management, public policy, health care, emergency management and planning.