The Department has always been acutely aware of the criticality of the functions provided by the administrative Divisions. The operations mission of the Department would not be possible without the daily work and support of those Bureaus and Divisions that report to the Deputy Chief of Administration. Equipment, facilities maintenance, management information services (MIS), staffing, finance, billing, accounting and payroll are just a partial listing of those mission critical support functions provided in this area. While the Department is constantly seeking ways to improve productivity and efficiency, it is worth remembering that the mission of the Department has grown tremendously in the last decade. The assimilation of EMS, the need for city-wide disaster preparedness, the preparation for the use of weapons of mass destruction (WMD), and the increase in violence in schools and at the workplace has required an abrupt up-ramping in the Department"s operational expertise and capabilities. An increase in operational responsibility requires an increase in the support structure.

The Department is currently in the process of developing a strategic five (5) year plan. This plan will be the product of a diligent work flow and business process analysis and is anticipated to take one year to prepare. This plan will include a formal proposal for reorganizing both administrative and operational functionalities within the Department. This reorganization will reflect modern management techniques, optimization of personnel and staff, recognition of the growing role of EMS in our Department, the need for better interdepartmental cooperation, and the need for strong fiscal management. The Department expects that this reorganization may result in some redeployment of the resources focused on by the Auditor. The new organization will represent the shape of Department as determined by operational goals and support requirements and will be used for the preparation of the FY 2003-2004 budget.

· Recommendation of Auditor"s report

The Fire Chief should:

1.1.1 Eliminate the EMS Administration Section

· Assessment of Department

The Department disagrees with the recommendation of the audit.

The activities of the EMS Administration Section include EMS Continuous Quality Improvement (CQI) and Risk Management, data collection and analysis, ambulance billing / revenue collection, development of specifications for medical equipment, and management of confidential medical records. None of these functions are performed by other bureaus or divisions of the Department. All of these activities are specialized and require EMS training and experience for effective management. The EMS Division does not manage administrative activities such as payroll, human resources, occupational health, scheduling of personnel, or purchasing that are appropriately handled by other areas of the Department.

The Audit states that "the Fire Department manages its emergency medical services administrative functions separately from its fire suppression administrative functions. This divides management accountability for various administrative activities, and reinforces an inappropriate distinction between fire suppression and emergency medical services¹." Divisions and Bureaus already exist within the Fire Department that manage their specialized administrative functions separately from the central administration of the Department. Those divisions include Fire Prevention and Investigation, Human Resources, Support Services, and Training. To varying degrees these Divisions are independently accountable for managing revenue programs, maintaining specialized records, collecting and analyzing data, or developing specifications for contracts and equipment. The Suppression Divisions of the San Francisco Fire Department do not currently participate in CQI or Clinical Research activities of any kind. Risk Management and Liability Mitigation programs are solely the purview of the EMS Division. No fire suppression offices deal with Risk Management to the extent or with the level of expertise, as does the EMS staff. To integrate these activities into existing administrative divisions that possess neither the expertise or the experience is impractical and counter-productive.

The Department does not support the recommendation to eliminate the EMS Administration Section. The Audit has not identified actual problems with CQI, Risk Management, or financial activities that are the responsibility of that section. Furthermore, the Audit provides no evidence to support the contention that administrative functions performed by the EMS Administrative Section reinforce an inappropriate distinction between EMS and fire suppression.

· Recommendation of Auditor"s report

1.1.2 Delete 1.0 classification H-43 EMS Administration Section Chief position and 1.0 classification 1426 Senior Clerk Typist position.

· Assessment of Department

The Department disagrees with the recommendation of the audit.

The audit recommends elimination of an H43 Section Chief and a 1426 Senior Clerk Typist. The audit fails to provide any work flow analysis to determine the practicality of this recommendation and whether there is in fact duplication of work. The Finance Division is expected to assume all EMS billing responsibilities but would not be provided with any additional staff to carry out this function. The suggested addition of medical records personnel to the Finance Division would only facilitate transfer of patient care reports to the billing contractor.

The H43 Administration Section position is not a single classification but rather one of five H43 EMS Section Chiefs. The Department believes that the six direct reports to the H43 represents an appropriate span of control commensurate with the large responsibilities of the reporting members. It is significant that the Audit recommends that the Manager of the new Division of Finance and Strategic Policy would have only three direct reports. It is inconsistent for the Audit to question the need for the position of H43 EMS Administrative Section Chief based on the number of direct reports while recommending creation of a similar management position with half as many reports. The position is responsible for the management of a number of complex and critical functions that involve many members of the Department and outside agencies in addition to the immediate reporting staff.

A list of the finance related duties of the EMS Administration Section Chief (assisted by the 1426 clerk) includes, but is not limited to the following:

· Review all regular monthly reports submitted by AIS, the current EMS revenue and billing contractor

· Meet regularly with Allied Information and Services (AIS - the Department"s EMS billing service) staff to discuss performance and review progress in meeting revenue targets

· Utilize reports from AIS to identify field providers with high error rates in their reporting

· Attend industry conferences to stay informed of planned changes in health care and reimbursement rates

· Direct and work proactively with the current billing and collections vendor to develop revenue enhancement programs that are within all federal, state, and local regulations

In addition, the report does not explain how the other functions that the H43 Section Chief is responsible for will be addressed. This position also manages the following areas:

· EMS data analysis and reporting

· Continuous Quality Improvement

· Risk Management

· Medical research

· Medical records maintenance

· Paramedic license renewal

· Bio-med equipment specification development and maintenance

· Development request for proposal (RFP) of EMS equipment

· Service contracts and development of EMS MOU"s and contracts with outside agencies.

The 1426 clerk assists the H43 EMS Chief in the accomplishment of these tasks.

· Recommendation Auditor"s report

1.1.3 Transfer the responsibility for emergency medical services electronic data collection and reporting, the Continuous Quality Improvement Program, and risk management to the proposed Strategic Policy, Planning and Analysis unit.

1.1.4 Delete 2.0 Classification H-33 Rescue Captain Positions

1.1.5 Transfer $221,342 in savings from the deleted H-33 Rescue Captain positions to fund civilian positions in the proposed Strategic Policy, Planning and Analysis Unit, who would perform data management and CQI functions.

·Assessment of Department

The Department disagrees with these recommendations of the audit.

These three interrelated Audit recommendations call for the transfer of the EMS data analysis, CQI, and Risk Management programs to a new Strategic Planning, Policy, and Analysis Unit that would be partially funded through the elimination of two H33 Rescue Captain positions. The Department sees no credibility in a recommendation to eliminate the positions of qualified personnel who have demonstrated excellent performance in the management of the EMS CQI and risk management programs, particularly since they would be replaced by civilians who would be required to have the same training and experience and a similar or greater benefit package.

The Audit has detailed the creation and functions of this new office in regards to staffing with civilian analysts, and in regards to finance, under the scrutiny of the Department"s current finance section. The Audit also prominently recommends integrating CQI, Risk Management and Research into the new office. The Audit does not note, detail, or acknowledge the fact that these activities and programs do not exist in application for the suppression divisions of this Department.

The Department supports the creation of a planning unit, but does not believe that CQI, Risk Management, and with some exceptions, data analysis, are appropriately handled by this type of unit. CQI and Risk Management are dynamic processes that require the daily participation of members who are educated and trained to provide the level of service, supervision, and management of EMS services that they are reviewing to improve performance.

Any reduction in the efficiency of these programs has the potential to result in multi-million dollar losses to the City for malpractice claims.

If officer-level, paramedic, nursing, or physician personnel are not assigned to the functions of Risk Mitigation, CQI, Research and CAD analysis, the Fire Department shall be in direct violation of local, county and state mandated regulations regarding the provision of ALS services to the public. Such violations could result in legal action being brought against the Department and the City and County. Legal actions could take the form of state-levied fines, sanctions or, in the extreme, revocation of the Fire Department"s license to provide paramedic services in the City and County of San Francisco.

California State, Title 22, Health and Safety Code of Regulations authorizes EMS County Medical Directors to set standards for ambulance provider Continuous Quality Improvement and Research. Once those standards are set, the county medical director is tasked with ensuring adherence to said policies. Additionally, the San Francisco County Medical Director mandates that each provider agency submit its own internal CQI plan for review. Once approved by the Medical Director"s Office, the plan is binding upon its provider agency to meet all requirements therein. The document, in effect, becomes that provider"s contribution to the overall county Quality Assurance (QA) plan.

The Fire Department has in place an excellent EMS Quality Improvement and Risk Management program, developed by the EMS Command and CQI staff, that has been approved by the Director of Public Health, the Fire Chief, and San Francisco General Hospital. The Audit does not cite a single problem with the current CQI and Risk Management programs.

The office of the San Francisco County Medical Director mandates an ALS provider agency to employ "...a paramedic, knowledgeable in the areas of pre-hospital care and quality assurance who is responsible for evaluating the medical quality assurance of services provided²". Additionally, the county policy for pre-hospital research mandates "...participating organizations will designate a representative to assist in the coordination of each research study³". The policy goes on to specify said representative as "...[sic] an EMT-Paramedic currently certified in the State of California⁴". Additionally, the internal CQI plan submitted by the Fire Department, which calls for "...CQI and Research activities...to be performed by Rescue Paramedic Captains...".

Field emergency medicine (i.e., paramedic) (QA) oversight must cover three (3) broad areas of prehospital care; assessment, treatment and skills maintenance. None of these QA parameters can be performed, evaluated or critiqued by civilian employees. Prehospital medical QA must be performed by individuals skilled and experienced in the theory and practical application of the activities they are overseeing. QA must be performed and guided by field experienced paramedics. Post-incident evaluation, clinical investigation and retrospective chart auditing are unique skills, best performed by field-experienced, academically prepared clinical officers. The CQI and Research Paramedic Captains are the Administration Clinical Officers for the San Francisco Fire Department.

The Department believes that these programs are the primary reason for the virtual elimination of EMS related clinical lawsuits. More importantly, the Audit does not describe how a small civilian planning unit including personnel with no EMS training or experience would be able to rapidly identify problems, develop solutions, create training programs and provide feedback to field personnel. The experienced EMS staff has a proven record of CQI and Risk Management because field personnel, dedicated CQI staff, training staff, and managers all work together to ensure that the Department provides the highest quality, lowest risk emergency patient care. The Audit has failed to identify even a single large urban Fire/EMS system anywhere in the United States that uses non-uniformed, non-sworn civilian personnel to provide EMS CQI and Risk Management.

EMS data analysis is a critical function that is used to modify operations, protocols, and training to ensure maintenance of high quality care. Rapid access to data on a daily basis is critical for EMS managers. This data should be available for use by planners for long-term projects, but it is much more sensible to maintain the current system where data analysis can be performed by personnel who are part of the every day working EMS team. The EMS Division is also responsible for and mandated to prepare regular reports for regulatory bodies such as the DPH EMS Section that are based on data analysis that non-EMS civilian staff could not possibly provide.

The Audit recommends staffing the new Strategic Planning with three (3) civilian financial analysts, one of whom would possess a paramedic, nursing, or medical license. These three analysts would, theoretically, provide the same level of CQI, Research, Risk Management and clinical oversight to the entire Department, that five EMS members provide today solely for the emergency medical services division. To expand all CQI and research programs would demand more, not less, staff members.

The Audit is unable to effectively demonstrate its assertion, unsupported by any evidence, that "...assigning these responsibilities to civilian staff, rather to sworn personnel would ensure that the data collection and reporting, CQI, and risk management functions are consistently applied to both fire suppression and emergency medical services."

Finally, any such change would have to be approved by the Department of Public Health consistent with their charter authority over the "management and control of emergency medical services." The Department of Public Health EMS Section has advised the Auditors that it does not support any reduction in the total number of person hours assigned to EMS QI or the capability of staff dedicated to QI to be reduced.

· Recommendation Auditor"s report

1.1.3 Transfer the responsibility for emergency medical services electronic data collection and reporting, the Continuous Quality Improvement Program, and risk management to the proposed Strategic Policy, Planning and Analysis unit.

·Assessment of Department

The Department disagrees with the recommendation of the audit.

As described in Section 1.1.3, the Department does not believe that this recommendation will improve the current level of service or provide increased operational efficiency. Rather, the Department believes that there would be a degradation of the EMS CQI and Risk Management due to the significant reduction in members currently dedicated to EMS CQI and risk management activities. Implementation of this recommendation will create a reduction of well-integrated prospective on-line CQI and QI-based training.

· Recommendation Auditor"s report

1.1.4 Delete 2.0 Classification H-33 Rescue Captain Positions

·Assessment of Department

The Department disagrees with the recommendation of the audit.

As previously described, the Department does not believe that this recommendation would improve the current level of service or provide increased operational efficiency. Rather, the Department believes that there would be a significant degradation of the EMS CQI and Risk Management programs through the loss of these positions. The Department sees no merit in replacing highly trained and motivated uniformed paramedics with civilian paramedics or nurses that would require similar or greater compensation packages.

· Recommendation Auditor"s report

1.1.5 Transfer $221,342 in savings from the deleted H-33 Rescue Captain positions to fund civilian positions in the proposed Strategic Policy, Planning and Analysis Unit, who would perform data management and CQI functions.

·Assessment of Department

The Department disagrees with the recommendation of the audit.

The Department does not believe that this recommendation would improve the current level of service or provide increased operational efficiency. Rather, the Department believes that there would be a significant degradation of the EMS CQI and Risk Management programs. The Department finds no analysis in the Audit that explains how EMS CQI and Risk Management activities that are performed by three full time paramedic FTE can be equivalently managed by three civilian analysts who would primarily be tasked with long range planning, grant writing, policy review, training program review, Risk Management, and other similar tasks for the entire Department.

· Recommendation of Auditor"s report

1.1.6 Transfer the responsibility for emergency medical service billing and revenue collection function, related medical records management, and the administration of fee amendments to the Division of Finance.

·Assessment of Department

The Department disagrees with the recommendation of the audit.

The Audit does not describe any actual inefficiencies in the current system of EMS accounting due to the fact that the EMS Administrative Section provides oversight for the EMS revenue collection program. The EMS revenue program is very large including $33 million dollars in gross service billings and $14 million dollars in revenue collections. This collection rate is consistent with other urban EMS systems in California. Other divisions within the Department manage the collection of millions of dollars in fees for their services.

The Department has worked for the past year to transfer some of the accounting functions involving the emergency medical services billing and revenue collection process to the Central Accounting Section of the Department. The Accounting section is already reconciling daily revenue collections with Allied Information and Services (AIS- the Department"s EMS billing service) and total monthly accruals for posting. It is not unusual for a section/division of a Department to be involved in the daily monitoring of a contractor, but the development and review of contracts always involves the Finance Section.

EMS Administration Section personnel work collaboratively with the Finance Division to develop appropriate accounting functions. The division of labor and responsibilities between the two units is clear. Health care finance is a complex field that is constantly changing. EMS Administrative personnel routinely attend industry conferences that include updated finance and revenue training along with other EMS related education; that information is then used to assist in managing and addressing issues related to EMS billing.

It should be noted that the Finance Division was involved in the review and selection process for the EMS billing and revenue contractor. Also, in other city Fire Departments the billing and collection process and contract development is managed and overseen by sworn personnel. The knowledge of the work is essential in ensuring that both the Department provides needed data for billing and the contractor is in compliance with Federal and State requirements for billing of medical services.

The Analyst fails to identify how work that is currently performed by EMS Division staff who have expertise in EMS finance could be assumed by existing Finance Division staff. The Audit does not provide any justification data or analysis that identifies actual inefficiencies or problems in accountability created by the current system. In fact, the Division of Fire Prevention and Investigation provides similar program oversight for revenue collection related to inspection and permit fees.

· Recommendation of Auditor"s report

1.1.7 Transfer 1.0 Classification 2112 Medical Records Technician position and the 1.0 Classification 2110 Medical Records Clerk position to the Division of Finance.

·Assessment of Department

The Department disagrees with the recommendation of the audit.

The EMS Division Medical Records Section annually collects, collates, and sends 65,000 patient care reports to the billing contractor. The medical records section is a critical component of both the billing process and the CQI program. As records are collected and sorted for billing, the charts are reviewed for sentinel events or clinical indicators which are then forwarded to Risk Management and CQI teams. The medical records personnel assist with the CQI functions. Medical Records staff also identify and search for charts that are essential in the investigation of complaints and the Risk Management program. If the Medical Records Section is transferred to the Finance Division, this plotting of clinical trends and mitigation of sentinel events will be impossible to accomplish.

The efficiency of the Medical Records Section is enhanced by the fact that it is located at the same site as the Office of the Medical Director, the EMS CQI and Research teams, and the EMS field operations staff. The SFFD Headquarters building has no space for this program and many inefficiencies would be created by requiring the Financial Office to supervise a multi dimensional program at a remote site. The Audit states that "transfer to the Division of Finance would not impede the availability of the two medical records positions to work with CQI staff in the new Strategic Policy, Planning and Analysis unit." The Department does not find this statement credible or supported by factual evidence or analysis. It is not logical that a unit that currently performs all of its functions in an integrated system, under one chain of command at a site shared by all of the personnel with whom the unit interacts, is going to function efficiently under a divided chain of command with personnel at different sites.

·Recommendation of Auditor"s report

1.1.8 Transfer the responsibility for tracking, disbursing and maintaining emergency medical services equipment and supplies to the Bureau of Equipment.

·Assessment of Department

The Department will analyze the recommendation of the audit.

The Department will explore the possibility of transferring some of the responsibility for the tracking and maintenance of biomedical equipment to the Bureau of Equipment. The EMS Division currently tracks, disburses, and maintains the Department"s inventory of expensive biomedical equipment. Defibrillators, for example, cost up to $12,000 each. The EMS Division must collect and analyze a data card from a defibrillator each time a machine is used. All machine failures must be reported by the EMS Division to the DPH EMS Section and in some cases the Food and Drug Administration (FDA). The manufacturer is also contacted whenever there is a machine failure.

The EMS Division has a budgeted position of CQI paramedic that is primarily responsible for the oversight and evaluation of the first responder defibrillation program, data management for the Advanced Airway project, and review of all ALS cardiac arrest resuscitations. This person has proved to be a logical candidate for the efficient evaluation, maintenance and troubleshooting of the most important piece of resuscitative equipment carried by paramedics, the portable cardiac monitor/defibrillator/pacemaker. Existing Bureau of Equipment personnel already work with the EMS Division to assist in the exchange of machines, pick up of data cards, etc. Although the Department sees no inefficiencies in the current system, it will explore the issue further.

·Department Action Plan or Timeline

The Department will proceed with analysis on the transfer of the responsibility for tracking, disbursing, and maintaining biomedical equipment to the Bureau of Equipment. There are a number of issues related to mandatory EMS reporting requirements that must be resolved. The Department expects to complete its analysis by July 2002.

· Recommendation of Auditor"s report

1.1.9 Transfer the 1.0 H-3 Fire Fighter Paramedic position, responsible for biomedical equipment, to the Bureau of Equipment.

· Assessment of Department

The Department disagrees with the recommendation of the audit.

The audit identifies this FTE as "...an H-3 firefighter/paramedic...former biomedical engineer...who produces Requests for Proposals, receives, distributes and trains...⁵"

The Department member to whom the audit refers is in actuality an H-1 Rescue Paramedic, not a firefighter/paramedic. The organizational chart identifies the funded position of `CQI Paramedic." This position is responsible for the oversight and evaluation of the first responder cardiac arrest program and data management for the Advanced Airway project and the Truck first responder defibrillation program. The position also oversees all ALS cardiac arrest resuscitations as a subset of the QI operation. Since the position oversees all cardiac arrest cases, it is a logical candidate for evaluation, maintenance and troubleshooting of the most important piece of resuscitative equipment paramedics carry, the portable cardiac monitor/defibrillator/pacemaker.

The Department and the DPH EMS Section will not support the transfer of the CQI paramedic to the Bureau of Equipment. In Section 2.3.1 the Audit is actually recommending the elimination of this position and converting it to a 1942 Assistant Materials Coordinator. The Audit is unable to effectively demonstrate its assertion that "Transfer to the Bureau of Equipment would not impede the availability of this position to work with the CQI staff in the new Strategic Policy, Planning, and Analysis Unit." A Materials Coordinator obviously could not carry out the CQI responsibilities of this position. This recommendation is not supported by any analysis of the current duties of this position nor how it integrated into the CQI process.

These critical functions must be carried out as part of the mission of the EMS Administration Section. The Audit"s recommendation to transfer this position to the Bureau of Equipment would result in the elimination of the State and County mandated cardiac arrest CQI program.

¹ Management Audit Of The San Francisco Fire Department, 2001 pg. 1.1-5

² San Francisco Department of Public Health Emergency Services Section, Policy 2120 - V, 1991

³ Ibid., Policy 1070

⁴ Ibid., Policy 1070

⁵ Management Audit Of The San Francisco Fire Department, 2001 pg. 1.1-4