The Audit recognized the following improvements to the City"s Emergency Medical Services system as a result of the EMS merger:

· Increased EMS coverage in most San Francisco neighborhoods

· Legal claims have decreased markedly

· The number of EMS complaints has steadily decreased

· (4) Rescue Captains per shift provide increased medical oversight in the field

· The Incident Management System identifies and investigates unusual occurrences

· EMS fragmentation has been reduced

· There has been increased cross-training of Fire Department personnel

· Fire and EMS dispatch functions are fully integrated

The Department offers the following expanded analysis of EMS system improvements as a direct result of the EMS merger:

On September 19, 1995, the Health Commission directed the Emergency Medical Services Agency to develop a plan to improve San Francisco"s Emergency Medical Services system. An open community process was used to create the plan in recognition that there were conflicting opinions as to what system San Francisco should pursue. Phase I of the process consisted of three Town Hall meetings and 51 work group meetings that produced 247 recommendations. The most significant recommendation was to implement a new, fire-based EMS system for both response and transportation. After review of the merger implementation plan developed in Phase II, the Fire and Health Commissions jointly adopted a resolution to merge the San Francisco Department of Public Health Paramedic Division into the Fire Department.

Pre-Merger - Critical EMS System Problems

The February 1996 Phase 1 Report identified the following critical problems:

1) An overly fragmented system which resulted in poor coordination and communication between emergency response agencies and wasteful duplication of services.

2) The single-tiered dispatch system, requiring two highly skilled paramedics, to respond to all calls wasted time and resources.

3) The system was unable to meet response time standards.

4) Inconsistent supervision and oversight due to lack of resources

5) Inadequate training

6) Poor response for multi-casualty incidents and disasters

7) Inherent inflexibility

8) The system failed to effectively serve several outlying neighborhoods such as the Hunters Point and Lake Merced areas.

9) The system contained a conflict of interest by housing in the same Department both the regulatory agency (EMS Agency) and the primary service provider it was required to regulate (DPH Paramedic Division).

Post-Merger - EMS System Improvements

The Fire/EMS merger has led to significant improvements in each of the critical problem areas identified in the Phase 1 Report. Although this merger, as with all mergers, has had many growing pains and difficult problems to overcome, the City"s emergency medical response system is now far more efficient and provides better care for patients.

1. The EMS system is no longer fragmented

· All first response to medical emergencies and 96% of ambulance response is now provided by the Fire Department.

· All dispatch and communications are managed by a centralized Emergency Communications Center. Fire and EMS units share the same Computer Aided Dispatch system and radio channels.

· There is a single integrated chain of command for EMS and Fire personnel.

· Almost every paramedic has cross-trained as a firefighter.

· Teamwork and efficiency at all types of emergencies has been greatly improved.

2. Dispatch Improvements

· Standardized Call Triage

The Fire and Emergency Medical Service Dispatch Centers were physically merged in March 1998. A multi-tiered Criteria Based Dispatch (CBD) system has been implemented. Calls are now triaged using a standardized interrogation and pre-arrival instructions. This system enabled the Department to successfully deploy a Basic Life Ambulance pilot program from 1999-2000.

· Multi-tiered Dispatch

The Department anticipates a further expansion of the concept of multi-tiered dispatch when the new Medical Priority Dispatch system is implemented in 2002. As the ALS Engine and Paramedic/EMT ambulance programs expand, the Department expects to improve its ability to dispatch different types of units depending upon the patient"s needs and chief complaint.

3. Reduced Response Times

· Although the number of responses to medical emergencies has risen by 20% based on data reported by the Department of Public Health prior to the merger, response times have been greatly reduced. Unfortunately, the Department and the Auditor disagree on this issue. The Department recognizes that reliable pre-merger call volume data is not available, but believes it presented considerable credible testimony to the Auditors on this issue. The Department addresses this issue at length in Section 4.2 of its response. The Department also submits that personnel who have actually provided the service under both systems would agree that ambulances arrive on the scene much more quickly since the merger.

· Roll times are a very accurate measurement of EMS system improvements. This is the amount of time it takes a unit to respond to a call after it has received a dispatch notice. Due to the lack of availability of reliable pre-merger EMS call volume data, the month of January 1998 is used to establish a baseline. This is the last month in which the EMS system was run on a model similar to that employed by the DPH Paramedic Division.

· Code 3 Life Threatening Calls

Code 3 Life Threatening roll times have improved by 18% since January 1998

· The 90^th percentile Code 3 Life Threatening roll time was 11 minutes and 14 seconds in January 1998

· 90^th percentile Code 3 Life Threatening roll time was 9 minutes and 13 seconds in December 2001.

· Code 3 Calls

Code 3 roll times have improved by 25% since January 1998.

· The 90^th percentile Code 3 roll time was 11 minutes and 21 seconds in January 1998

· 90^th percentile Code 3 roll time was 8 minutes and 31 seconds in December 2001.

· Code 2 Calls

Code 2 roll times have improved by 24% since January 1998.

· The 90^th percentile Code 2 roll time was 17 minutes and 32 seconds in January 1998

· 90^th percentile Code 2 roll time was 13 minutes and 29 seconds in December 2001.

4. Improved Medical Oversight

· Supervision

Redeployment of existing personnel allowed the Department to staff four paramedic supervisors in the field each day without increasing the number of EMS personnel in the Department. These supervisors respond to fire, rescue, and medical emergencies where they provide direct care to patients as well as the clinical and administrative supervision of subordinate staff. These Rescue Captains ensure accountability through direct on-line medical supervision, written documentation of performance on over 7500 calls per year, investigation of clinical complaints, and field training.

· Quality Improvement and Risk Management

The Incident Management System

The EMS Division has developed a comprehensive Quality Management Plan to continuously examine and improve the emergency medical services provided by the Department. The Risk Management Component of the Quality Management Plan is responsible for establishing a multidimensional, systematic and comprehensive approach to Risk Management functions.

The most significant component of this program is called the Incident Management System or "IMS". The IMS is a means for identifying and investigating "sentinel events". These are instances of an unusual occurrence that are brought to our attention through direct observation, review of care, letter or phone call indicating a complaint or concern. Each "IMS" receives a unique identifying number and is triaged by the Medical Director as low risk, moderate risk or high risk. Each IMS incident is investigated by a Rescue Captain and then actions are taken consistent with the Department"s Managing Problem Performance (MPP) Program. If individual, group or Department-wide training is required, it is referred to the In-Service Training Section. If policies or protocols need to be changed or developed, that is done through the chain of command or through the EMS Section of the Department of Public Health. This reduces that the likelihood of a recurrence.

Reduction in EMS Related Complaints

During the first year after the merger, the EMS Division investigated nearly 200 concerns that were brought to our attention regarding the services we provide. (During this time period, the Department provided emergency medical services to more than 60,000 people.) Almost all of the concerns were found either to be of "no merit" or were viewed as opportunities to re-educate or to re-train personnel in our effort to continually improve the service we provide to the Community. The number of complaints and concerns received by the Department has steadily decreased. (See Exhibit 4.0.1 below.)

Exhibit 4.0.1: EMS-Related Complaints

Reduction in Legal Claims

Prior to the merger of the Paramedic Division into the Fire Department, legal claims filed with the City and County of San Francisco regarding pre-hospital clinical care were managed by the Risk Management office at San Francisco General Hospital. Since the merger, all risk management activities are conducted through the Medical Director"s and EMS Chief"s offices. The number of EMS claims has dropped dramatically since the merger. Prior to the merger, approximately one claim was filed per month. In the last 36 months there have been no EMS related legal claims against the Department (see attached chart) This clearly shows that our paramedics and EMT"s are providing excellent patient care. The Quality Management Program and Incident Management System effectively identify problems and seeks solutions that serve to improve our performance. The increased level of supervision, training, and CQI made possible by the creation of the EMS Division as part of the merger is undoubtedly a major reason for these improvements. (See Exhibit 4.0.2 below)

Exhibit 4.0.2: EMS-Related Claims Against CCSF

Research

The Department is actively working to partner with other healthcare investigators, funding sources, and agencies to participate in pre-hospital research projects.

The Department has participated in major research studies on the Prehospital Treatment of Status Epilepticus and the treatment of stroke patients. Articles on these studies were published in national EMS journals, including one last month in the prestigious New England Journal of Medicine.

The Department has been asked to assist in two new research projects: identification of "High Utilizers" of emergency services in order to develop interventions to assist these residents and decrease their likelihood of requiring emergency services and "Bi-phasic vs. Mono phasic" cardiac defibrillation.

5. Expanded Training

· The Department is very committed to providing high quality EMS training programs. These programs were made possible by the improvement in clinical supervision and oversight. More importantly, EMS training is an integral part of the CQI and risk management programs.

· In-Service Training

The Department now provides tens of thousands of student hours of EMS and health and safety training each year. 250 paramedics receive at least 48 hours of training every two years, 1100 EMT"s and 500 first responders receive at least 36 hours of training every two years. The Department is in full compliance with State and Local mandated EMS training requirements as well as various labor contract provisions.

· EMS Academy

The Department, in cooperation with City College, runs a locally accredited paramedic training program for firefighters and other interested students. The EMT training program for new recruits is now a college credit program. The EMS Academy is a certified American Heart Association Training Center.

6. Better Disaster Response

· The Department now has a much improved response and operational system to manage multi-casualty incidents and disasters. EMS, rescue, and suppression activities are coordinated through an integrated Incident Command System. Advanced Life Support resources, including ambulances and ALS Engines, are now decentralized to the neighborhoods where they will be most needed during large disasters. The Department has been the lead agency in coordinating the City-wide Metropolitan Medical Response System to address large scale disasters or terrorist attacks. The Fire Department is responsible for coordinating inter-department and City-wide disaster drills on a regular basis.

7. Cross-training for Flexibility

· Over 100 former DPH paramedics have been cross-trained as firefighters. Over 70 experienced firefighter paramedics have been hired from other departments. A smaller number of firefighters have cross-trained as paramedics. As more members receive paramedic and firefighter cross-training, the Department improves its flexibility to respond to a variety of incidents. Cross-training has greatly increased the number of personnel on duty each day who can respond to fires, technical rescues, and EMS incidents without increasing the overall FTE count. Many of our paramedic firefighters are trained to deliver care in special situations such as hazardous material and technical rescue incidents. The soon to be implemented Rapid Paramedic Response System will further enhance our flexibility to quickly respond to any type of emergency with appropriately trained personnel.

8. Paramedics in Each Neighborhood

· Virtually every neighborhood in San Francisco now has an ambulance deployed from a fire station. As the ALS Engine program expands through paramedic hires, cross-training, and implementation of the Split Paramedic Response System, there will eventually be a paramedic in every fire station in the City. There are currently almost three times as many paramedic staffed units in the City as there were before the merger.

9. Regulatory Oversight

· There is no longer a conflict of interest between the EMS regulatory authority, the DPH EMS Section, and the primary EMS provider, the Fire Department. The Department of Public Health EMS Section regulates the Fire Department"s EMS services consistent with the requirements of the Title 22 State Requirements and the City Charter that vests the Health Commission with responsibility for management and control of the Emergency Medical System.

If success is measured by creating major improvements in the delivery of service, the Fire EMS merger has been a huge success.

· Audit Review

The Department has reviewed the Budget Analyst"s report, including this "Introduction" section that summarizes much of the Budget Analyst"s recommendations about the provision of EMS in the Department. Comprehensive analysis is provided in later sections of this report. A brief summary of the Department"s response to each section is provided below. Further analysis and response to specific Audit recommendations will be found in specific sections later in the document.

EMS Configuration prior to July 1, 1997:

This section describes the EMS system configuration under the DPH Paramedic Division that staffed between 8 and 16 (average of 12 units/ 24 hr day) dynamically deployed units. The report does not describe in any detail the multiple problems, previously listed, faced by the Paramedic Division that provided the impetus for the merger of the Paramedic Division into the Fire Department. If the EMS system had been working well, there would not have been broad-based support for the merger. The Paramedic Division simply did not have the resources to succeed as the primary EMS provider for the City.

EMS Transfer Process

The Audit, which documents delays in the merger and cross-training process for paramedics and firefighter, fails to mention the significant impact of the 20% increase in EMS workload that occurred during the same period. The Department recognizes that reliable pre-merger call volume data is not available, but believes it presented considerable credible testimony to the Auditors on this issue. In addition, prolonged negotiations between the unions and City government slowed progress considerably.

The Audit description of "Phase IV" of the merger process states that the deployment of 16 ambulances was not achieved until FY 1998-99, which is incorrect. The Fire Department deployed 16 paramedic ambulances on February 21, 1998.

Current EMS Configuration:

Staffing and Service Levels

The Audit calculates that the Fire Department employs 285.05 FTE to deliver EMS in FY 2000-01 versus 190 FTEs on June 30, 1997, the day before the Fire-EMS merger took place. The Audit does not fully credit the increased efficiencies in how EMS service is provided by the Fire Department, or the increased EMS service responsibilities.

The DPH Paramedic Division used 190 FTE to staff:

· An average of 12 ambulances over a 24 hour period

· one field paramedic supervisor

The Fire Department, with 285 paramedic FTEs, a 50% increase in the number of paramedics rather than total FTE, now staffs:

· An average of 20.5 ambulances over 24 hours (78% increase)

· 4 field paramedic supervisors (400% increase without additional FTE)

· 5 ALS Engines

· A paramedic engine and BLS ambulance on Treasure Island

· Two paramedics at the Airport 24 hours per day

Overall, there has been a 244% increase in the number of paramedic-staffed units (ambulances, supervisors and ALS engines), which has resulted in dramatic reductions in response times and other system improvements. [See Section 4.2 of report]

Cost per Unit

The Department has provided figures to the Board of Supervisors and the Auditors showing that the Fire Department cost to staff an ambulance is now $850,000 per year, versus a $1.2 million per ambulance cost of units staffed under the DPH Paramedic Division.

Supervision and Management

The Audit infers, in Table 1, on page 15, and in their report on page 17, that the new Fire Department is top-heavy in management, supervision and administration. However, the Budget Analyst"s own data in Table 1 reveals the following information:

· The DPH Paramedic Division had 190 employees, of which 28 were Paramedic Captains or other uniformed staff, for a 14.7% "management and supervision" percentage of staff. This represents one supervisor/manager for 5.8 employees.

· The Fire Department EMS Division has 285 employees "available" for EMS with a total of 36 FTEs in Paramedic Captain or other management positions for a 10.9% "management and supervision" percentage of staff. This represents onesupervisor/manager for 6.9 Employees

· The percentageof EMS personnel assigned to management/ supervision / administration has actually dropped 26% since the Fire-EMS merger.

· The percentage of EMS supervisors and managers per employee is less than either the current or pre-merger fire suppression employee to supervisor/manager ratios.

The Department supplied data for the Audit which documented that a total of 32.5 FTEs, including 29.5 from the DPH Paramedic Division and three from the Fire Department, were assigned full time to EMS supervisory, management and administrative responsibilities. Currently 35 employees staff similar positions. This is a real increase of only 2.5 FTE (10%) performing EMS administrative responsibilities despite a 50% increase in the number of paramedic personnel and a tremendous expansion of the training and quality improvement programs. Despite this fact, the Audit actually recommends cutting key EMS leadership and technical support positions.

The following chart shows that there has been very little change in the total number of management, supervisory, and administrative positions as a result of the merger.

Transition Costs:

The Budget Analyst"s report states that there have been significant increases in the cost of EMS service provided by the Fire Department, despite assurances that the merger would be cost neutral in FY 1997-98. The Department does not agree with the Audit"s statement that there has been an increased cost of $ 1,020,123 "due largely to increased supervisory staffing." No new FTEs were added as part of the process of creating the new EMS supervisory and management structure. Existing FTE positions were upgraded to create an appropriate level of management and supervision. These changes were described in detail in the public planning documents and were approved by the Board of Supervisors as part of the normal Fire Department budget process. The Department submitted the following analysis to the Auditors which shows that the actual costs of these position upgrades was $ 255,287 in FY 96-97 dollars.

ANALYSIS OF CONVERSION OF DPH POSITIONS IN FY 96-97 DOLLARS

*includes 5% fire suppression premium

DPH POSITIONS CONVERTED TO SFFD EMS SUPERVISORS/MANAGERS

$ 3,101,340 minus $ 2,846,053 = $ 255,287

ESTIMATED COST OF CONVERSIONS IN FY 96-97 DOLLARS = $ 255,287

Many of the "extra" costs that are described as created by the merger are actually due to new wage and benefit packages that were approved by the Board of Supervisors after meeting with labor as part of the regular process of negotiating new memorandums of understanding.

The Audit cites increased personnel costs regarding salary, benefits, retirement, etc. However, the report does not mention the increased productivity of paramedics who moved from a 40 hour work week to a 48 hour week, a 20% increase in work hours, which dramatically increased the number of ambulances staffed and deployed by the Fire Department.

The Department does not agree with the Auditors statement that "the Fire Department increased its annual personnel expenditures by a further $2,471,851." The Budget Analyst stated that if DPH had similarly increased the number of paramedics to staff four additional ambulances, it could have done so for $856,438 less." The Audit does not provide any data to support this claim. The Department points out that it takes at least ten 2532 paramedic FTE to staff one ambulance with seven days per week, 24 hours per day coverage. Four additional ambulances would therefore require at least 40 additional paramedic FTE. Each 2532 paramedic earns at least $ 80,000 per year with benefits. 40 FTE multiplied by $80,000 is $3.2 million dollars, well in excess of the $2,471,851 spent by the Fire Department according to the Audit.

It is true that the City is spending more to provide EMS services since the merger. This Department response cites many instances of the improvement in these services that are a direct result of the merger. It also must be recognized that there have been many changes in health care since the merger. The Board of Supervisors has heard numerous reports at committees of hospital emergency department overcrowding, higher patient acuity, and significant problems related to changes created by HMOs. These health care problems also affect the Fire Department"s pre-hospital service that has seen a large increase in the total number of patients.

EMS Workload Analysis:

The Department disagrees with the findings of the Audit on issues such as: the dispatch of multiple units to EMS calls, utilization of short shifts, workload distribution, and response time data. This information is comprehensively covered in the Department"s response to section 4.2 "EMS Service Configuration".

The Department also believes the Audit has not adequately considered the impact of the additional EMS service and reconfiguration by the Department. In the first paragraph of Section 4.2, the Budget Analyst states that while the Department increased ambulance staffing 20% from 17.5 to 20.5 units, it increased staffing by 33.8% from 183 to 245 FTEs. The report fails to mention that many of these FTEs are not assigned to dedicated EMS units, but instead to staff ALS Engine positions at San Francisco International Airport and Treasure Island. Approximately 36 of these positions simply replace pre-existing H-2 firefighter positions on ALS engines.

In fact the number of paramedics required to fill all required positions each day has increased from 34 per day in 1998, to 48 per day in 2001, a 38% increase. See below:

1997:

17 Medic units x 2 Paramedics = 34 per day

2001:

20 Medic units x 2 Paramedics = 40 per day

6 ALS Engines x 1 Paramedic = 6 per day

2 additional Paramedics at SFO= 2 per day

48 per day

Note: This increase in staffing reflects the significant increase in service provided to the community approved by the Board of Supervisors in the FY 1999-2000 budget by increasing available ambulances.

CONCLUSIONS:

The Department agrees that there are more paramedics providing service to the City today than before the merger. This was the intention of the merger. However, Table 2 which compares EMS resources is potentially misleading:

· The estimate of 8-16 ambulances deployed per day under DPH is not directly comparable to the 20 plus units deployed by the Fire Department on a 24 hour basis. DPH at most averaged 12 units per day over a 24 hour period. The Fire Department has increased ambulance staffing by a considerable 83%.

· It does not recognize that two paramedics now provide ALS coverage at the Airport each day.

· It does not recognize the enormous improvement in training due to the dedication of staff to the that area

· It does not recognize the improvements created by dedicating staff to CQI and risk management activities

As stated previously, the Department believes that the Audit"s response time analysis is flawed and incomplete. It disagrees with the response time figures included in Table 3.

Response times and system performance is discussed in detail in Section 4.2

Recommendations on Restructuring the EMS Division and the Provision of EMS Services:

These recommendations are discussed in detail in other sections of the response.

Accomplishments of the Fire Department:

This Audit appears to be incomplete and perfunctory regarding the accomplishments of the Fire-EMS merger. The Audit contains only one short paragraph describing the major improvements in the delivery of EMS services as a result of the merger.