Residual EMS Division Functions

The EMS Division currently comprises five sections: (1) the EMS Operations Section, (2) the EMS Special Operations Section, (3) the EMS Academy Section, (4) the EMS In-service Training Section, and (5) the EMS Administration Section. This report recommends that the functions of four of these sections be transferred elsewhere in the organization. The EMS Special Operations Section should become a direct report to the Deputy Chief of Operations (see Section 2.1, Operations Division Reorganization). The EMS Academy Section and the EMS In-service Training Section should be transferred to a new Division of Fire and Medical Training (see Section 1.4, Reorganize Training and Education). EMS Administration Section functions should be transferred to the Fire Department"s other administrative sections and to the new Strategic Policy, Planning and Analysis Unit (see Section 1.1, Rationalize Administrative Functions).

Once these structural adjustments have been implemented, the residual EMS Division would retain development, implementation, and evaluation responsibility for:

· Emergency medical services field operations management and performance monitoring. The current EMS Operations Section is responsible for medical supervision in the field. Such supervision is provided by the four Classification H-33 Rescue Captains who are assigned to each 24 hour shift¹. These Rescue Captains are responsible for the day-to-day administration and field deployment of paramedics. They do not report to Battalion Chiefs or Assistant Chiefs except when supervising emergency medical services within larger events involving fire suppression staff. Instead they report to the EMS Operations Section Chief who provides daily monitoring and problem solving for emergency medical services field operations staff for approximately 60 percent of his time.

· (1) Emergency medical services policies and procedures, (2) field personnel, equipment, and supply action plans, and (3) emergency medical services equipment and technology selections. These functions occupy approximately 40 percent of the EMS Operations Section Chief"s time.

The residual EMS Division would comprise (a) the EMS Chief and a Classification 1450 Executive Secretary I, (b) the Classification H-43 EMS Operations Section Chief and a 0.50 FTE 1426 Senior Clerk Typist, (c) 14.00 FTE Classification H-33 Rescue Captains (of whom 4.00 FTEs are on duty each 24 hours), and (d) 4.00 FTE Classification H-33 Rescue Captains who are temporarily detailed to the Combined Emergency Communications Center (of whom 1.00 FTE is on duty each 24 hours)². The total staff of the EMS Division would be 21.50 FTEs. All staff would work closely with the EMS Medical Director and Assistant EMS Medical Director, who report to the Director of the Department of Public Health, on matters requiring medical and regulatory oversight.

Future Structural Arrangements

There are two alternative approaches for the future structural arrangement of the EMS Division"s residual functions: (a) restructuring the EMS Division as a smaller EMS Unit, or (b) transferring the EMS Division"s residual policy development, implementation, and evaluation functions to the new Strategic Policy, Planning and Analysis Unit, and more closely integrating EMS Division operations management responsibilities into the existing fire suppression operations command structure.

The advantages of retaining a separate EMS Unit would be:

· Maintaining a central advocacy point for emergency medical services at a time when many Fire Department staff still question the merits of the transfer of emergency medical services to the Fire Department.

· Having a dedicated emergency medical services resource to work with other parts of the Department as they absorb their new devolved emergency medical services responsibilities (for example, the new Division of Fire and Medical Training, the Division of Finance, and the Bureau of Equipment).

· Maintaining the close integration of policy development and field operations management for emergency medical services at a time when those services are expected to experience significant change.

· A clearer line of accountability to the EMS Medical Director.

The disadvantage of retaining a separate EMS Unit is that there would not be full structural integration of an emergency medical services perspective into either the Fire Department"s policy development function, or its operations command structure. It is noted, however, that the Strategic Policy, Planning and Analysis Unit and the EMS Unit would be required to integrate their policy development and performance monitoring work. Furthermore, the EMS Operations Section already works closely with the fire suppression operations command structure.

The advantage of a more structurally integrated approach would be the potential to achieve full integration of fire suppression and emergency medical services in terms of both coordinated policy development and coordinated service delivery. However, the disadvantage of a more structurally integrated approach is the potential for emergency medical services, which have less staff and resources than fire suppression services, to receive less than optimal attention from senior management if there was no central advocacy point for emergency medical service concerns. There has been significant opposition from within the Fire Department to assuming full responsibility for emergency medical services. This has manifested itself through (a) cultural differences between fire fighters and paramedics, (b) the resistance on the part of both fire suppression and emergency medical services staff to further integration of fire suppression and emergency medical services management, training, and planning, (c) the Fire Department"s insistence on only recruiting into Classification H-2 Fire Fighter, (d) the Fire Department"s focus on maintaining traditional approaches to its service delivery, and (e) emergency medical service field staff"s perception that senior fire suppression managers do not fully understand or support their role. This organizational culture represents a significant barrier to service integration.

While we favor full integration in the medium term, we believe that the disadvantage of a more structurally integrated approach outweighs the disadvantage of retaining a separate EMS Unit in FY 2001-2002 through FY 2002-2003 while the other structural adjustments recommended by this report are consolidating. Nevertheless, the advantage of a more structurally integrated approach is potentially significant. We consulted nine of the combined fire suppression/emergency medical service systems identified by the EMS Division as "successful"³ to determine how they structured their chains of command. Eight of those systems operated fully integrated chains of command for their fire suppression and emergency medical services staff. The Administrative Services Manager for the Norfolk Fire-Rescue Department commented that the big problem of separate chains of command is reinforcing an "us-versus-them mentality." This can be minimized by a unified chain of command supported by cross-training, good promotion and overtime opportunities for cross-trained staff, and shift rotation between fire apparatus and ambulances. Most of these integrated chains of command were supported by (a) senior paramedics providing field oversight (equivalent to the role played by the Classification H-33 Rescue Captains), and (b) senior emergency medical services staff responsible for developing emergency medical services protocols, dealing with paramedic incidents and discipline issues, and complying with oversight medical agencies.

We therefore recommend a two-phase restructuring process:

(1) Initially, the residual EMS Division should be restructured as a smaller EMS Unit. This new EMS Unit would comprise 21.50 FTEs which is 15.50 FTEs smaller than the 37.00 FTEs currently employed in the EMS Division. While the EMS Chief position would still be required to ensure senior management representation of emergency medical services, there would no longer be a justification for a Classification H-43 EMS Operations Section Chief as the EMS Chief would now have sufficient capacity to directly manage the four Classification H-33 Rescue Captains in the field each day. However, the EMS Operations Section Chief position has a significant policy development responsibility and this function should become the responsibility of a new 1.00 FTE Classification 1824 Principal Administrative Analyst position. The new Principal Administrative Analyst would be charged with working closely with the new Strategic Policy, Planning and Analysis Unit on emergency medical services policy issues. The elimination of the Classification H-43 EMS Operations Section Chief position would save $103,644 in salary costs and $28,051 in mandatory fringe benefit costs, for a total savings of $131,696. Offset against this would be $85,425 in salary costs and $23,558 in mandatory fringe benefit costs for the new Classification 1824 Principal Administrative Analyst position at the top step (total cost of $108,983). The total personnel savings would be $22,713.

(2) During FY 2001-2002 through FY 2002-2003, the Fire Chief should convene a working group to establish a completely integrated chain of command with appropriate emergency medical services oversight mechanisms by FY 2003-2004. Once this integrated chain of command has been implemented, the residual EMS Unit should be disbanded and its policy development, implementation, and evaluation functions should be transferred, along with sufficient staffing resources, to the Strategic Policy, Planning and Analysis Unit.

Conclusions

The current scope of the EMS Division would be reduced by (a) relocating the EMS Special Operations Section as a direct report to the Deputy Chief of Operations, (b) transferring emergency medical services training and education functions to the new Division of Fire and Medical Training, and (c) eliminating the EMS Administration Section.

Once these structural adjustments have been implemented, the EMS Division would retain residual (a) policy development, implementation, and evaluation functions, and (b) operations management functions.

Recommendations

The Fire Chief should:

4.1.1 Restructure the residual EMS Division as a smaller EMS Unit, eliminate the Classification H-43 EMS Operations Section Chief position, and create a new Classification 1824 Principal Administrative Analyst position.

4.1.2 Convene a working group in FY 2001-2002 through FY 2002-2003 to establish a completely integrated chain of command with appropriate emergency medical services oversight mechanisms by FY 2003-2004.

4.1.3 Once the integrated chain of command has been established, transfer emergency medical service policy development, implementation, and evaluation functions, and sufficient staffing resources, to the new Strategic Policy, Planning and Analysis Unit.

Costs and Benefits

The elimination of the Classification H-43 EMS Operations Section Chief position would save $103,644 in salary costs and $28,052 in mandatory fringe benefit costs, for a total savings of $131,696. Offset against this would be $85,425 in salary costs and $23,558 in mandatory fringe benefit costs for the new Classification 1824 Principal Administrative Analyst position at the top step (total cost of $108,983). The total annual personnel savings would be $22,713.

¹ Rescue Captain 1 is responsible for all paramedics in Fire Division 1. Rescue Captain 2 is responsible for all paramedics in Fire Division 2. Rescue Captains 3 and 4 have split responsibility for all paramedics in Fire Division 3.

² While the EMS Operations Section Chief is responsible for determining which Classification H-33 Rescue Captains are temporarily detailed to the Combined Emergency Communications Center and for tracking their leave entitlements, the responsibility for their day-to-day management and performance supervision rests with the Battalion Chief in charge of Fire Department operations at the Combined Emergency Communications Center. The four Classification H-33 Rescue Captain positions at the Combined Emergency Communications Center will eventually be phased out as all uniformed staff are replaced by civilian dispatchers.

³ San Francisco Fire Department, Emergency Medical Services Division, Analysis of Urban/Metropolitan Fire-based EMS in the U.S. In this report, the EMS Chief and the EMS Operations Section Chief identified the following combined fire suppression/emergency medical services systems as "successful": Central Pierce Fire and Rescue, Las Vegas Fire Department, Phoenix Fire Department, St. Paul Minnesota, Miami-Dade Fire, Sarasota County Emergency Services, Norfolk Fire-Rescue Department, Tampa Fire-Rescue, and San Diego Fire and Life Safety. Of these nine systems, only Sarasota County Emergency Services operated separate chains of command for its fire suppression and emergency medical services staff.