The Department disagrees with the recommendation of the Audit to completely eliminate the EMS Division and have all of its functions absorbed by other units. This recommendation is inconsistent with the EMS management structure in large Fire/EMS Departments. It is critical for a Department whose emergency service is 70% medical to have a strong EMS Division to better serve the public and the Department.

The Department views this as a proposal not only to eliminate the EMS Division but also to remove personnel in the following critical EMS leadership and technical support positions:

EMS Chief - potentially eliminated in FY 2003 as part of disbanding of entire EMS unit

EMS Operations Section Chief - eliminated

EMS Administration Section Chief - eliminated

EMS Training Section Chiefs - at least one eliminated

EMS CQI Captain - eliminated

EMS CQI/Research Captain - eliminated

EMS CQI Paramedic - eliminated

It is important to note that such substantive changes to the current EMS management structure would require review and approval by the Health Commission, which, by City Charter, is responsible for the "management and control of the City"s Emergency Medical Services."

The Department acknowledges that the merger is not yet complete. It does not agree that the dissolution of the EMS division is the answer to the issues and problems that are being experienced by the Fire Service throughout the country as a result of the change in mission created by the expansion of EMS. The "full structural integration of fire and EMS" will be complete only when firefighter/ paramedics and firefighter/EMT"s are working side-by-side on all the various response units. A strong EMS Division is evidence that emergency medical services are valued equally along with the other missions of the Department.

The Department implemented the Rapid Paramedic Response System pilot program on January 5, 2002. This program is an important step in creating the opportunity for firefighters and paramedics to work on engines, trucks, and medic units.

· Merger Planning

One advantage San Francisco had in designing its Fire-EMS system was that the planners were able to examine the organizational structure of other Fire-EMS systems, many of which are over 25 years old, and learn from Fire-EMS experts what worked in their systems.

A frequent concern voiced by Fire-EMS managers/chiefs/supervisors in many systems was that they had insufficient administrative/supervisory resources and staff to adequately provide high quality EMS. Fire EMS experts reported that they often did not have sufficient authority/rank in the organization to represent EMS interests.

The initial group of Fire-EMS consultants included:

· Jim Page - the leading Fire-EMS expert in the nation

· John Sinclair - Secretary of IAFC EMS Section

· Kevin Brame - Lead instructor for the CA State Fire Marshals Office.

· Eugene McCarthy - Captain LA County Fire EMS systems expert

The final organizational structure of the SFFD EMS Division was developed in response to these concerns/comments raised by Fire-EMS professionals around the country. The organizational structure was developed by senior medical staff at the San Francisco Department of Public Health, San Francisco General Hospital, the EMS Agency, senior DPH Paramedic Division staff, other health care professionals, and Fire Department staff assigned to the merger process. The EMS Division was designed to be structurally strong enough to ensure that the health care delivery model of EMS would not be diminished by integration into the Fire Department, which was ten times the size of the DPH Paramedic Division.

Many Fire-EMS systems are struggling with the fact that the expansion of the EMS mission has created conflict with the traditional fire suppression and prevention roles. This was reflected in the recently commissioned National Fire Academy report "Americans at Risk" that rewrote the 30 year old "America Burning" report. This is one of the reasons that Fire/EMS managers recommended creation of a strong EMS division to ensure strong clinical oversight, quality improvement, and training. Many fire departments such as Dallas and Los Angeles are expanding their EMS divisions and increasing the rank structure.

· The Los Angeles Fire Department Experience

The Los Angeles City Fire Department (LACFD) has provided EMS first response and transport for decades. Until the early 1990"s, however, the paramedics were not cross-trained as firefighters. The LA City FD originally had a separate EMS Division, with an EMS chief, who was responsible for EMS operations. When paramedics began to cross-train as FF/PM"s in the early 1990"s, the LA Fire Department, with its PMs cross-trained as FFs, eliminated its EMS Division, moving all of its functions into the Field Operations bureau, which is responsible for providing fire suppression. The word "EMS" was largely eliminated from the LA Fire Department"s command structure. Many problems related to EMS dispatching, field operations, CQI, and training were not addressed for several years.

The EMS problems grew over the years and eventually impacted the quality of care provided to the residents of Los Angeles. After these problems were well publicized in the media, hearings were held in which the Fire Department was strongly criticized by the City Council for the lack of attention paid to EMS issues.

One result of these hearings was that the LACFD reconstituted its EMS Division. Additionally, EMS supervision was seen as such a high priority, that LA City Fire is increasing the number of Paramedic Captains ("RCs") from 8/day to 20/day,supervising 80 ambulances; this represents a 250% increase in supervisory staffing.

· Changing the EMS Division Structure

The recommendations from Fire/EMS industry leaders, local health care professionals, and members of the Department regarding the structure of the EMS Division were reviewed and approved by hundreds of participants during the Phase I and Phase II planning process.

The structure and function of the proposed SFFD EMS division was presented verbally and in written form to the City"s Health and Fire Commissions as well as the Board of Supervisors. In 1996, the San Francisco Health and Fire Commissions issued a Joint Resolution supporting the merger and the creation of the SFFD EMS Division.

· Recommendation of Auditor"s report

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.

· Assessment of Department

The Department disagrees with the recommendation of the audit.

The EMS Division should be maintained as a strong unit to oversee the quality of the Department"s EMS programs. The EMS Division should have continued responsibility for EMS operational planning, EMS clinical supervision, EMS clinical investigations, Continuous Quality Improvement (CQI), research, and input into the development of EMS education and training programs. The maintenance of the medical records and oversight of the EMS revenue program has been addressed in Section 1.1.

Replacing the Classification H43 EMS Operations Section Chief position with a civilian Administrative Analyst does not address assumption of the current work responsibilities of the EMS Operations Chief. The EMS Ops Chief is primarily a "problem-solver" dealing with a myriad assortment of issues and "crises" on a daily basis. In a typical day, the EMS Ops Section Chief uses a combination of EMS clinical and supervisory experience, knowledge of local and state regulations, BLS and ALS treatment protocols, national training and educational standards, and familiarity of other EMS systems to oversee the clinical care provided by the Department. The civilian analyst"s positions is not designed to manage the problems and issues which occur daily in the management of complex EMS operations and would simply pass the problems onto someone else.

The current EMS Ops Chief is available 24 hours a day, seven days a week, in person and/or by pager to deal with EMS issues and incidents. On an average weekend, the Ops Chief receives at least 3 to 4 pages regarding EMS operational issues. Given the evolving nature of EMS in this Department, with pilot programs yet to be launched, the EMS Ops Chief currently averages some 60+ hours per week to fulfill all of his responsibilities. Two civilian analysts would be required just to satisfy the work schedule demanded by the position.

The EMS Division Command staff should continue to include both an EMS Chief and an EMS Operations Section Chief to deal with the roles and responsibilities listed below.

The Department maintains that the EMS Chief should continue to be responsible for their duties and responsibilities. A list of these duties and responsibilities includes, but is not limited to:

· Management and Supervision of EMS Division performance

· Direct supervision of EMS Section Chiefs in charge of EMS Operations and EMS Administration Section

· Work with the EMS Medical Director to plan, direct, manage and implement and evaluate EMS services

· Liaison with Division of Training Chief regarding EMS training curriculum development, performance

· Liaison with Strategic Policy, Planning and Analysis Unit regarding EMS policy and planning

· Represent Department at local & state EMS regulatory organizations and ensure system compliance with all laws and EMS regulations

The Department maintains that the EMS Operations Section Chief should continue to be responsible for their duties and responsibilities. A list of these duties and responsibilities includes, but is not limited to:

· Monitoring clinical performance and adherence to all mandated standards and objectives of EMS system through daily RC clinical evaluations and reports.

· Utilizing Computer Aided Dispatch information and CQI reports to analyze EMS operational performance.

· EMS Clinical Supervision provided through field Rescue Captains

· Supervision of field Rescue Captains and acting Captains

· Functioning as EMS liaison to Emergency Communications Department on EMS issues

· Represents Department at City policy and decision making meetings

· Backs-up EMS Chief in his/her absence

· Control and distribution of narcotics

· Response to major incidents

· Attends national conferences to bring back new EMS information to disseminate to Department.

· Identify and solve operational needs and problems

The Audit has not effectively demonstrated its assertion that the EMS Chief could perform the duties of the EMS Operations Chief as described above in addition to the extensive duties already performed by that position.

· Recommendation of Auditor"s report

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.

·Assessment of Department

The Department concurs with the recommendation of the audit.

The Department agrees to convene a group including outside experts within one year to review the current chain of command. The Audit implies that the existence of an EMS Division necessitates maintenance of a separate complex chain of command that somehow interferes with the operations of the Department. The Audit further states on page 4.1-4, that when ten "successful" Fire-EMS systems were contacted, 9 of the 10 already have merged chains of command for suppression and emergency medical services staff.

The Audit uses the list of 10 "Successful" Fire-EMS systems to argue for dissolution of the EMS Division, yet fails to address the fact that these systems all staff "EMS Chief" positions, and in the larger systems, deploy full EMS divisions to manage EMS services. Fire departments in Phoenix, Sarasota County, Florida, Miami-Dade Fire Rescue, and San Diego all deploy EMS "divisions" whose functions are consistent with that of the San Francisco Fire Department EMS Division. In Phoenix and Sarasota County the EMS Chief holds rank equal to the field operations/suppression deputy chiefs, reflecting the importance of EMS to the organization.

Further, it should be noted that the list of 10 "Successful" Fire-EMS Systems was provided to the Auditor. This list never intended to list the 10 "best" Fire-EMS systems, but to list 10 systems that were performing some sort of new or innovative service that should be reviewed for possible incorporation by SFFD. The purpose of this list was clearly communicated to the auditor and the word "successful" was always placed in quotation marks to make remind the auditor not take the contents out of context, which the Audit unfortunately did.

The Audit reports that there is a separate chain of command for EMS in the Fire Department. This is not accurate. All field EMS personnel are directly in the fire suppression chain of command. Firefighter paramedics are directly supervised by fire officers. The only exceptions are the four Rescue Captains (RCs) who report to the EMS Division and serve as the independent quality assurance and clinical oversight extension for the EMS Medical Director. At all incidents, the Rescue Captain reports to the incident commander on the scene and serves as medical group supervisor under the Incident Command System. The structure of the RC chain of command is no different than the Arson Investigators who work 24-hour shifts in the field, but report to the Fire Marshal.

·Department Action Plan and timelines:

The Department will proceed with plans to convene a group that will include outside experts, to review the current chain of command. Plans for this group should be complete by July 2002.

· Recommendation of Auditor"s report

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

·Assessment of Department

The Department disagrees with the recommendation of the audit.

The Strategic Policy, Planning and Analysis Unit, as described in the Audit, will not be able to carry out efficiently or effectively the CQI, risk management, development of training standards, and long range planning functions currently handled by the EMS Division. The Audit has recommended a great many responsibilities and functions for the new Planning Unit. These include development of multi-year strategic plans, new organizational goals, new performance measures, CAD data analysis, research, continuous quality improvement programs, risk management, adoption of new technologies, improved service outcomes, grant writing, policy and protocol revision & development of new training standards. All of this is reportedly to be accomplished by three or four civilians who may have little or no experience with the operational aspects of the San Francisco Fire Department. The Department supports working with the Planning Unit to ensure compliance with overall strategic planning goals. The actual development of EMS operational and service plans must be done by uniformed professionals who possess operational experience and knowledge of the San Francisco EMS/Fire Service.

The Audit proposes to "fund" the establishment of this new policy and planning unit by eliminating EMS positions such as the CQI Rescue Captain positions. However, it is unreasonable to assume that even 50% of the new Analysts positions in the planning unit will be spent on EMS. The net result is a further reduction in time that is currently spent by the EMS staff to manage change in the dynamic, rapidly changing field of EMS.

In addition, this would be in violation of State and County regulations. California Code of Regulations Title XXII and San Francisco County EMSS policy 2010 mandate the use of experienced pre-hospital care providers. Please refer to the discussion of section 1.1.3 for further background on this issue.