The Rosenbaum report

A Sept. 27, 2007, report that sought to reform and unify the D.C. Fire Department. In D.C. fire department, a cold war simmers between chief, rank and file

Task Force on
Emergency Medical
Services
Report and Recommendations

District of Columbia
Adrian M. Fenty, Mayor
September 27, 2007

Task Force on Emergency
Medical Services
Report and Recommendations

Task Force Mission
The Task Force on Emergency Medical Services will examine the system-wide delivery
of Emergency Medical Services (EMS) in the District of Columbia. It will give practical,
timely, and strategic guidance on how to improve this critical service. The task force
will focus on how the District can improve the management, training, operations and
culture of the EMS function to provide the highest quality of professional and
compassionate pre-hospital medical care. The task force will conclude its work by
submitting a targeted set of recommendations and an implementation plan with input,
process and output metrics, to the Mayor and DC Council.

Task Force Members

Adrian M. Fenty – Mayor, District of Columbia

Dan Tangherlini – City Administrator, District of Columbia

Linda Singer – Attorney General, District of Columbia

Vincent Gray – Chairman, Council of the District of Columbia

Mary Cheh – Ward 3 Councilmember, District of Columbia

Phil Mendelson – At-Large Councilmember and Chair of the Committee on
Public Safety and the Judiciary, District of Columbia

Toby Halliday – Rosenbaum family member

Patrick Regan – Rosenbaum family attorney

Michael Williams, MD – Medical Director, DC Fire and EMS

Richard Serino – Chief, Emergency Medical Services, Boston, MA

Rebecca F. Denlinger – Chief, Fire and Emergency Services Department,
Cobb County, Georgia

2

Dennis L. Rubin – Task Force Chair and Chief, DC Fire and EMS

Joseph A. Barbera, MD – Co-Director, George Washington University
Institute for Crisis, Disaster, and Risk Management

District of Columbia Task Force on Emergency Medical Services

A Letter from the Mayor
On January 6, 2006, the District of Columbia suffered a terrible tragedy when David E.
Rosenbaum was assaulted on one of our city’s streets, resulting in his death two days
later. By appointing the Task Force on Emergency Medical Services (EMS), my goal was
to learn lessons from what transpired on that day and to work to ensure that, in the
future, any individual who calls EMS is provided with fast, compassionate, and
professional care at every stage of the process.
This report is the first step in attaining that goal and represents the culmination of a
lengthy process of collaboration and deliberation by the Task Force. It summarizes the
work of the Task Force, including its research into best practices, its efforts to obtain
input from members of the public and other stakeholders on how to improve EMS, and
its set of recommendations for reform, at both the city-wide, systemic level, as well as
within the Department of Fire and Emergency Medical Services (FEMS).
The recommendations of the Task Force address longstanding obstacles to reform of
our EMS system. First, the Task Force recommends reforming the organizational
structure of FEMS to elevate and strengthen the EMS mission. Over 75 percent of 9-1-1
calls from citizens to FEMS are calls for medical assistance. With an increased focus on
the EMS mission, including a well-resourced Medical Director and Assistant Chief for
EMS, as well as enhanced field supervision of EMS providers, the Department will be
better equipped to provide the highest quality pre-hospital patient care for every call
for service. In addition to this organizational reform, the combination of improved
training, education and quality assurance, more frequent performance evaluation, and
better employee qualifications and discipline will ensure that every employee of the
Department provides the best possible emergency medical care.
Second, the Task Force recommends that FEMS transition to a fully integrated, allhazards agency. This means that all candidates for operational positions going forward
will be sworn, public safety employees who will be required to have the same minimum
qualifications, and be cross-trained at basic levels of EMS, fire prevention, fire
suppression, hazardous materials and technical rescue. The aim of this
recommendation is to improve performance and eliminate a cultural divide that has
persisted within the agency for too long – a divide that has created two performance
standards, competition between divergent missions, and inequities in pay and benefits
among employees. This recommendation of the Task Force seeks to treat all of the
Department’s employees fairly and equitably, and to unite them behind one mission:
the delivery of the best EMS and all hazards service in the nation.
I want to thank the members of the Task Force for their commitment to achieving this
goal and for the time they dedicated to compiling these recommendations. I am
confident that residents of the District will benefit from their hard work for years to
come.
Sincerely,

Adrian M. Fenty
Mayor

3

District of Columbia Task Force on Emergency Medical Services

Introduction
This report summarizes the work, findings, and recommendations of the Task Force on
Emergency Medical Services (EMS) (“Task Force”) appointed by Mayor Adrian M. Fenty
on March 8, 2007. 1
This report provides:

Background on the DC emergency medical services system;

An overview of Task Force meetings;

A summary of benchmarking research and other analysis conducted by the
Task Force, including discussion of the strengths and challenges faced by the
Department of Fire and Emergency Medical Services (FEMS);

1

Information on the genesis and work of the Task Force;

A list of recommendations.

The Office of the City Administrator (OCA) engaged the consulting services of The Abaris

Group to assist OCA staff with the work of the Task Force. The Task Force appreciates the
excellent research, guidance and support provided by The Abaris Group on this project.

4

District of Columbia Task Force on Emergency Medical Services

BACKGROUND
Origin and Membership of the Task Force
On January 6, 2006, David E. Rosenbaum was assaulted on Gramercy Street in
Northwest, Washington, DC. The Department of Fire and Emergency Medical Services
(FEMS) responded and transported Mr. Rosenbaum to Howard University Hospital.
Tragically, Mr. Rosenbaum died on January 8, 2006 due to a head injury sustained
during the assault.
Following Mr. Rosenbaum’s death, questions were raised about the emergency medical
care provided to him by FEMS and Howard University Hospital personnel. On January
19, in a letter to the Office of the Inspector General (OIG), then-City Administrator
Robert C. Bobb requested a review of the response to Mr. Rosenbaum. OIG conducted
the review and issued a written report of its findings on June 15, 2006. OIG concluded
that there was an “unacceptable chain of failure” in the provision of emergency medical
care and other services to Mr. Rosenbaum as required by FEMS and Howard University
Hospital protocols. 2
On November 20, 2006, the family of David E. Rosenbaum filed a $20 million lawsuit in
DC Superior Court against the District of Columbia and Howard University Hospital,
claiming that Mr. Rosenbaum was a victim of official negligence and medical
malpractice.
On March 8, 2007, Mayor Fenty announced a settlement agreement negotiated by
Attorney General Linda Singer and the Rosenbaum family. The settlement required the
creation of a task force to investigate the circumstances surrounding the response of
FEMS to Mr. Rosenbaum and the issuance of a report with recommendations for
improving the delivery of EMS by FEMS in the District of Columbia within six months.
Mayor Fenty announced the following members of the Task Force on April 4, 2007:
Dennis L. Rubin – Task Force Chair and Chief, DC Fire and EMS
Adrian M. Fenty – Mayor, District of Columbia
Dan Tangherlini – City Administrator, District of Columbia
Linda Singer – Attorney General, District of Columbia
Vincent Gray – Chairman, Council of the District of Columbia
Mary Cheh – Ward 3 Councilmember, District of Columbia
Phil Mendelson – At-Large Councilmember and Chair of the Committee on Public
Safety and the Judiciary, District of Columbia

2

June 15, 2006 letter to Mayor Anthony A. Williams from Charles J. Willoughby, Inspector
General.

5

District of Columbia Task Force on Emergency Medical Services

Toby Halliday – Rosenbaum family member
Patrick Regan – Rosenbaum family attorney
Michael Williams, MD – Medical Director, DC Fire and EMS
Richard Serino – Chief, Emergency Medical Services, Boston, MA
Rebecca F. Denlinger – Chief, Fire and Emergency Services Department, Cobb
County, GA
Joseph A. Barbera, MD – Co-Director, George Washington University Institute for
Crisis, Disaster, and Risk Management

6

District of Columbia Task Force on Emergency Medical Services

June 2006 Office of Inspector General (OIG) Report
The OIG investigation and report focused specifically on the medical response to David
E. Rosenbaum on January 6, 2006. The report concluded that there was an
“unacceptable chain of failure” 3 in the provision of emergency medical and other
services provided to Mr. Rosenbaum as required by FEMS protocols. The specific
findings related to FEMS were as follows:

Engine 20 personnel did not follow all applicable rules, policies, protocols, and
procedures.

Firefighter/EMTs did not properly assess the patient.

Oral communication and standard reports were not adequate.

The ambulance did not arrive on the scene expeditiously.

Ambulance EMTs did not thoroughly assess the patient.

Transport of the patient to the hospital did not follow FEMS’ protocols.

Ambulance EMTs did not properly document their actions.

The report recommended that FEMS take the following actions:

Develop and implement a standardized performance evaluation system for all
firefighters.

Take steps to comply with its own policy on evaluating EMTs on a quarterly
basis.

Assign quality assurance responsibilities to the employee with the most
advanced training on each emergency medical call. The designated employee
should: (a) have in-depth knowledge of the most current protocols, General
Orders, Special Orders, and other management and medical guidance; (b)
monitor compliance with FEMS protocols by all personnel at the scene; and (c)
monitor on-the-spot guidance as required.

Promptly reassign, retrain, or remove poor performers.

7

Immediately implement a reporting form for firefighter/EMTs who respond to
medical calls so first responder actions and patient medical information can be
documented.

3

Ensure all personnel have current required training and certifications prior to
going on duty.

Consider installing global positioning devices in all ambulances to assist EMTs
in expeditiously reaching their destinations on emergency calls.

Id.

District of Columbia Task Force on Emergency Medical Services

Past Reviews of DC Fire and Emergency Medical Services
The work of the Task Force builds on a history of previous investigations of the delivery
of emergency medical services through FEMS. In 1989, Productivity Management
Services, the District’s internal consulting group, culminated a two-year, 11,000-hour
engagement with FEMS with the publication of a report titled Blueprint for Change The
130-page report documented the EMS areas studied and offered several
recommendations for improving EMS delivery in the District.
In 1997, TriData Corporation and Arthur Andersen LLP conducted a comprehensive
assessment of FEMS and produced a written report titled Development and
Implementation of a Management Reform Plan for the District of Columbia. The
assessment and report identified deficiencies and recommended specific actions for
improvement.
In October 2002, OIG conducted a review of FEMS based on complaints from the public.
Several problem areas were identified and suggestions were provided to the
Department. The OIG again reviewed FEMS in June 2006, specifically the emergency
response to Mr. David E. Rosenbaum (see previous section).
A matrix of the problem areas and recommendations from these four reports is included
as Appendix I of this report. A review of all of these documents suggests that,
although there have been some improvements made to the EMS system in the District,
many historic problem areas remain unresolved today.

Task Force Meetings
The Task Force established an aggressive meeting schedule to meet the Rosenbaum
settlement agreement’s requirement that its work be completed in six months. It
scheduled six meeting dates: April 17, 2007; May 24, 2007; June 18, 2007; July 17,
2007; and September 19 and 20, 2007. The Task Force added a working session on
September 4, 2007 to continue discussions on its recommendations.
The kickoff meeting held on April 17, 2007 began with a presentation by the Inspector
General, Charles Willoughby, on the OIG investigation into the District’s response to the
assault on David E. Rosenbaum. Dr. Michael Williams, FEMS Medical Director, then
explained the actions FEMS has taken in response to the OIG report. Speakers for the
two labor organizations that represent FEMS employees, American Federation of
Government Employees (AFGE) Local 3721 and International Association of Fire Fighters
(IAFF) Local 36 offered their views on the best ways to organize EMS delivery. Task
Force members also briefly discussed it’s the Task Force mission statement.
The second meeting was held May 24, 2007. The Task Force approved the following
mission statement by unanimous voice vote:

The Task Force on Emergency Medical Services will examine the system-wide
delivery of Emergency Medical Services (EMS) in the District of Columbia. It
will give practical, timely, and strategic guidance on how to improve this
critical service. The task force will focus on how the District can improve the
management, training, operations and culture of the EMS function to provide
the highest quality of professional and compassionate pre-hospital medical

8

District of Columbia Task Force on Emergency Medical Services

care. The task force will conclude its work by submitting a targeted set of
recommendations and an implementation plan with input, process and output
metrics, to the Mayor and DC Council.
OCA staff also presented the findings of the benchmarking research conducted by the
consultant on EMS best practices. Dennis Rubin, FEMS Chief and Task Force Chairman,
gave a presentation entitled “EMS: The Path Forward,” summarizing his vision for
improving EMS within FEMS. The meeting included testimony by several members of
the public, including current FEMS employees.
The third meeting was held June 18, 2007. Robert Malson, President of the DC Hospital
Association, gave a presentation. Mr. Malson was joined by Dr. Joseph Wright, Medical
Director of Emergency Medical Services at the Children’s National Medical Center and
Dr. Carlos Silva, Medical Director at the George Washington University Hospital. Dr.
Bruce Siegel, a researcher at George Washington University, also gave a presentation
on assessing the state of emergency care in the District of Columbia, a research project
funded by the RAND Corporation and authorized by the Community Access to Health
Care Act of 2006.
The Task Force then reviewed materials summarizing the strengths, weaknesses,
opportunities and threats of different EMS systems, including the following models:

Third service;

Fully integrated fire-based;

Fire-based with a partially separated EMS function;

Public utility;

Private service;

Public health.

The fourth meeting was held July 17, 2007. The primary agenda item was the
discussion of recommendations of the Task Force. Nine recommendations were under
consideration, grouped into three areas:

External issues;

Workforce development issues;

Operational issues.

The Task Force approved four recommendations in principle that covered external and
workforce development issues, with leave for the staff to complete a final draft.
An all-day working session was held September 4, 2007 to continue discussion about
recommendations. Chief Serino gave a presentation on Boston’s delivery of EMS
through a third service model. Task Force members worked through the structure
issue. Members ultimately focused on how to elevate the EMS mission and how to offer
better supervision and support to EMS providers within FEMS. Draft recommendations
on this issue were discussed and approved in principle, although some members asked
that the third service model idea remain under consideration by the Task Force. Task
Force members also re-visited the workforce development recommendations considered

9

District of Columbia Task Force on Emergency Medical Services

at the July meeting and made some specific changes in the wording and timing of those
recommendations.
The Task Force met again in a closed working session on September 19, 2007.
Members completed their work on the recommendations, including recommendations on
Department of Health regulation of EMS, demand management and hospital closure
issues, and operational issues covering peak load staffing, dynamic deployment,
scheduling, ambulance duty and rapid EMS response.
At the Task Force’s final meeting on September 20, 2007, members conducted a final
review of their recommendations and discussed how an implementation plan for the
recommendations could be developed, as well as last steps in completing the final
report of the Task Force.

10

District of Columbia Task Force on Emergency Medical Services

EMS BENCHMARKING RESEARCH AND FINDINGS
Survey Template
At the Task Force’s request, The Abaris Group researched the practices of high
performing EMS systems. Based on the priorities of the Task Force, OCA staff and the
consultant developed a benchmarking survey template to collect information from other
jurisdictions. The template addressed thirteen (13) specific areas consisting of:

General system information (9 questions)

Personnel practices and employee evaluations (15 questions)

Training and certification practices (7 questions)

Quality improvement practices (4 questions)

Dispatch/communications processes (5 questions)

Deployment strategies (18 questions)

Command and control, medical direction, and documentation (7 questions)

Budget issues (4 questions)

Technology utilization (3 questions)

Hospital diversion issues (4 questions)

Demand management strategies (4 questions)

System evaluation processes (7 questions)

Other issues (11 questions)

The Abaris Group conducted the surveys through a series of telephone interviews with
key EMS management personnel from each of the 11 jurisdictions.
While it is important to state at the outset that no single EMS system is considered a
model system, “best practice” EMS systems generally are considered high-performance
systems when they:

Achieve rapid response times for life threatening calls (8 minutes or less 90%
of the time);

Demonstrate strong medical direction and oversight

Utilize variable shifts and staffing patterns;

11

Provide Advanced Life Support (ALS) level care;

Employ state-of-the-art technology;

District of Columbia Task Force on Emergency Medical Services

Operate in-house quality improvement (QI) programs capable of measuring
clinical performance. 4

Each of the eleven systems surveyed employed one or more of these components of a
high-performance EMS system. Several of the practices or programs used by the
jurisdictions surveyed could be emulated by FEMS to enhance EMS delivery in the
District, although it should be noted that FEMS already has some of the components of
a high-performance EMS system, including the provision of ALS, rapid response times,
and full-time medical direction.
Table A below lists the jurisdictions that were surveyed and the reasons they were
chosen.

Table A

System

Comparable Comparable Comparable
Comparable Geographic
Resident
Daytime
Call Volumes
Size
Population Population

Mentioned as Best
Practice by Task
Force/Presenters1

Austin (Travis County), TX
Boston, MA
Fairfax, VA
Houston, TX
Memphis, TN
Montgomery County, MD
Phoenix, AZ
St. Petersburg/Clearwater
(Pinellas County), FL
Richmond, VA
San Diego, CA
Seattle, WA

4

Common clinical performance measures include pain management; customer satisfaction;
trauma management; advanced airway management; and cardiac arrest data.

12

District of Columbia Task Force on Emergency Medical Services

Table B below provides demographic information related to approximate population,
geographical area served as well as a description of the density of the jurisdictions
surveyed.

Table B

Resident
Population

System

Daytime
Population

Service
Area
(Square
Miles)

Density
Urban

Suburban

Rural

Houston, TX

1,900,000

3,000,000

622

50%

35%

15%

Phoenix, AZ

1,470,000

2,200,000

540

90%

10%

San Diego, CA

1,250,000

1,250,000

320

60%

39%

1,050,000

1,400,000

407

80%

20%

Fairfax, VA
1

Pinellas County, FL

2

1,000,000

1,000,000

280

95%

5%

Montgomery County, MD

960,000

960,000

497

38%

24%

Memphis, TN

850,000

1,000,000

350

75%

25%

Austin (Travis County),
TX

825,000

1,100,000

1,100

20%

20%

Boston, MA

590,000

1,200,000

49

100%

Seattle, WA

585,000

1,500,000

83

50%

582,000

992,000

61

100%

200,000

200,000

63

100%

1%

Washington DC
Richmond, VA

Notes:

13

1

Winter population reaches 1,400,000

2

Daytime populations are estimated

District of Columbia Task Force on Emergency Medical Services

50%

38%
60%

Agency Structure
One of the survey’s first findings was that high quality EMS is delivered in many kinds
of systems and agency structures (a more detailed discussion of the structure issue is
included under the EMS System Design Options section of this report). The systems
surveyed ranged from fire-based to third service to private systems. Table C below
provides additional information on the systems studied.

Table C

System
Austin (Travis County), TX
Boston, MA
Fairfax, VA
Houston, TX
Memphis, TN
Montgomery County, MD

Fire Dept First Responders
Ambulance
Life
Threatening
Non-Life
Life Threatening
Non-Life
Calls
Threatening calls
Calls
Threatening calls
BLS

3rd Service ALS

3rd Service ALS

First Responders None
ALS
BLS

3rd Service ALS
Fire ALS

3rd Service BLS
Fire BLS

BLS or ALS

BLS

Fire ALS

Fire BLS

ALS
BLS or ALS

BLS
Fire ALS
BLS or ALS sent only Fire ALS
if BLS ambulance
response is extended
Closest unit
Fire ALS

Fire BLS
Fire BLS

None
None
None
BLS

Private ALS
Private ALS
Fire/Private ALS
No Initial dispatch

Pinellas County, FL
Richmond, VA
San Diego, CA
Seattle, WA

Closest unit &
closest ALS
ALS
BLS
ALS
BLS

Washington DC

ALS

Phoenix, AZ

BLS

BLS or ALS

Private ALS
Private ALS
Fire/Private ALS
Fire ALS, can
downgrade to
Private BLS
Fire ALS

Fire BLS

Fire BLS or ALS

EMS Workload
The survey captured the main measures of EMS workload: 911 call volume, number of
EMS responses, and number of ambulance transports. The comparison revealed that
the District has very high call volume for a city of its size, the fourth-highest call
volume of any of the cities surveyed. Even when adjusted on a per square mile or per
capita basis, the District has the second-highest call volume of the cities surveyed.
Graphs A and B below illustrate the District’s high EMS workload.

14

District of Columbia Task Force on Emergency Medical Services

Graph A

EMS Calls and Transports
0

50,000

100,000

150,000

200,000

Houston, TX
170,000

Pinellas County, FL

232,286

128,726

Phoenix, AZ

117,380

Washington DC

107,162

Austin (Travis County), TX
San Diego, CA

100,000

Boston, MA

100,000
93,000

Memphis, TN

80,000

Montgomery County, MD
Fairfax, VA

62,038

Seattle, WA

62,000

Richmond, VA

15

250,000

40,000

District of Columbia Task Force on Emergency Medical Services

Calls

Transports

Graph B

Demand Management Strategies
The District’s high call volume suggests that it would benefit from improved demand
management strategies, or strategies to reduce the number of non-emergency or
otherwise inappropriate calls for EMS service. The benchmarking survey revealed
potential areas where such a strategy could be focused. For example, DC FEMS is the
only system surveyed that provides non-emergency transports from medical facilities
and nursing homes to hospitals as part of the 911 response system. FEMS also
responds to and performs more critical care transports than any other 911 EMS systems
surveyed. In addition, a high number of EMS responses in the District involve nonemergency requests for assistance from the homeless, substance abusers, or patients
with mental illnesses.
What are other systems doing to manage EMS misuse? Many of the systems surveyed
by the Task Force use separate private ambulance services for non-emergency calls and
rarely handle critical care transports or non-emergency transfers. The EMS systems
surveyed are also using a variety of programs to reduce responses to high frequency

16

District of Columbia Task Force on Emergency Medical Services

EMS users, including programs that divert serial inebriants to detoxification programs
(San Diego Inebriant Program and San Francisco Home Team Program), programs that
triage non-emergency calls at the dispatch stage (Richmond’s Dispatch Nurse Triage
Program), and education programs on the proper use of 911 (Care Houston).

Hospital Diversion Issues
The District’s provision of EMS is also affected by the length of time FEMS ambulances
spend dropping off patients at area hospitals. In comparison with the EMS systems
surveyed, FEMS has significantly higher hospital diversion rates and significantly longer
ambulance drop-off times. The benchmark survey indicated that all of the surveyed
EMS systems are affected to varying degrees by hospital diversion practices and longer
than desired patient drop-off times for patients transported to hospitals. Half of the
systems reported that hospital diversion has a major impact on their EMS systems.
Patient drop-off times ranged from 20 minutes to 41 minutes on average (with FEMS
having the highest average at 41 minutes), while most have established a drop-off time
goal of between 20 – 30 minutes. In addition to the benchmark survey, FEMS studied
the issue of hospital wait times in early 2007 by surveying 100 of the 200 most
populous cities in the United States. FEMS published a progress report on March 28,
2007 that showed DC’s wait time was 79% longer than the average of the jurisdictions
surveyed. FEMS’ data indicates that 55% of the EMS call duration is spent in the
hospital waiting to transfer care to the hospital staff.
How are other jurisdictions confronting the hospital diversion and drop-time issues?
Some of the EMS systems are using EMS supervisory staff to respond to the hospitals in
an effort to get ambulances back in service. Some of the EMS systems will “close”
hospital EDs to ambulances when drop-off times start to get longer. Other EMS
systems are moving to not recognizing hospital diversion, including Austin, TX; Boston,
MA; Contra Costa, CA; Detroit, MI: Fresno, CA; Las Vegas, NV; and Tucson, AZ. In Las
Vegas, legislation was enacted to limit diversion & hospital drop times. Table F below
summarizes the hospital diversion information.

17

District of Columbia Task Force on Emergency Medical Services

Table D
Level of
System
Diversion
Austin (Travis County), TX Minimal

Receiving
Hospitals

Notes
10 Austin/Travis County does not recognize divert, will
close hospital to ambulances when long drop-off
times occur
Drop times tracked, staying constant. Regional task
force looking at issue

Richmond, VA

Minimal

Seattle, WA
Memphis, TN
Montgomery County, MD

Minimal
Moderate
Moderate

San Diego, CA
Boston, MA

Moderate
Major

Fairfax, VA
Houston, TX
Phoenix, AZ

Major
Major
Major

Pinellas County, FL

Major

14 EMS supervisors respond to hospitals with delays,
hospitals placed on divert if keep ambulance longer
than 60 minutes or 2 for 30 minutes

Washington DC

Major

10 Average drop time 41.3 minutes, supervisor
redirecting units at dispatch

14 No current diversion policy
EMS supervisors respond to hospitals with delays,
hospitals placed on divert if keep ambulance longer
than 30 minutes
18
11 Lowest since 2000, suspended diversion for Oct-06
and this summer
12 20 minute drop time goal, can be up to 60
Longer drop-off times
28 EMS & hospital task force created to address issue

EMS System Response Times
The benchmarking research suggests that FEMS response times are at the level of a
high performance jurisdiction. FEMS has established response time goals that include
having the first paramedic on-scene in 8 minutes or less 90% of the time and having
the first ambulance on-scene 13 minutes or less 90% of the time. These times are
measured on a regular basis and are being met and exceeded consistently. Of the
systems surveyed, first-responder response time goals range from 4 - 8 minutes or less
90% of the time. Of the systems surveyed, most use ambulance response time goals
ranging from 8 minutes to 12 minutes or less 90% of the time or less for lifethreatening calls. Response time information is provided in graph D below.

18

District of Columbia Task Force on Emergency Medical Services

Graph C
Minutes at 90th percentile
1

2

3

4

5
6
7
Phoenix (BLS)
DC (BLS)

First
Responder

8

9

10

11

12

13

14

15

Memphis

First
Paramedic
on Scene

Ambulance

Austin
Houston
Phoenix (ALS)
Pinellas (ALS)
Fairfax (ALS)
San Diego (ALS)
DC (ALS)
Memphis
Houston
Richmond (ALS)
Austin
Phoenix (ALS)
Pinellas (ALS)
Seattle (BLS)
San Diego (ALS)
DC (1st Ambulance)
San Diego
(ALS non-life-threatening)

Personnel Practices
The hiring practices, work rules and employee representation for FEMS employees are
unique in comparison with all of the other jurisdictions surveyed. This uniqueness may
contribute to cultural problems within the agency. Of the EMS systems surveyed, each
employ either all uniformed or all civilian personnel for field work. FEMS uses a mix of
uniformed (dual-role employees trained in fire suppression, hazardous response and
EMS) and non-uniformed employees (single-role employees trained only in EMS) for
field workEach one of the fire or EMS agencies surveyed uses a single hiring process
and common hiring standards for their recruits, and a single set of work rules for their
employees. FEMS, on the other hand, uses two separate hiring processes and hiring
standards: one for single-role positions and a different one for multi-role positions.
FEMS employees also work under two sets of work rules and two bargaining groups,
each with separate labor contracts and differing disciplinary processes.

EMS Certifications
Because the issue of having the proper or current EMS certifications of FEMS personnel
was raised in both the 2002 and 2006 OIG reports, the EMS benchmarking survey asked
jurisdictions how certifications are monitored and how the agency ensures they are
current. All of the systems surveyed provided re-certification training as part of the on-

19

District of Columbia Task Force on Emergency Medical Services

going continuing medical education (CME) training. Some of the systems have the
Medical Director’s office monitor expiration dates of individual providers’ certifications.
A few systems use specific software to track their personnel’s certification status.
Many of the systems provide performance feedback both to the individual holding the
certification and the individual’s supervisor on a periodic basis. In response to the
2006 OIG report, FEMS has implemented a practice of daily certification card
inspections of EMS personnel. Benchmarking research suggests this practice may be
excessive and that a more systematic approach would be better.

Performance Evaluations
The 2006 OIG report recommended that FEMS develop and implement a standardized
performance evaluation system for all employees. Some of the Task Force members
also voiced concern over the lack of regular clinical performance evaluations of FEMS
personnel. For the EMS systems surveyed revealed that performance evaluations
generally consist of standard annual performance reviews and some form of clinical
performance appraisal. The frequency of the clinical appraisals ranged from monthly to
annually, with most of the EMS systems conducting clinical performance evaluations on
either a quarterly or semi-annual basis. EMS systems in Austin (TX), Houston (TX), and
San Diego (CA) use EMS Battalion Chiefs or EMS Field Medical Officers in the field to
evaluate clinical performance. FEMS is moving toward a similar system of field clinical
evaluations for EMS incidents. In Phoenix, the Department’s Medical Director evaluates
clinical performance during monthly continuing education classes. When a clinical
performance issue is identified, most of the EMS systems surveyed attempt to improve
performance by employing retraining and education strategies before initiating any
disciplinary procedures.

Quality Improvement
The 2006 OIG report recommended that FEMS make significant enhancements to its
quality assurance/quality improvement (QI) program. All of the EMS systems surveyed
have formalized QI programs with dedicated staff for the QI function. Many of the
systems used a “peer-review” process where paramedics review care provided by other
paramedics. Most also use clinical performance indicators consisting of cardiac arrest
survival rates, including the presence of a pulse at the Emergency Department and the
percentage of patients discharged from the hospital. Most also conduct some form of a
customer service satisfaction survey for system feedback. Some systems have medical
oversight provided by an external agency but most have the responsibility to ensure
that patient care provided by their service is reviewed internally. The oversight
provided by external agencies is mainly in the area of issuing certifications and
licenses, vehicles inspections or permitting, approving equipment and medication
inventories, and investigations of complaints made to the agency.
FEMS has some of the elements of a formalized QI program in place including a fulltime medical director, the ongoing roll-out of an electronic patient care reporting (ePCR) system, and the ability to measure cardiac arrest survival rates. FEMS also
recently hired a Quality Medical Manager, who is a registered nurse, to oversee the
Department’s QI program. It should be noted that only four of the systems surveyed
are using electronic patient care reports, although five of the systems are moving to an
e-PCR system in the near future. Most of those surveyed said the QI process will be
simplified and improved through the use of an e-PCR system, because the enhanced

20

District of Columbia Task Force on Emergency Medical Services

data collection will increase the number of performance indicators that can be
measured and make trends easier to identify.

Deployment Strategies
All systems surveyed use fire department first response units consisting of fire engines
at both the BLS and ALS level. The minimum number of ambulances deployed by the
systems surveyed range from 8 to 76 with the maximum number ranging from 15 to 76.
The average number of daily unit hours for ambulances ranges from 232 hours to 1,824
hours. EMS calls per unit hour range from 0.17 to 0.70 for the systems surveyed. Calls
per unit hour rations reflect the activity of the system and generally should be in the
range of 0.30 to 0.40 for public agencies. FEMS deploys fire engines at both BLS and
ALS levels as first response units. On average, 37.5 ambulances are deployed daily,
equating to an average of 900 daily unit hours. FEMS is at 0.36 calls per unit hour for
ambulances.

The EMS systems surveyed use both static (same number of units are deployed at all
times), and dynamic (number of units fluctuates depending on call demand) deployment
strategies. Most of the fire-based systems use a static deployment strategy while the
third service and private service systems use a combination of static and dynamic
deployment. Six of the third service and private systems use some form of system
status management (SSM) for deployment of ambulances. SSM utilizes historical EMS
response data, including the time and location of calls, from the systems CAD and with
reasonable accuracy predicts the locations of EMS calls. EMS managers then develop a
deployment plan based on this historical data and position EMS response units where
the predicted calls will occur. Table E below illustrates the ranges of daily deployment
of the systems surveyed.
FEMS uses a static deployment strategy, despite the fact that the daily EMS call volume
in the District fluctuates with higher demands for service in the daytime and lower
numbers of calls at night. An analysis of the ambulance staffing currently in place by
FEMS indicates a surplus of ambulances during the night shift and that ambulance
scheduling does not match the rise and fall of calls throughout the day. FEMS also
uses a combination of both BLS and ALS ambulances that creates scheduling and
deployment challenges. Detailed staffing charts contrasting call volume and the
number of ambulances by day and time of day are included in Appendix II.

21

District of Columbia Task Force on Emergency Medical Services

Table E
System
1

Pinellas County, FL
Boston, MA
Seattle, WA2
Phoenix, AZ 2
San Diego, CA
1

Richmond, VA
Austin (Travis County), TX
Washington DC
2

Houston, TX
Memphis, TN 2
Montgomery County, MD
Fairfax, VA 2
Notes:
2

1

2

Max
Units
45-50
ALS
20 BLS
6 ALS
7 ALS
8 BLS
20 BLS
13 ALS
29 ALS
19 ALS
33 ALS
37.5
ALS &
BLS
54 BLS
33 ALS

Min
Units
12 ALS
11 BLS
3 ALS
7 ALS
4 BLS
16 BLS
5 ALS
21 ALS
8 ALS
30 ALS
37.5
ALS &
BLS
54 BLS
33 ALS

24 BLS
18 ALS
43 ALS

Avg Daily
Calls/
System Status
Unit Hours Unit Hour
Mgmt
662
0.70 Yes

22 BLS
18 ALS
42 ALS

452
312
648
552
262
756
900

0.61 Minimal, dispatcher
discretion
0.54 ALS is static, BLS is
dynamic
0.54 Some static, some
dynamic
0.50 Yes
0.42 Yes
0.39 No
0.36 No

1,824
792

0.35 No
0.32 No

984

0.22 No

1,020

0.17 No

9-1-1 and inter-facility units are combined

Estimated average daily unit hours based on minimum and maximum units

Challenges for FEMS
The benchmarking survey provided the Task Force with a baseline of information that
could be used to assess FEMS strengths and areas in need of improvement. After
comparing FEMS with the surveyed jurisdictions, the following strengths of FEMS were
identified:

Excellent distributions of Fire and EMS stations throughout the District

Measurable rapid response times:
o

91% for first paramedic on-scene in 8 minutes or less

o

96% for first ambulance on-scene in 13 minutes or less

Active and full-time Medical Director

Partially implemented electronic patient care reporting (e-PCR) system

The following challenges for FEMS were identified:

22

Two sets of separate hiring practices, work rules, disciplinary standards and
bargaining agreements contribute to a cultural divide within the agency and
inconsistent standards for employees.

District of Columbia Task Force on Emergency Medical Services

Quality of training is uneven

Lack of field clinical supervision and support for EMS

Clinical evaluations of EMS personnel are infrequent

A formal Quality Improvement program is not in place

Prolonged hospital drop-off times

High number of inter-facility transports and critical care transfers

Static deployment strategy does not match dynamic population

EMS System Design Options
The Task Force members from the first meeting forward decided to explore all possible
options for the delivery of EMS in the District. This decision was reflected in the Task
Force mission statement’s broad goal of examining EMS delivery by the District, rather
than just by FEMS. At the request of the Task Force, staff and the consultant prepared
a SWOT analysis 5 of eight potential EMS system design options for the Task Force to
consider. The types of EMS systems examined by the Task Force members included:

Third Service

Private Service – BLS & ALS transportation

Private Service – BLS transportation only

Fire-Based Service – Current system

Fire-Based Service – Fully integrated

Fire-Based Service – Partially separated EMS function

Public Utility Model

Public Health Model

It was noted throughout the analysis that simply changing the structure and design of
the system does not ensure an improvement in the quality of patient care or improve
the supervision of EMS personnel responding to EMS incidents. At the June 18, 2007
meeting, the pros and cons of each system were analyzed by the Task Force. The third
service and fully integrated fire-based options received the most attention. A summary
prepared by the consultant characterized options for EMS support as follows:

Third Service: Positives

Single focus mission approach;

5

The SWOT analysis examined the strengths, weaknesses, opportunities, and
threats of each model.

23

District of Columbia Task Force on Emergency Medical Services

Workforce dedicated to the EMS mission;

The type of system desired by some of the current single-role EMS providers
and some citizen groups;

FEMS’ single-role providers already available for this type of system;

Single set of work rules and labor contract for EMS employees;

Improved public perception of EMS delivery.

Third Service: Negatives

Duplication of functions and costs;

Duplication of management staff;

Significant impact on District budget;

Significant amount of time required to implement, potentially delaying shortterm improvement in quality of patient care;

Would undermine District’s progress toward integrating EMS within FEMS;

Potential for on-scene conflicts over patient care (EMS responders would be
on-scene from two separate agencies);

Scene control and unity of command issues;

Potential communications errors from adding another agency to dispatch.

Privatization of EMS Transport: Positives

Contract-mandated performance;

Ability to provide 911 and non-911 transportation services;

Ability to implement peak staffing schedules;

Ability to implement system status management (SSM) strategies;

Improved billing and collection processes;

Fast implementation

Ability to allocate FEMS resources for other needs

Privatization of EMS Transport: Negatives

Potential for decreased service;

24

Potential for increased ambulance fees;

Potential for subsidy provided by the District;

District of Columbia Task Force on Emergency Medical Services

Limited government control outside of any contractual provisions;

Decrease in available surge capacity currently provided by FEMS in the event of
a large scale emergency;

Limited depth of skills and response capabilities (specifically hazardous
materials and extrication services);

Potential negative impact on preparedness during federal events in the District.

Fire-Based Options: Positives

System already in place with existing facilities, vehicles, and personnel;

Surge capacity immediately available for large scale emergencies and federal
events;

Integrated first response and ambulance transport function;

Economy of scale with multi-role, cross-trained personnel;

Possible development of a single set of work rules and single contract, as well
as equal pay and benefits for all employees;

Ability to identify EMS costs separately from first-responder costs;

Perception that FEMS has improved its commitment to EMS.

Fire-Based Options: Negatives

Public perception of no perceived improvement of EMS delivery and patient
care;

Without full integration and equal pay and benefits, single-role providers may
feel they are being pushed out of the organization;

Complete transition to all multi-role providers may take several years;

Without full integration, fewer career advancement opportunities for single-role
employees;

Without full integration, separate work rules, labor contracts and cultural
issues would remain.

The public utility model has similar strengths, weaknesses, opportunities and threats as
the private models except the District would actually own the vehicles and equipment.
The public health model has similar characteristics to the third service model, but
would be operated by the Department of Health. The system design options
spreadsheets with the complete list of strengths, weaknesses, opportunities and threats
are included in Appendix III.
After considerable review, the majority of the Task Force members favored a fully
integrated fire-based EMS system with more robust EMS management and oversight.

25

District of Columbia Task Force on Emergency Medical Services

The majority of Task Force members felt that the benchmarking research and other
presentations to the Task Force did not support the proposition that improved EMS
delivery can only be accomplished with an entirely new organizational structure.
Having made this decision, the Task Force still felt that dramatic change is required
within FEMS to improve EMS service delivery. The recommendations in the next section
are designed to produce such change.

26

District of Columbia Task Force on Emergency Medical Services

Task Force Recommendations
Recommendation 1
The Department of Fire and Emergency Medical Services shall transition to a fully
integrated, all hazards agency.
a) All entry-level candidates for operational positions shall be required to have the same minimum
qualifications. All operational employees shall be cross-trained at basic levels of EMS, fire
prevention, fire suppression, hazardous materials and technical rescue.
b) The Department shall offer current single-role providers basic training for all hazards on a
phase-in basis. The Department shall allow single role providers to meet adjusted fitness
standards that fairly and reasonably accommodate their incumbent status, including their age and
level of experience.
c) The Department shall continue to maintain a cadre of personnel who are specialized EMS
providers at various levels of training who serve primarily in patient care. The overall size of the
Department’s workforce creates an opportunity for specialization among employees, permitting the
inclusion of those with a passion for patient care without compromising excellence in fire
suppression, rescue, hazardous materials response, and other services. 6
d) All employees shall have the same basic pay and benefits. The City Administrator shall develop
a plan, no later than March 31, 2008, to transition to pay and benefits parity between current
single-role medical providers and dual-role providers.

Recommendation 2
Reform Department structure to elevate and strengthen the EMS mission.
a) The Mayor shall appoint a Medical Director who shall hold the rank of Assistant Fire Chief. The
Medical Director shall report to the Fire/EMS Chief but may be removed only by the Mayor. The
Medical Director shall be a physician licensed to practice to medicine in the District of Columbia,
board certified in a medical specialty that represents the broad patient base that EMS serves
(emergency medicine, general surgery, family medicine, or internal medicine). Candidates must
also have four years of substantial experience in EMS or other similar out-of-hospital care, including
experience as EMS Medical Director, Assistant Medical Director or successful completion of a
recognized EMS fellowship.
The Medical Director shall: provide medical oversight for all aspects of emergency medical services
provided by the Department including, but not limited to written policies, procedures and protocols
for pre-hospital emergency medical care, medical training, and quality assurance of medical
services; supervise the administration of emergency medical care; and work collaboratively with
the Fire/EMS Chief, assistant and deputy chiefs, and other personnel in the Department. The
6

It is the sense of the Task Force that the personnel referenced in Recommendation 1(c) would
only serve on fire apparatus in cases of emergency or other serious need.

27

District of Columbia Task Force on Emergency Medical Services

provision of emergency medical care by the Department’s certified emergency medical technicians
shall be under the license of the Medical Director.
b) There shall be an Assistant Chief for Emergency Medical Services (EMS), reporting directly to the
Chief of the Department. The Assistant Chief for EMS shall have at least 15 years of experience in
the practice of emergency medicine as a paramedic or higher level of practice and leadership
experience in EMS. 7 The Assistant Chief for EMS shall have the staff needed to implement and
sustain the recommendations and meet the objectives of the Task Force, and will have
responsibility for analysis and planning for all medical units, including strategic planning, budgeting,
program evaluation, special operations, and prevention.
c) The Chief shall also create additional positions of EMS Battalion Chiefs and EMS Captains for the
purpose of (1) ensuring strengthened, 24 hour a day, seven days a week, supervision of EMS
delivery in the field and (2) creating an EMS career track for those personnel who are specialized
EMS providers at various levels of training who serve primarily in patient care.
d) Department leadership, at all levels, shall work to facilitate the integration of the full EMS
mission and of single-role providers into multi-role operations. No later than November 20, 2007,
the Chief will convene a group of departmental personnel, at least half of whom are current or
former single-role personnel, to identify, review, address, and report to the City Administrator
conditions that may convey a lower priority for the EMS mission or complicate integration of
functions and employees. These issues include, but are not limited to:

Station alarm bells for fire apparatus calls but not ambulance calls;

Ambulances positioned at rear doors rather than front doors, when available;

Station names and insignia that omit or de-emphasize EMS apparatus;

Use of “DCFD” insignia on some vehicles, uniforms, and other locations;

Omission or lower emphasis on the contributions of single-role EMS providers;

Obstacles, perceived and real, to incorporating single-role employees and their
workload into multi-role operations.

Recommendation 3
Improve the level of compassionate, professional, clinically competent patient care
through enhanced training and education, performance evaluation, quality assurance,
and employee qualifications and discipline.

Training and Education
a) The Medical Director shall implement, no later than December 31, 2008, a comprehensive
training and educational program for emergency medical technicians and paramedics. The program
shall include new employee orientation, periodic classroom and internet-based continuing training,
case review and peer learning opportunities, simulation exercises and field-based training. The
Department shall pursue partnerships with medical education institutions to enhance training and
clinical practice and increase the internal training capacity of the Department. The training program
may include Department and external trainers under contract, as deemed appropriate by the
7

It is the expectation of the Task Force that a national search will be conducted for this position.

28

District of Columbia Task Force on Emergency Medical Services

Medical Director.
b) The Medical Director shall establish, no later than November 20, 2007, procedures to certify the
operational competency of medical providers at all levels of training within the Department. This
may include, but is not limited to, (i) demonstration of compassionate and professional service to
patients; (ii) successful execution of key clinical competencies in the field; and (iii) completion of a
minimum number of hours or medical calls under provisional status.
c) The Medical Director shall establish, no later than November 20, 2007, a process to evaluate
current employees for proficiency at their respective levels of clinical privileges. This evaluation and
certification process shall be completed not later than December 31, 2008. Effective December 31,
2008, response to medical calls may be provided only by Department apparatus with at least one
field-certified provider as described above.

Performance Evaluation
d) Effective immediately, the Medical Director shall oversee the clinical performance evaluation of
all personnel with medical certification at least once a year. In addition to any other disciplinary
basis (see sub-recommendation (k) below), based on the results of the annual performance
evaluation, personnel may be approved for continued duty, assigned to supplemental training,
placed on provisional EMS status, or temporarily or permanently relieved of their EMS proficiency
status. The Department shall also provide enhanced field supervision as ongoing quality assurance
for all personnel.
e) The Medical Director shall establish, no later than December 31, 2007, a clearly documented
chain of patient care with clear evaluation and treatment documented by each provider as follows:

The first arriving provider should document the situation as well as patient
evaluation and treatment;

A formal process for “giving report” and transferring care to the next provider
should be conducted; this process should be repeated as patient care is
transferred until full transfer to emergency department staff or other
appropriate final patient destination staff;

Documentation requirements should include: (1) all evaluation and treatment,
(2) all providers, (3) all care transfers, and (4) documentation of arrival at the
receiving facility as well as who and when the transfer to receiving facility
personnel occurred.

Online medical direction to FEMS personnel shall be provided only by licensed
physicians who are adequately trained and are designated as qualified by the
Medical Director. Online medical direction shall be subject to the QI process.

f) The Chief, no later than December 31, 2007, shall design and implement an annual program to
recognize and publicly reward employees for EMS performance that demonstrates exceptional
compassion, professionalism, and clinical competence.
g) The Chief shall periodically conduct confidential, anonymous surveys of Department employees
regarding their attitudes, concerns, and opinions relating to the Department’s provision of
emergency medical services. The first survey shall be completed no later than December 31, 2007.

29

District of Columbia Task Force on Emergency Medical Services

Quality Assurance
h) The Medical Director shall, no later than December 31, 2008, take the following steps to develop
a performance evaluation and quality control/quality assurance:

Establish a FEMS peer review program that promotes a culture of excellence;

Work with other jurisdictions and the federal government to regionalize system
management;

Issue customer satisfaction surveys, internal and external, that focus on EMS
service;

Improve response time evaluation that has a goal of measuring time to
patient’s side;

Measure and analyze patient outcome;

Improve complaint tracking by FEMS.

Qualifications and Discipline
i) The Chief shall, no later than December 31, 2007, establish hiring preferences for candidates
and, subject to collective bargaining agreements, promotional preferences for employees with
degrees from recognized accredited higher education institutions and relevant certifications or
skills.
j) The Chief shall require, effective with the next contract:

All personnel 8 to maintain or acquire EMS certifications in order to be retained
as employees of the Department after December 31, 2010;

All candidates for promotion to the rank of Sergeant or higher to have served
as a field-certified EMS provider, according to criteria established by the
Medical Director that requires a minimum cumulative number of patient
contacts, assessments and treatments. 9

k) The Chief shall, no later than December 31, 2008, establish an Internal Affairs Unit, table of
penalties, online records and tracking for Quality Assurance/Quality Control, and disciplinary
timelines for operational employees. Penalties for employee misconduct should be swift, fair and
appropriate.
l) The District Attorney General, in consultation with the Chief of the Department, shall submit to
the Chair of the DC Council Committee on Public Safety and the Judiciary, no later than November
20, 2007, recommendations to strengthen the Department’s ability to terminate Department
employees for medical malfeasance and misconduct.
m) The FEMS Chief, Dr. Barbera, and Mr. Halliday shall complete a plan to monitor implementation
and performance measures relating to the recommendations of the Task Force that includes input,
process and output metrics. Progress on implementation and performance shall be monitored
through ongoing CapStat sessions to which all members of the Task Force shall be invited,
8
For the purposes of this recommendation, the term “personnel” does not include support or
administrative staff, which includes communications and legal staff.
9
It is the intent of the Task Force that this criterion will constitute a new policy that requires employees
to demonstrate excellent performance in patient care before being promoted.

30

District of Columbia Task Force on Emergency Medical Services

including sessions in April and October of 2008 that will specifically address the implementation and
performance monitoring plan.

Recommendation 4
Enhance responsiveness and crew readiness by revising deployment and staffing
procedures.
a) The Mayor shall establish a goal of providing ALS response times according to the National Fire
Protection Association Standard 1710, 100% of the time, as well as a goal of providing transport
responses within 13 minutes, 100% of the time. The Department shall conduct quality
improvement review of those calls where the goal is not achieved. No later than March 20, 2008,
and every six months thereafter, the Mayor shall certify that the District of Columbia has met this
goal, or announce what steps are being taken to achieve this goal.
b) The Mayor and Chief shall work together to come with a recommendation to the Council to
implement shorter shifts for all employees and other recommendations to ensure the goal of
having alert and awake employees who can provide competent patient care. 10
c) The Chief shall establish, no later than March 31, 2008, and as available staff allows, a practice
for assignment to transport duty in which employees are permanently assigned to ambulance
service for periods of not less than 90 days, rather than intermittently with fire apparatus duty.
d) The Chief shall report, no later than March 31, 2008, on procedures for peak load staffing of
transport units, that enable an adequate number of units to meet response time targets. The Chief
shall also establish by the same date a procedure for dynamic deployment of units to provide
coverage when any particular area of the District experiences a shortage of available units.
e) The Chief shall develop and implement a series of service delivery alternatives that provide
efficient, rapid response with a variety of apparatus and personnel.

Recommendation 5
Reduce misuse of EMS and delays in patient transfers.
a) The Chief, in partnership with other District agencies and providers, shall develop and begin to
implement, no later than March 31, 2008, an outreach program for patients with chronic needs.
b) The Chief, in cooperation with other District agencies, shall develop and implement, no later
than March 31, 2008, a public education program regarding appropriate use of the 911 system.
c) The Chief and the Director of the Office of Unified Communications shall, no later than
December 31, 2008, collaborate to improve the 911/311 dispatch process so that call takers and
dispatchers have improved training and enhanced ability to distinguish between emergency and
non-emergency medical calls.
d) The Medical Director, with the support of the City Administrator shall, no later than November
20, 2007, establish and clarify roles and responsibilities for the Department and the Metropolitan

10
It is the sense of the Task Force that the Mayor and Chief should consider schedules that avoid having
employees work more than 24 consecutive hours, especially with additional hours on ambulances.

31

District of Columbia Task Force on Emergency Medical Services

Police Department for treatment of uninjured intoxicated patients and for transport of patients to
the District’s detoxification facility.
e) Effective immediately, the Medical Director should exercise his full authority to order hospital
emergency rooms within the District not to close to Department transports, and to require hospitals
and medical providers to accept the transfer of care of a patient or patients within a specified
period of time.
f) The City Administrator shall, no later than November 20, 2007, convene a working group
including hospital CEOs, DOH, and the Medical Director to meet quarterly to address and develop
standards for drop times, diversion, and closure, and to improve procedures for tracking patient
outcomes. The Medical Director should consider the results and recommendations of this group in
exercising his discretion under the previous paragraph.
g) The Medical Director shall, no later than September 30, 2008, develop a procedure to authorize
patients to be transported to a pre-approved clinic or other non-emergency medical facility,
appropriate to the patient's need.
h) The Medical Director and the Director of the Department of Health shall develop and implement,
no later than September 30, 2008, a system of alternative transportation options (such as
scheduled van service, taxi vouchers, or MetroAccess vouchers), as well as protocols to refuse
transport for non-urgent patients, when appropriate, subject to the authorization of a medical
supervisor.

32

District of Columbia Task Force on Emergency Medical Services

Recommendation 6
Strengthen Department of Health (DOH) oversight of emergency medical services.
a) The Director of the Department of Health, in collaboration with EMS stakeholders, shall, no later
than December 31, 2007, draft legislation or regulations or other administrative actions to improve
oversight of all EMS providers 11 and ambulance companies in the District of Columbia. The Mayor
shall present the resulting draft to the DC Council for consideration. The legislation shall include,
but not be limited to:

License and/or certification requirements for EMS provider agencies, vehicles,
personnel, and training facilities;

Requirements for health care institutions, such as assisted care facilities, to
provide or procure independent inter-facility transport services for nonemergent needs, and authority for DOH to impose fines and/or penalties for
failure to comply;

Specified levels of education, training, and satisfactory test performance in
order to be lawfully assigned to work in an EMS provider capacity;

Requirements for ongoing professional education and training and periodic
recertification testing, both written and practical, administered by independent
entities, as a condition for renewal of certification;

Fair and effective enforcement, including sanctions for unacceptable
performance and deliberate malfeasance, and standards and processes for
revocation of EMS provider certification and EMS provider entity licensure and
certification in appropriate cases;

Requirements for all EMS provider entities, including the Department, to
provide routine reporting on quality of care issues to the Department of
Health;

Authority to re-engineer the protocol revision process to improve the timeliness
with which EMS protocols are updated; and

Authority for DOH to issue fines and penalties to hospitals that fail to accept
Department transports and assume care of patients within a specified period of
time pursuant to the procedures established through recommendation 5 (f).

b) DOH shall immediately adopt the National Highway Traffic Safety Administration standards for
EMS certification at all levels of training and as the minimum standard for the District of Columbia.
Whenever possible, accreditation by nationally recognized bodies shall be adopted to establish
testing and certification requirements.

11

The phrase “EMS provider” includes all levels of EMTs and paramedics.

33

District of Columbia Task Force on Emergency Medical Services

APPENDIX I
Matrix of Findings and Recommendations from Previous Studies of EMS
Delivery in Washington DC

A-1

EMS Findings Matrix
Area
Demand

Response Time

Operations

Workload

Staffing

Training

Quality Assurance

A-2

Blueprint for
Change
TriData IG 2002 IG 2006
Finding
Rising call demand (incidents per capita)
X
Transporting patients who do not need an ambulance
X
No community outreach plan to educate public on when to call 9-1-1
X
Poor dispatch to scene time
X
X
X
Extremely ineffective first response by fire apparatus
X
X
FEMS does not measure significant time intervals impacting response time
X
Ambulance locations not chosen to reflect geographic demand variation
X
Inability to track staff with poor response/turnout time
X
Inadequate knowledge of street addresses
X
X
No plan for dynamic unit re-deployment
X
No staffing change to reflect time of day variations
X
Outmoded EMS operating practices
X
Excessive drop time at hospitals
X
Heavy workload/too few units
X
No provision for meal breaks
X
Personnel "Burnout"
X
Inadequate number of paramedics in Field Operations
X
Short career ladder (have to be trainer to become supervisor)
X
X
Absenteeism (300 hrs/FTE/yr of unscheduled leave)
X
Detailing ambulance field personnel to perform administrative work
X
Overtime costs (80,000 hrs in FY88)
X
EMS staff loss of benefits due to short week/long week schedule
X
Perceived lack of parity in pay and retirement
X
Vacancies for field positions
X
Inadequate training
X
Few paramedic training classes
X
Inadequate time spent training on geographical and navigaton unit
X
Standard of training at FEMS Training Academy questionable
X
Scope of EMT practice misunderstood
X
Inadequate quality assurance
X
Inadequate supervision - number (1:28) and skill level (non-paramedic)
X
Chart review process handled manually
X
No checkout procedure for firefighter EMTs
X
No QA oversight of firefighter first responders
X
CQI stopwatch monitoring of ambulance en route time is insufficient
X
CQI Unit not evaluating/monitoring field performance of EMTs
X

EMS Findings Matrix
Area

Quality Assurance
(continued)

Communications

Logistics

Billing

Organization
Technology
Other

A-3

Blueprint for
Change
TriData IG 2002 IG 2006
Finding
Some personnel working without proper certification
X
X
Ambulance crew did not properly document actions on Form 151
X
EMT with highest level of certification not in charge
X
Faulty patient assessment / no thorough patient assessment completed
X
Faulty transfer of patient from ambulance to hospital ER staff
X
FEMS requirement for completing form 902 EMS not followed
X
No patient priority assigned or incorrect priority assigned
X
Oral communication between first responders and transport flawed
X
Oxygen delivery to patient contrary to protocols
X
Patient's clothing not removed for thorough examination
X
Transport decision not based on FEMS protocol
X
Poor call to dispatch time
X
Poorly integrated field/communications operations
X
Antiquated card-based medical priority dispatch system
X
Communications not consistently professional
X
Comms division has no written polices and operating procedures
X
Communications division not meeting standards for response time
X
Fuel supply problems
X
Oxygen supply problems (ambulances out of service seeking resupply)
X
Vehicle wear and tear
X
Employees in Med Repair Unit lack training/resources to do proper repairs
X
Equipment stored in Medical Repair Unit lacks accountability
X
Low reimbursement rate (9%)
X
EMS billing - paper handling problems
X
EMS billing - poor documentation
X
EMS billing - poor facilities/antiquated equipment
X
EMS billing - work process inefficiencies
X
Difficulties in accountability/discipline from split structure
X
X
Difficulties in timekeeping from split structure
X
X
Lack of computer maintenance
X
Little/no injury EMS public prevention education
X
Lax enforcement of uniform/clothing regulations
X
Deficiencies cited in prior reports not corrected
X

EMS Recommendations Matrix
Area

Demand

Response Time

Recommendation
Implement the Omega protocol to identify calls that can be referred to other points in the
health care system
Allow paramedics the option of refusing to transport patients not in need (or give tokens for
taxi or Metro service)
Gain PSAP accreditation (precursor to implementing the Omega protocol)
Develop procedures to minimize turnout time
Institute a policy to eliminate the need to close station house doors when proceeding on lifethreatening emergencies
Monitor response time of individual field personnel
Ensure that emergency medical response units adhere to national and FEMS standards for
response time
Ensure that data on all time intervals that affect response time are collected and reviewed on a
regular basis
Compile the en route times for all ambulances and PECs from the CAD system on a monthly
basis and share with CQI unit for monitoring
Shift to peak load schedules / Fully implement peak load staffing to match deployment of
units to time-of-day demand
Implement dynamic unit redeployment / Implement systems status management to spread
available vehicles according to geographic demand
Modify policy allowing crews to spend 45 minutes in the hospital after transporting a patient /
reduce hospital drop times to under 20 minutes
Fire units should respond to ALL calls, eliminating the current policy of conditional response

Blueprint for
Change
TriData IG 2002 IG 2006
X
X
X
X
X
X
X
X
X
X

X

X

X

X

X

X

A-4

X
X
X
X

Institute a clear policy on how and when crews are to be relieved
Develop procedures for crews to report equipment malfunctions in their vehicles
Acquire up to 15 additional ambulances to meet peak hour demand requirements
Implement paramedic engine companies to provide rapid advanced life support
Offer civilian EMS staff the opportunity to take firefighter training and switch to FFD
Remove engine companies from most "Bravo" level calls, to conserve resources for true
emergencies
Give EMS crews formal breaks in their schedule (similar to police department)
Work with hospitals and health department to reduce hospital drop times

Operations

Discontinue paired response of ALS and BLS units
On non-critical calls, let firefighter first responders determine whether transport is needed
Implement an all-ALS ambulance fleet (and hire/train paramedics to staff the units)
Reassign ambulances to different locations to provided more balanced geographic coverage

X
X
X
X
X
X
X
X

EMS Recommendations Matrix
Area
Operations (cont)

Management

Staffing

Training

Quality Assurance

A-5

Recommendation
Augment the number of rapid response units (2 additional units)
Develop ALS and BLS agreements with the Bethesda-Chevy Chase Rescue Squad to provide
EMS coverage in upper Northwest DC
Establish a project team to prepare detailed standard operating procedures (SOPs)
Institute a performance evaluation system for supervisors
Conduct an impartial review of the qualifications of incumbent EMS managers
Make the promotional process competitive (through an examination)
Eliminate or reduce the weight of the residential preference in making promotions
Establish clear promotional criteria tied to job descriptions
Develop and implement a standardized performance evaluation system for all firefighters.
Evaluate EMTs on a quarterly basis, following FEMS policy.
Promptly reassign, retrain, or remove poor performers.
Reduce unscheduled leave of EMS personnel from 300 hours/year to under 150/year, through
improved management supervision
Hire enough EMS supervisors to provide for a 1:10 span of control
Assess staffing shortages and determine how many additional paramedics should be hired
Coordinate with all senior level managers to address and take appropriate action with
employees who have patterns of abusing leave
Ensure that the locations of new areas and streets within the District are disseminated to all
FEMS employees, and incorporated into all geography and training classes
Establish qualifications and create a hiring policy for EMS training instructors
Assess qualifications of all EMS training managers and instructors
Ensure all personnel have current required training and certifications prior to going on duty.
Immediately implement a reporting form that is mandated for use by firefighter/EMTs who
respond to any medical call.
Assign quality assurance responsibilities to the employee with the most advanced training on
each emergency medical call.
Hire additional evaluators for the CQI unit so that it can fulfill its mission
Ensure that the CQI unit has the necessary staff and resources to complete field evaluations
on paramedics within the 2-year certification period
Reassign all detailed CQI Unit evaluators back to the CQI office
Coordinate with DOH to develop a policy on paramedic certification extensions
Ensure that FEMS follows the most recent version of District regulations governing
paramedic certification and recertification
Develop a field evaluation process for basic EMTs similar to that used for paramedics
Hire sufficient staff to perform field evaluations on basic EMTs when feasible

Blueprint for
Change
TriData IG 2002 IG 2006
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X

EMS Recommendations Matrix
Area

Communications

Logistics

Recommendation
Give dispatchers explicit command authority over field units
Implement ProQA medical priority dispatch (MPD) system
Implement an Automatic Vehicle Location (AVL) system
Implement a Unit Statusing System (USS)
Ensure that there is adequate staff for the Communications division
Create and promulgate written policies and standard operating procedures for the
communications division
Consider installing global positioning devices in all ambulances / implement an in-vehicle
navigation system
Establish a mobile supply unit to restock ambulances in the field
Limit access to all areas used by the Medical Equipment Repair Unit to unit employees during
service hours
Hire staff in the MERU to expand the hours of operations from 16 to 24
Conduct an inventory of all equipment in the MERU on a regular basis and report
discrepancies to division management
Identify training needs for MERU employees
Ensure MERU employees have the necessary tools to repair the agency's medical equipment
Coordinate with procurement officer to ensure that all contracts for the purchase of
equipment contain provisions for training MERU employees on how to make repairs
Reorganize EMS on a third service or separate ambulance department (alternatively, a crosstrained, dual-role firefighter system makes sense from the perspective of cost and productivity

Organization

Technology

Public Education

Other

A-6

Have EMS training and EMS QA report to the EMS medical director
Convene a panel to recommend between a separate EMS agency and a cross-trained, dual-role
department
Implement pen-based computer-assisted patient care documentation
Automated quality assurance function using computerized documentation
Implement an inventory control system
Hire and train an EMS public education specialist
Develop and implement a written community outreach plan to educate the public on abuse of
the EMS system and the impact on response
Ensure the public is well-informed about when to call 3-1-1
Organize a committee to review the 1989, 1997, and 2002 reports and develop a
comprehensive strategic plan to address the issues covered

Blueprint for
Change
TriData IG 2002 IG 2006
X
X
X
X
X
X
X

X

X
X
X
X
X

X
X

X
X
X
X
X
X
X
X
X

A-7

APPENDIX I I

Peak Load Staffing Analysis

Sunday BLS & ALS Calls - 2007 Jan-Jun
35

30

30

25

25

20

20

15

15

10

10

5

5

0

0

High
Hour of Day
High
90th Percentile
Average
Low
Ambulances

A-8

90th Percentile

Average

Low

BLS & ALS Ambulances

40

35

Calls

40

Ambulances

0:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00
23
21
15
6

29
21
15
7

19
18
14
0

21
20
14
6

16
14
9
3

14
11
7
3

15
9
7
2

15
13
9
2

19
15
10
4

17
14
11
2

19
17
12
6

21
19
14
5

25
18
14
8

30
21
15
8

22
20
14
6

24
21
14
7

26
19
15
5

21
19
15
6

20
19
14
3

24
22
16
8

26
20
15
7

20
19
15
10

20
18
12
6

18
17
12
7

38

38

38

38

38

38

38

37

37

37

37

37

37

37

37

37

37

37

37

38

38

38

38

38

Prepared by The Abaris Group 7/16/2007

Monday BLS & ALS Calls - 2007 Jan-Jun
35

30

30

25

25

20

20

15

15

10

10

5

5

0

0

High
Hour of Day
High
90th Percentile
Average
Low
Ambulances

A-9

90th Percentile

Average

Low

BLS & ALS Ambulances

40

35

Calls

40

Ambulances

0:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00
15
13
10
5

14
13
10
5

10
10
7
4

13
10
8
5

13
9
6
1

11
9
6
2

17
13
9
3

20
16
11
4

24
19
16
6

26
23
16
7

28
23
18
5

23
21
18
11

26
25
18
10

26
23
18
11

31
23
19
13

25
22
18
11

28
26
18
10

30
23
17
10

21
21
17
11

30
21
16
7

27
24
16
10

24
23
17
8

26
24
15
8

21
15
12
2

38

38

38

38

38

38

38

37

37

37

37

37

37

37

37

37

37

37

37

38

38

38

38

38

Prepared by The Abaris Group 7/16/2007

Tuesday BLS & ALS Calls - 2007 Jan-Jun
35

30

30

25

25

20

20

15

15

10

10

5

5

0

0

High
Hour of Day
High
90th Percentile
Average
Low
Ambulances

A-10

90th Percentile

Average

Low

BLS & ALS Ambulances

40

35

Calls

40

Ambulances

0:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00
16
15
10
5

15
14
9
4

15
11
7
3

12
10
6
0

12
10
6
2

11
10
6
1

15
12
9
4

17
15
11
6

22
21
14
8

26
24
18
11

25
22
17
9

30
23
19
11

29
27
20
8

24
24
17
5

26
25
18
8

28
25
19
9

28
25
19
9

25
24
18
12

31
23
17
10

26
24
17
8

23
20
15
8

29
23
17
6

23
20
14
8

20
18
12
3

38

38

38

38

38

38

38

37

37

37

37

37

37

37

37

37

37

37

37

38

38

38

38

38

Prepared by The Abaris Group 7/16/2007

Wednesday BLS & ALS Calls - 2007 Jan-Jun
35

30

30

25

25

20

20

15

15

10

10

5

5

0

0

High
Hour of Day
High
90th Percentile
Average
Low
Ambulances

A-11

90th Percentile

Average

Low

BLS & ALS Ambulances

40

35

Calls

40

Ambulances

0:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00
19
15
12
6

14
12
8
3

16
13
8
3

12
10
7
4

10
8
5
1

11
9
6
3

11
11
8
3

18
15
10
5

24
18
14
8

27
25
18
10

26
21
17
7

27
24
19
12

26
22
18
11

27
23
17
11

27
23
19
12

23
23
17
8

33
25
20
12

26
23
16
7

24
23
17
9

27
22
16
10

27
21
15
8

25
22
16
9

20
16
12
7

22
17
13
5

38

38

38

38

38

38

38

37

37

37

37

37

37

37

37

37

37

37

37

38

38

38

38

38

Prepared by The Abaris Group 7/16/2007

Thursday BLS & ALS Calls - 2007 Jan-Jun
35

30

30

25

25

20

20

15

15

10

10

5

5

0

0

High
Hour of Day
High
90th Percentile
Average
Low
Ambulances

A-12

90th Percentile

Average

Low

BLS & ALS Ambulances

40

35

Calls

40

Ambulances

0:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00
16
13
11
4

17
12
9
5

16
14
9
2

10
10
6
2

12
10
7
3

13
9
6
2

11
10
7
2

18
15
12
4

22
19
16
11

22
22
17
11

25
20
16
8

27
24
17
10

29
27
19
10

25
23
18
12

27
25
22
10

26
24
18
14

29
25
18
10

20
20
17
11

26
23
18
9

24
22
18
10

23
20
15
8

27
24
16
9

27
21
17
10

21
20
13
4

38

38

38

38

38

38

38

37

37

37

37

37

37

37

37

37

37

37

37

38

38

38

38

38

Prepared by The Abaris Group 7/16/2007

Friday BLS & ALS Calls - 2007 Jan-Jun
35

30

30

25

25

20

20

15

15

10

10

5

5

0

0

High
Hour of Day
High
90th Percentile
Average
Low
Ambulances

A-13

90th Percentile

Average

Low

BLS & ALS Ambulances

40

35

Calls

40

Ambulances

0:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00
16
14
10
5

17
13
9
3

16
14
10
2

14
12
7
4

15
9
6
1

11
9
6
3

15
13
9
6

15
14
10
5

24
20
15
8

25
22
17
10

26
22
16
8

27
22
16
11

30
26
19
9

31
22
18
10

31
25
19
8

28
23
19
13

30
27
19
12

28
24
18
7

27
24
17
10

29
24
18
12

25
24
17
8

27
23
18
12

27
22
18
7

25
21
17
8

38

38

38

38

38

38

38

37

37

37

37

37

37

37

37

37

37

37

37

38

38

38

38

38

Prepared by The Abaris Group 7/16/2007

Saturday BLS & ALS Calls - 2007 Jan-Jun
35

30

30

25

25

20

20

15

15

10

10

5

5

0

0

High
Hour of Day
High
90th Percentile
Average
Low
Ambulances

A-14

90th Percentile

Average

Low

BLS & ALS Ambulances

40

35

Calls

40

Ambulances

0:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00
24
22
14
7

20
19
14
9

20
18
14
6

25
21
14
4

15
12
9
4

13
12
7
2

15
11
9
4

15
11
8
4

16
15
10
2

19
18
13
6

21
18
13
8

23
19
14
7

28
23
16
6

21
20
16
9

24
20
16
7

25
19
16
10

26
22
18
11

26
23
16
9

24
22
17
11

28
23
17
7

25
23
18
9

27
24
18
7

23
23
17
7

28
22
17
11

38

38

38

38

38

38

38

37

37

37

37

37

37

37

37

37

37

37

37

38

38

38

38

38

Prepared by The Abaris Group 7/16/2007

APPENDIX III
Models for Delivering Emergency Medical Services: Strengths,
Weaknesses, Opportunities, and Threats

A-15

Third Service
A separate City Department with its own budget, management
structure & staff utilizing single-role personnel to provide
Advanced Life Support (ALS) level ambulance transportation

EMS System Design Options 1
Private Service - BLS & ALS Transportation

Private Service - BLS Transportation Only

A contracted service with a commercial private ambulance service that
provides transportation at the Basic Life Support (BLS) & Advanced Life
Support (ALS) levels; BLS or ALS first-response units provided by the
fire department
Performance mandated by contract
Decreased operating costs to the District
Respond to 911 & non 911 transports
Increased ambulance response efficiencies (peak staffing)
System status management deployment

A contracted service with a commercial private ambulance service
that provides transportation at the Basic Life Support (BLS) level;
Advanced Life Support (ALS) provided by fire department firstresponse units (PECs or Other Type Vehicle)
Performance mandated by contract
Decreased operating costs to the District
Respond to 911 & non 911 transports
Increased ambulance response efficiencies (peak staffing)
System status management deployment

Strengths

Separate city department
Single focus mission approach
Available work force (single-role providers)
Dedicated workforce
Decreased culture clash (Fire vs. EMS)
Desired by current single-role provider workforce
Desired by some citizen groups

Weaknesses

Duplication of functions/costs
Duplication of management staff

Likely ambulance fee increases
Likely need for District to provide subsidy

Likely ambulance fee increases
Likely need for District to provide subsidy

Limited career advancement options
Significant roll out process
Unwinds current significant progress to integrate

Loss of immediate FEMS surge capacity
Limited depth of skills/response, i.e. Haz Mat, extrication
Limited control outside of contract provisions

Loss of FEMS immediate surge capacity
Limited depth of skills/response, i.e. Haz Mat, extrication
Limited control outside of contract provisions

Risk of decreased availability due to non-911 transports

Risk of decreases availability due to non-911 transports
Need for FEMS Paramedic to accompany transport unit on ALS
transports

Opportunities

Potential to enhance public perception
High performance design by contract
Perceived enhanced medical treatment
Fast option to implement
Ability to create stronger workforce relationship with hospital staff Ability and speed to meet accreditation requirements (CAAS)

High Performance Design by Contract
Accreditation Requirement

Ability to reallocate FEMS resources for other needs
Threats

Budget impact
Negative media attention

Profitability
Personnel Turnover

No perceived improvement over current system

Personnel unfamiliar with streets/addresses

Personnel Unfamiliar with Streets/Addresses

Does not address underlying need on quality & supervision
Culture clash risk remains due to need for fire first-response

Community
Examples

Profitability
Higher percentage of personnel turnover

Possible subsidy from the District
Resentment by fire personnel
Resentment by public
Does not address underlying need on quality & supervision

Possible Subsidy from City
Resentment by Fire Personnel
Resentment by Public
Does not address underlying need on quality & supervision

Boston EMS; Austin/Travis County EMS

Pinellas County, San Diego, Richmond

Seattle

1

A-16

Changes with the structure of EMS governance does not assure changes to the quality and supervision issues needed.

Fire-Based Service - Current System
The current fire department system in Washington DC using both
single-role & multi-role personnel

EMS System Design Options
Fire-Based Service - Fully Integrated

Fire-Based Service - Partially Separated EMS Function

100% Paramedic Engine Companies providing ALS first-response with
100% Multi-Role Personnel; BLS Ambulances staffed with Multi-Role
personnel; Single-Role personnel replaced through attrition with Multirole personnel
Adequate fire & EMS staff
All hazards mission approach
Existing infrastructure & support services
Existing management staff
Existing apparatus/ambulances
Integrated first-response & ambulance response
Interchangeable personnel (multi-role)
Career advancement options
Response times meet or exceed industry standards
Immediate surge capacity

Fire department first-response at both BLS & ALS level with multi-role
personnel; BLS & ALS ambulances with single-role personnel; EMS
function under the Medical Director with separate budget for Quality
Improvement & Training staff
Adequate fire & EMS staff
Existing infrastructure & support services
Existing management staff
Existing apparatus/ambulances
Integrated first-response & ambulance response
Response times meet or exceed industry standards
Immediate surge capacity

May still result in poor public perception
Single-role providers may feel they are being pushed out of the
organization
Can take several years for complete transition & integration

May still result in Poor Public Perception
Uncertainty for all personnel regarding future delivery of EMS

EMS Task Force Recommendations
Current plan for enhanced medical direction
New Fire Chief/Medical Director & support staff

Single set of work rules
Single labor contract for new hires
All personnel have the same mission

Easier to identify cost of providing EMS, not including first-response
Strong medical direction possible
Enhanced on-scene supervision

Increased hospital involvement & support

Enhanced on-scene supervision

Negative media attention
Continued culture clash (Fire vs. EMS)

Negative media attention
Continued culture clash (Fire vs. EMS) until transition is completed

Does not guarantee resolution of all identified underlying issues
related to QI
May be perceived as "business as usual"

Does not guarantee resolution of all identified underlying issues related Does not guarantee resolution of all identified underlying issues related to
to QI
QI

Strengths

Currently in place
Adequate fire & EMS staff
Fire station locations optimized
All hazards mission approach
Existing infrastructure & support services
Existing management staff
Existing apparatus/ambulances
Integrated first-response & ambulance response
Interchangeable personnel (multi-role)
Career advancement options
Response times meet or exceed industry standards
Immediate surge capacity

Weaknesses

Poor public perception
Inadequate EMS on-scene supervision
Static deployment
Separate work rules for multi-role & single-role providers
Separate labor contracts for multi-role & single-role personnel

Gives fire personnel a reason to not support EMS mission
Competition for budget funds
Continues to promote separateness of single-role & multi-role personnel

Perception of single-role providers towards FEMS commitment to
providing EMS
Disparity in pay & benefits (single vs. multi-role)
Poor quality medical control issues
Opportunities

Threats

Community
Examples

A-17

Phoenix, Houston, Memphis, Fairfax County, Montgomery County

Negative media attention
May be perceived as "business as usual"