HomeMy WebLinkAboutMINUTES - 07212015 - D.14RECOMMENDATION(S):
1. ACCEPT the recommendation from the Health Services Director regarding the award of a contract to the Contra
Costa County Fire Protection District (CCCFPD), on behalf of the "Alliance". The Alliance refers to the contractor
and subcontractor arrangement established between CCCFPD and American Medical Response (AMR), respectively,
associated with the proposal to provide emergency ambulance services.
2. AUTHORIZE the Health Services Director, or designee, to negotiate a contract with CCCFPD as sole bidder for
emergency ambulance services and subject to sub-contracting with American Medical Response, in accordance rates
and terms specified in Plan A as described in the response to the Emergency Ambulance Request for Proposal for the
period of January 1, 2016 through January 1, 2021 with the option to renew the contract for an additional 5 years
subject to a Board finding that the Alliance is in compliance with contract requirements and standards prior to January
1, 2020.
3. DIRECT the Health Services Director, or designee, staff to return to the Board with a negotiated contract for final
approval no later than September 2015.
APPROVE OTHER
RECOMMENDATION OF CNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
Action of Board On: 07/21/2015 APPROVED AS RECOMMENDED OTHER
Clerks Notes:
VOTE OF SUPERVISORS
Contact: Patricia Frost,
925-313-9554
I hereby certify that this is a true and correct copy of an action taken and entered on the minutes of the Board
of Supervisors on the date shown.
ATTESTED: July 21, 2015
David Twa, County Administrator and Clerk of the Board of Supervisors
By: , Deputy
cc:
D.14
To:Board of Supervisors
From:William Walker, M.D., Health Services Director
Date:July 21, 2015
Contra
Costa
County
Subject:Recommendations for Award of the Emergency Ambulance RFP (Request for Proposal) for Exclusive Operating
Area (EOA) I, II and V
FISCAL IMPACT:
The current emergency ambulance contract requires no subsidy and under Plan A it is anticipated that a subsidy
will not be required during the first five years of the new contract. The financial impact of the proposed Alliance
bid for emergency ambulance services is contained in the attached report titled "Independent Financial Review of
Elements Related to the County's Ambulance RFP", authored by Citygate Associates, LLC and facilitated by the
County Administrator's Office.
BACKGROUND:
Request for Proposals Process
On February 27, 2015, the Contra Costa Emergency Medical Services Agency, the Local EMS Agency
(LEMSA), posted the Board-approved 2015 Contra Costa County Request for Proposal for Emergency
Ambulance Service. On March 19, 2015 the LEMSA and RFP consultant Fitch and Associates conducted a
mandatory proposer’s conference with three prospective bidders in attendance:
The Alliance: The contractor and subcontractor arrangement established between CCCFPD and AMR, and
approved by the CCCFPD Governing Board on May 12, 2015.
Falck Northern California
Medic Ambulance
The deadline for the receipt of emergency ambulance service proposals was May 21, 2015 at 4pm. A single
emergency ambulance proposal was received from the Alliance. A public proposal opening was conducted at 4pm
on May 21, 2015 at the LEMSA offices located at 1340 Arnold Drive in compliance with the Brown Act. The
Alliance proposal was posted on the LEMSA website that same day.
A proposal review process followed and was conducted in accordance with requirements approved by the
California EMS Authority. The proposal review process was managed by the LEMSA and its RFP Consultant
(Fitch and Associates). A multi-disciplinary proposal was reviewed and scored by a panel of four out-of-county
independent EMS professionals and one local representative appointed by the Board. In addition two board
appointed independent observers from the county were invited to observe the two-day panel review proceedings
on June 4-5, 2015. The proposal review panel concluded with a presentation by the Alliance on June 5, 2015. The
findings of the proposal review panel were submitted to the Health Services Director shortly following the panel
review meeting. Subsequently, the Health Services Director requested from the Alliance on June 22, 2015. This
information was received prior to the request deadline of 5pm on July 6, 2015.
Independent Financial Review Process
The Board of Supervisors directed County Administrator to conduct an independent financial review of bids
submitted in response to the LEMSA RFP for emergency ambulance services. The County Administrator's Office
retained Citygate Associates LLC to provide the independent financial review and render an opinion on the
relative strengths and weaknesses of each proposal. Upon reviewing the bid submitted by the Alliance as
described above, the County Administrator's Office determined that additional financial information was
necessary to properly conduct the financial review and render and opinion. On June 8, 2015, the County
Administrator formally requested the additional information from CCCFPD as lead agency for the Alliance and
received a response on June 15, 2015. Alliance representatives met with Citygate Associates LLC for follow up
discussion regarding the financial aspects of the proposal on June 19, 2015 and have remained in contact during
the report development phase.
Alliance Proposal Structure
The Alliance model, with a first responder Fire District as contractor and the private ambulance provider as
subcontractor is an entirely new approach for providing emergency ambulance services not seen previously in
California. The Alliance model has the potential to provide a Countywide EMS System benefits and challenges in
the following areas:
Collaboration between first responders and ambulance personnel may be significantly improved
Efficiencies associated with co-located dispatch and resulting enhancements in coordinated deployment
and operations of emergency medical services for the communities served could be realized.
A complex contracting structure adds to the number of governing boards involved in approval processes
which may reduce the private ambulance provider’s (now a subcontractor under the Alliance model) level
of responsiveness and flexibility in the provision of services.
Confusion over LEMSA roles and responsibilities may increase associated with LEMSA statutory
requirements under Title 22, Division 9: Prehospital Emergency Medical Services and California
Emergency Services Law Health and Safety Code Division 2.5 responsible for medical control, patient
safety and prehospital care oversight as part of an coordinated EMS System plan for countywide
emergency services.
It would be the intent of the LEMSA to fulfill its roles and responsibilities as the contract administrator and Local
EMS regulator in a similar fashion as it has conducted business with previous contractors. The Health Services
Director and LEMSA staff request that the Board consider all information when determining the recommendation
to award and provide direction to staff on the procurement for county emergency ambulance services for EOA I,
II, and V.
Links to Key Documents
1. Contra Costa EMS RFP webpage: http://cchealth.org/ems/rfp.php
2. Request for Proposals: Exclusive Operator for Emergency Ambulance Service Contra Costa County (February
27, 2015) http://cchealth.org/ems/pdf/RFP2015-contracosta-ambulance.pdf
3. Alliance Proposal and Supporting documents:
http://cchealth.org/ems/pdf/RFP2015-ccfpd-amr-proposal.pdf
http://cchealth.org/ems/pdf/RFP2015-ccfpd-amr-exhibits9.pdf
CONSEQUENCE OF NEGATIVE ACTION:
The emergency ambulance contract would not be awarded at this time. The current contract with American
Medical Response (AMR) for emergency ambulance service ends on December 31, 2015. In order to continue
emergency ambulance services to Exclusive Operating Areas I, II and V (which covers approximately 90% of the
county emergency ambulance services) past December 31, 2015; EMS staff would recommend that the Board
direct EMS staff to renew the AMR contract for an additional 18 months and to go back out to bid for emergency
ambulance services.
CHILDREN'S IMPACT STATEMENT:
Not applicable.
CLERK'S ADDENDUM
Speakers: Peter Clark, Happy Valley Improvement Association; Bill Granados, CCC Fire Protection District
Advisory Commission; Dan Colbath, Firefighters' Local 1230. Supervisor Mitchoff expressed her desire to see
staff's analysis, recommendations and thoughts on the two components (operating and savings) of a reserve
fund. The Board ADOPTED all recommendations as presented, to include the recommendations of the
consultant Citygate Associates LLC.
ATTACHMENTS
Plan A Summary
Summary of 2015 Contra Costa Emergency Ambulance RFP Plan A & B Requirements
Final Report: "Independant Financial Review of Elements Related to the County's Ambulance RFP". Citygate
Associates LLC July 2015
Citygate Associates LLC PowerPoint Presentation
Request for Proposals: Exclusive Operator for Emergency Ambulance Service
Alliance Bid Response
Alliance Bid Response- Supporting Documents
Alliance Bid Response- Section VI Financials
Summary of 2015 Contra Costa Emergency Ambulance Plan A RFP Requirements
1
2
1 Content from Request for Proposal at http://cchealth.org/ems/pdf/RFP2015-contracosta-ambulance.pdf
22 Content from Request for Proposals at http://cchealth.org/ems/pdf/RFP2015-contracosta-ambulance.pdf
Summary of 2015 Contra Costa Emergency Ambulance Plan A RFP Requirements
Summary of 2015 Contra Costa Emergency Ambulance Plan A RFP Requirements
Summary of 2015 Contra Costa Emergency Ambulance RFP Plan A & B Requirements
Plan A Plan B
Rates Apply to Both Plans Under RFP
Why Two Plans?
The two plan RFP model was created in response to findings and recommendations in the 2014 EMS System Modernization Project (http://cchealth.org/ems/pdf/2014-EMS-
System-Modernization-Study.pdf). That report provided a detailed review of the countywide emergency medical services including ambulance utilization, current prehospital
medical science and health/EMS risk profile within the community AND what would potentially be required over the next 10 years. The EMS System study recommendations
addressed regional coordination, dispatch, education, workforce, public mobilization, basic and advanced life support response/treatment, community paramedicine, healthcare
integration, community health monitoring and EMS System finance. The findings of the study made a number of recommendations to position the Contra Costa EMS System for
continued success as a next generation EMS System supporting improved patient care outcomes over the next 10 years. The two plan RFP gives the County unprecendented
flexibility to adjust to unknown and dynamic variables over the next 10 years.
Plan A Plan B
During the EMS System Modernization Study, Contra Costa community hospitals identified the need for a non-emergency paramedic level interfacility transport (IFT) to support
timely performance based medical transportation for patients who had medical conditions beyond the capability of non-emergency basic life support medical transportation but
did not require Critical Care Nurse Transportation. The current RFP creates an exclusive operating area for this level of medical transportation. Paramedic interfacility medical
transportation is not currently provided within Contra Costa County. This new function supports the EMS System by bringing additional revenue to the ambulance provider to
provide EMS System enhancements and sustain emergency ambulance services over the term of the contract.
No subsidy EMS System desired
No subsidy EMS System expected
Summary of 2015 Contra Costa Emergency Ambulance RFP Plan A & B Requirements
Plan A Plan B
The “maximum” response time arrival time in urban communities for “Emergency
Ambulance” under Plan A remains 11:45 minutes countywide, with the exception
of Richmond which is 10:00 minutes. Contra Costa is a tiered EMS system with fire
first responders typically arriving within 4-7 minutes of being dispatched for code 3
(lights and sirens calls). See additional response time details for Plan A that follow.
There are 3 ambulance emergency response zones under Plan B. Plan B consolidates the
two emergency response zones in West County, making Richmond uniform with the rest
of urban West County.
The “maximum” response time in urban communities for “Emergency Ambulance” under
Plan B adds one minute to current urban emergency ambulance response times. This
minute would potentially be mitigated through faster call processing times at the dispatch
level. Contra Costa is a tiered EMS system with fire first responders typically arriving
within 4-7 minutes of being dispatched for code 3 (lights and sirens calls). See additional
response time details for Plan B that follow.
Summary of 2015 Contra Costa Emergency Ambulance RFP Plan A & B Requirements
Plan A Plan B
No County EMS Agency Compliance Monitoring, Contract
Management and Regulatory Activities funding
Under Plan A, there is no cost recovery for additional support of “Systems of Care”
or prehospital technology enhancement. Systems of care programs coordinated by
the EMS Agency include Cardiac Arrest, STEMI, Stroke and EMS for Children.
Under Plan B, the RFP assumed 2-3 million dollars of EMS System savings for the
ambulance provider. A 70% EMS Agency cost recovery to support countywide EMS System
improvements of 750K was allocated for system benefit (2% of the total value of the
emergency ambulance services contract). This additional funding would be reinvested in
the countywide EMS System to support ongoing “Systems of Care” programs for Cardiac
Arrest, STEMI, Stroke and EMS for Children. Additional funding would benefit prehospital
technology/communications supporting health information exchange and integration of
mobile health services with the health care delivery system.
Summary of 2015 Contra Costa Emergency Ambulance RFP Plan A & B Requirements
Plan A Plan B
The “maximum” response time in urban communities for “Emergency Ambulance” under
Plan B adds one minute to current urban emergency ambulance response times. This
minute would potentially be mitigated through faster call processing times at the dispatch
level. Contra Costa is a tiered EMS system with fire first responders typically arriving
within 4-7 minutes of being dispatched for code 3 (lights and sirens calls).
Reduces the number of Response Zones from 5 to 4, with the consolidation of two
zones in East County and urban response expectations expanded to Discovery Bay
and Byron.
Reduces the number of Response Zones from 5 to 3 by merging the Richmond Zone with
the rest of urban West County, along with the consolidation in East County as identified in
Plan A. Further expands the urban response zone requirements to cover Bethel Island
and surrounding higher density population areas.
Summary of 2015 Contra Costa Emergency Ambulance RFP Plan A & B Requirements
Plan A Plan B
Table of Contents page i
TABLE OF CONTENTS
Section Page
Section 1—Executive Summary....................................................................................................1
1.1 What This Review Is ....................................................................................... 1
1.2 What This Review Is Not ................................................................................ 1
1.3 Citygate’s Capstone Opinions ......................................................................... 2
1.3.1 Total Expense to Revenue Comparison for Plan A and B .................. 3
1.4 The Fiscal Differences of Plan A and Plan B .................................................. 4
1.5 The Fiscal Health of AMR and the CCCFPD ................................................. 5
1.6 Risk Control Strategies and Implementation Recommendations .................... 5
Section 2—Background .................................................................................................................7
2.1 Citygate’s Document Review .......................................................................... 7
2.2 Citygate’s Project Methodology ...................................................................... 7
Section 3—Current State of Ambulance Economics ..................................................................9
3.1 The State and Regional EMS Picture .............................................................. 9
3.1.1 Medi-Cal, Medicare, Covered California, and Commercial
Insurance ............................................................................................. 9
3.2 Covered Contra Costa ................................................................................... 11
3.2.1 Health Insurance Coverage in Contra Costa County ......................... 11
3.3 AMR Revenue History in Contra Costa County ........................................... 12
Section 4—The Business Structure of the Alliance Proposal...................................................18
4.1 AMR’s Subcontract with CCCFPD .............................................................. 18
4.1.1 Deployment Plan A and B Costs to be Paid to AMR by CCCFPD .. 18
4.1.2 Terms of the CCCFPD and AMR Contract ....................................... 19
4.1.3 Alliance Proposal Risk Impact to the Taxpayer ................................ 20
4.2 CCCFPD Roles and Responsibilities in the Alliance Proposal ..................... 21
4.2.1 One Chief Officer Oversight Position ............................................... 22
Table of Contents page ii
4.2.2 Ambulance Billing ............................................................................ 22
4.2.3 Merged Dispatch ............................................................................... 23
4.2.4 Separate Training/CQI for Fire Paramedics – “As Is” ...................... 23
4.3 AMR’s Roles and Responsibilities in the Alliance Proposal ........................ 23
4.3.1 An Almost Identical AMR Effort to the Current Model ................... 23
Section 5—Operations Review as the Cost Driver....................................................................26
5.1 Deployment Levels and Resultant Staffing ................................................... 26
5.1.1 Alliance Plan A Deployment ............................................................. 27
5.1.2 Alliance Plan B Deployment ............................................................. 27
5.2 Plan A Likely Response Time Compliance .................................................. 28
5.3 Plan B Likely Response Time Compliance ................................................... 29
5.4 Staffing for Administrative, Training, Dispatch, and Community Education
Support .......................................................................................................... 31
5.4.1 Community Education ....................................................................... 32
5.4.2 Quality Control and Overall Logistical Positions Needs and
Appropriateness ................................................................................. 32
Section 6—Alliance Economic Proposal ....................................................................................33
6.1 Transport Volume Over Time ....................................................................... 33
6.2 Billing by Payer Type .................................................................................... 34
6.3 Alliance Revenue Estimate Model ................................................................ 35
6.4 GEMT Absence, Near-Term Forecast, and the Wide Variance of Possible
Revenues ....................................................................................................... 36
6.4.1 Description of GEMT Program ......................................................... 36
6.4.2 CCCFPD’s Intent to Seek GEMT Reimbursement ........................... 37
6.4.3 The GEMT Program, Medi-Cal Fee for Service, and Medi-Cal
Managed Care .................................................................................... 37
6.4.4 Characteristics of Contracted Billing Service Agreement ................ 38
6.4.5 DHCS’s Determination of the CCCFPD’s Allowable GEMT
Expenses ............................................................................................ 38
Table of Contents page iii
6.4.6 Potential Expansion of the GEMT Program to Medi-Cal Managed
Care ................................................................................................... 40
6.5 Plan A and B Revenue and Cost Projection Analysis ................................... 40
6.5.1 Total Expense to Revenue Performance for Plan A and B ............... 43
6.6 Estimate of AMR Profit and Reasonableness ............................................... 44
6.7 AMR Fiscal Health/Corporate Review ......................................................... 45
6.8 CCCFPD Fiscal Health / Corporate Review ................................................. 47
6.8.1 CCCFPD Financial Capacity ............................................................. 47
Section 7—Fiscal Risk Control Strategies .................................................................................51
7.1 Risk Control Strategy #1: Establish Alliance Contracts as an Enterprise
Operation ....................................................................................................... 51
7.2 Risk Control Strategy #2: Establish a Significant Reserve Fund of 6 Months
of Revenues Plus a Capital Equipment Replacement Reserve ...................... 52
7.3 Risk Control Strategy #3: Eventually Calibrate Transport Fees to True Costs
through Audits of Expenses and Adherence to Stipulated Contract
Provisions ...................................................................................................... 54
7.4 Risk Control Strategy #4: When Revenues Exceed Needed Reserves,
Consider Lowering Transport Fees, Not Cross-Subsidizing Non-Alliance
CCCFPD or County EMS Agency Operations ............................................. 54
7.5 Risk Control Strategy #5: Establish a County Board of Supervisors and
CCCFPD “Compassionate” Set of Billing Policies for CCCFPD-Managed
First Responder and Ambulance Revenue Collection to Include a Write-
Down and Write-Off Policy .......................................................................... 55
Section 8—Opinions Summary and Implementation Recommendations ..............................56
8.1 Citygate’s Opinions ....................................................................................... 56
8.2 Implementation Recommendations ............................................................... 58
Appendix A—List of Acronyms .................................................................................................60
Table of Tables
Table 1—Alliance Plan A and B Economics .................................................................................. 3
Table 2—Cost Differences for Plan B ............................................................................................ 4
Table of Contents page iv
Table 3—Total System Costs per Unit Hour for Plans A and B .................................................... 4
Table 4—Plan A Staffing Hours and Costs .................................................................................. 19
Table 5—Plan B Staffing Hours and Costs .................................................................................. 19
Table 6—Administrative and Logistical Support ......................................................................... 31
Table 7—Number of Transports in Contra Costa County ............................................................ 33
Table 8—Payer Types from AMR in Contra Costa County ......................................................... 34
Table 9—AMR National Payer Experience ................................................................................. 35
Table 10—County RFP Ambulance Rates ................................................................................... 35
Table 11—AMR Contra Costa County Net Cash Collections by Type ....................................... 36
Table 12—Plan A and B Cost per Unit Hour ............................................................................... 41
Table 13—Deployment Plan A ..................................................................................................... 42
Table 14—Deployment Plan B ..................................................................................................... 42
Table 15—Cost Differences Between Plans A and B .................................................................. 43
Table 16—Total System Costs per Unit Hour for Plans A and B ................................................ 43
Table 17—Plan A and B Economics ............................................................................................ 44
Table 18—Deployment Plan A Expenses..................................................................................... 45
Table 19—Deployment Plan B Expenses ..................................................................................... 45
Table 20—Envision Healthcare Holdings, Inc. (EVHC) Fiscal Health Measures ....................... 46
Table 21—CCCFPD “Balance Sheet” by Fiscal Year ................................................................. 48
Table 22—CCCFPD Statement of Revenues, Expenditures, and Change in Fund Balance ........ 49
Table of Figures
Figure 1—Increase in 9-1-1 Government Payments in Contra Costa County .............................. 13
Figure 2—Average County Patient Charge and Net Cash Received per Transport ..................... 14
Figure 3—Historical and Projected Annual Incident Volume ...................................................... 14
Figure 4—Historical and Projected Annual Transports................................................................ 15
Figure 5—Historical and Projected Monthly Incident Volume .................................................... 16
Figure 6—Historical and Projected Monthly Transports.............................................................. 16
Section 1—Executive Summary page 1
SECTION 1—EXECUTIVE SUMMARY
Citygate Associates, LLC was retained by Contra Costa County to independently review the
economics of the next generation ambulance proposals expected to be received in response to the
County’s February 27, 2015 Emergency Ambulance Service Request for Proposals (RFP). While
this fiscal review was designed to analyze competing proposals, only one proposal was received
from the Contra Costa County Fire Protection District (CCCFPD) and American Medical
Response, West (AMR), which they labeled the “Alliance.”
1.1 WHAT THIS REVIEW IS
This fiscal review therefore was directed at evaluating the Alliance proposal economics and the
key drivers of those economics for reasonableness of methods and results. Additionally, the
fiscal health of each provider was analyzed to understand the capacity of the Alliance to not just
provide the promised service, but to reasonably weather economic downturns. The key areas
covered by Citygate’s review are:
The background of ambulance economics
The structure of the Alliance business partnership
Operational measures, since they drive costs (ambulance staffing)
The reasonableness of the Alliance revenue estimations
Citygate’s Opinions, Fiscal Risk Control Strategies, and Implementation
Recommendations should the Alliance approach be approved by the Board of
Supervisors.
1.2 WHAT THIS REVIEW IS NOT
This review is not a complete review of all aspects of the Alliance proposal, which is the purview
of the County’s separate proposal review committee and process. This fiscal analysis also does
not examine the fiscal health and needs of the County EMS Agency and other EMS care needs in
the County. This review provides enough background to compare the two service-to-cost plans
(Plan A and B) proposed by the Alliance against reasonably expected revenues. The overall
policy choice of whether to proceed with either plan proposed by the Alliance and make other
decisions as to the services provided by the County EMS Agency and CCCFPD is up to the
Board of Supervisors.
Section 1—Executive Summary page 2
1.3 CITYGATE’S CAPSTONE OPINIONS
In the technical sections of this report (Sections 4 through 6), Citygate offers a total of 15
opinion statements. These statements are also found in list form for ease of reading in Section 8
on page 56. These discrete opinions are collectively summarized in this Executive Summary.
It is undisputed that 9-1-1 ambulance system revenues are falling nationally to the point where
some systems will no longer be able to operate without a public subsidy, as many have for over
30 years. Selecting the best alternative pathway and approach to managing the EMS fiscal risk
will be a critical policy decision. The optimal path should contain fiscal and performance triggers
as well as decision points to assist the Board in making the course corrections necessary to avoid
long-term fiscal issues and hasty short-term operational changes. Identifying early warning flags
that will provide the needed lead-time to make responsible and prudent decisions is a vital policy
objective.
The approach to managing the ambulance system fiscal risk can take alternative forms. The
Board may choose to become more fully involved by managing the ambulance service contract
via its EMS Agency and the CCCFPD leadership for dispatch and field services coordination.
This arrangement may contain certain operational and logistical advantages. Revenue collection
and monitoring will be a key indicator of success. If a further decline of rev enue collection is
inevitable, early identification is critical. Timely development and implementation of mitigation
alternatives is vital to long-term program sustainability. Alternatively, the Board can choose to
operate under the old model of ambulance provider direct contracts and hope that the private
provider would give sufficient notice if default becomes evident.
Generally speaking, as this report will describe, if there are not enough health care system
payments to cover the costs of ambulance care, the taxpayers in every community are the
fallback resource to fund 9-1-1 ambulance services. The current Alliance proposal shifts the
ultimate economic responsibility from the ambulance contractor (which is guaranteed a fixed
payment), to the taxpayers of the CCCFPD. Even if this is an acceptable policy alternative, the
CCCFPD is smaller in service area than the area covered by the ambulance contract.
Consequently, the taxpayers in some non-CCCFPD service areas would have less exposure to
ambulance fiscal risk in the case of system default (for example, the taxpayers in the City of
Richmond). This creates a greater burden on the CCCFPD taxpayer base from a risk perspective.
As for the overall economics of the Alliance proposal, they are conservative and consistent with
the system demand for ambulances and the available revenues in the current and near-term
system. As such, the Alliance Plan A offers similar services to the current system in a positively
balanced economic model.
To the Alliance’s credit, its proposed Plans A and B are not reliant on using new revenue
sources, such as Ground Emergency Medical Transport (GEMT) revenues on some types of
Section 1—Executive Summary page 3
Medi-Cal transports. As this study will describe, it is problematic that these revenues can not be
realized quickly, or at high volumes, so the Alliance was again conservative in its approach.
The Alliance’s approach in projecting Average Patient Charges (APC) and expected net
collections by payer type is both conservative and prudent. The question of payer mix is one of
the most difficult and problematical aspects of this projection, given the uncertainties
surrounding health care reform. AMR believes that much of the change resulting from the
Affordable Care Act (ACA) has already been reflected in the 2014 paye r mix data, that those
shifts are stabilizing in 2015, and therefore projecting the status quo is the most prudent course
of action at this time.
While this approach is reasonable, we believe that continued deterioration of net collections due
to changes in payer mix remains one of the largest risks going forward, and one that will need to
be evaluated in light of other risks and opportunities in the Alliance projections. To shield
against this issue, Citygate has made several contractual implementation re commendations to
separate and ensure, to the degree possible, the economic solvency and sustainability of the
system.
1.3.1 Total Expense to Revenue Comparison for Plan A and B
Before reviewing total revenue to expenses, it must be understood that the Alliance projected
declines in net collections from the recent past of 27.1% to 24.6%. Such declines could actually
exceed that forecast if recent trends of rising deductibles and rejected payment claims above the
Medicare or regional averages continue. What makes the 24.6% net revenue also disturbing is
that, before the last recession and federal health care reform pressures, for decades a “low” net
ambulance collection rate was 66%. Some communities collected more than that, although no
community collected more than 90%. The Emergency Medical Services (EMS) industry is
openly discussing the net collection percentage at which a public subsidy would need to occur
since a private provider cannot be expected to run the system, incur all the risk, and make only a
profit of 3-5%.
In summary, the total revenue to expense projection of the Alliance’s Plan A and B are shown
below:
Table 1—Alliance Plan A and B Economics
PLAN A PLAN B
Description Year 1 (2016) Year 2 (2017) Year 3 (2018) Year 1 (2016) Year 2 (2017) Year 3 (2018)
Revenue $39,184,619 $40,707,971 $42,293,630 $39,184,619 $40,707,971 $42,293,630
Expenses $37,211,143 $38,327,477 $39,477,301 $36,741,220 $37,843,457 $38,978,760
Gain $1,973,476 $2,380,494 $2,816,329 $2,443,399 $2,864,514 $3,314,870
Section 1—Executive Summary page 4
1.4 THE FISCAL DIFFERENCES OF PLAN A AND PLAN B
The only major cost difference between the two plans is eight field employees and a small
reduction in operating costs. There are no overhead personnel expense reductions. The Alliance
made a public education commitment of $300,000 per plan, exceeding the Plan A requirement of
$100,000 and meeting the Plan B requirement of $300,000. The Alliance also met the
requirement that it price and provide paramedic-level inter-facility transports (IFT) between
health care facilities upon request. The Alliance’s proposed pricing is in the middle of what
could be expected, and the IFT billing will be completed by the CCCFPD and any resultant
revenues remain with the Alliance.
There is an addition in Plan B for a required annual payment of $750,000 to the County EMS
Agency for system patient care enhancement uses and emerging issue pilot projects. This charge
is theoretically funded from operational savings due to longer response times and shifted
response time measurement zones in Plan B. The cost differences between the plans can be
summarized as:
Table 2—Cost Differences for Plan B
Plan B Difference Amount
Plan B Cost Reductions ~ ($1,220,000)
Plan B EMS Agency Fee ~ $750,000
Plan B Net Reductions ~ ($470,000)
Given these statements by the Alliance on Plan A versus Plan B, the fact that the cost savings for
Plan B are only $470,000 net due to the charge for County EMS Agency program enhancement
uses, and the better response times and system compliance provided by Plan A (to be explained
in our report), it is obvious that Plan A provides shorter response times at a lower Unit Hour cost.
In both Alliance Plan A and Plan B proposals, the total system costs per Unit Hour are:
Table 3—Total System Costs per Unit Hour for Plans A and B
Plan Unit Hour Cost
Plan A $148.89
Plan B $152.52
Thus, the reduced coverage in Plan B actually costs more per Unit Hour than Plan A due to the
EMS Agency programs enhancement fee mandated in Plan B.
Citygate observes that the deployment hours for Plan B are estimated from a software model
used by AMR and, due to the changes in response zones, new estimations are involved. No
Section 1—Executive Summary page 5
software model estimates are perfect. In deployment planning, different mathematical
approaches yield different results.
Citygate would strongly encourage the County not to implement Plan B all at once, if at all. If
chosen for implementation, the Alliance should be allowed to test some reductions in some areas
and then, based on closely-observed metrics, make adjustments. This measured, incremental
approach is consistent with the values of Continuous Quality Improvement (CQI).
1.5 THE FISCAL HEALTH OF AMR AND THE CCCFPD
The AMR profit component is segregated as a separate line item in the Alliance Expense Budget,
providing a level of transparency. Also, AMR allocated a reasonable 10% of total expenses to
cover non-field Depreciation and Amortization, Interest, Taxes, thus leaving a reasonable level
of Net Profit for AMR in the range of 3 to 6%.
We note that AMR national liquidity ratios stayed very consistent between 2013 and 2014, and
the profitability ratios improved from 2013 to 2014. Given the diversity of ambulance costs and
declining payer type payments across the country, for AMR to have stable liquidity and profit
ratios showing slight improvement, it suggests AMR is weathering the ambulance industry
revenue decline as well as, if not better than, the other large national providers.
Given CCCFPD’s current reserves and inclusion in the overall County tax collection and
distribution system, the CCCFPD has the funds to begin monthly payments to AMR for several
months and fund other start-up costs, until new ambulance billing revenue catches up to
expenditures. At that point, the CCCFPD must first repay its cash advances and then build the
recommended ambulance enterprise reserves before it can true up revenue to ambulance rates.
1.6 RISK CONTROL STRATEGIES AND IMPLEMENTATION RECOMMENDATIONS
In Section 7 of this report Citygate offers several Fiscal Risk Control Strategies. They are
summarized here:
Risk Control Strategy #1: Establish Alliance contracts as an Enterprise Operation,
similar to other local governmental fee-for-service programs, such as water and
sewer operations.
Risk Control Strategy #2: Establish a significant reserve fund of 6 months of
revenues plus a capital equipment replacement reserve; also establish best practice
financial policies as part of the business plan.
Risk Control Strategy #3: Eventually calibrate transport fees to true costs through
audits of expenses and adherence to stipulated contract provisions.
Section 1—Executive Summary page 6
Risk Control Strategy #4: When revenues exceed needed reserves, consider
lowering transport fees, not cross-subsidizing non-Alliance CCCFPD or County
EMS Agency operations.
Risk Control Strategy #5: Establish a County Board of Supervisors and CCCFPD
“Compassionate” set of billing policies for CCCFPD-managed first responder and
ambulance revenue collection to include a write-down and write-off policy.
Based on our Opinions and Fiscal Risk Control Strategies, Citygate recommends the CCCFPD,
AMR, and the County EMS Agency pursue final implementation contracts, and offers the
following best practice-based recommendations to guide this process:
1. Fully identify the fiscal relationship between the parties, their separate fiscal
exposure for each other’s decisions (such as staffing levels), and start-up capital
costs.
2. Board policy should require that ambulance loss risk only be transferred to the
taxpayer for unforeseen, catastrophic losses, as would be the case in the current
system if the ambulance contractor were to fail.
3. Fine the contractor only for material breach, not small, per-minute fines.
4. Rather than fine for small response time misses, require that the deployment plan
account for equitable response time coverage for similar land use and population
densities. Then if the Alliance delivers the required response time performance,
only gross neglect to deploy or respond should trigger a fine and/or lead to
default.
5. Define in the contract between the County EMS Agency and the CCCFPD a clear
delineation of roles, responsibilities, and authorities as it pertains to operational
authority and regulatory oversight.
6. Require the CCCFPD to report to the Board of Supervisors quarterly on response
times, payer mix, and a rolling revenue-to-date report and near-term revenue-to-
expense forecast.
7. Annually require an independent audit of the revenues to expenses and the
viability going forward of the contract terms. Once ambulance reimbursements
settle under health care reform, the formal audits could perhaps move to two-year
cycles.
Section 2—Background page 7
SECTION 2—BACKGROUND
2.1 CITYGATE’S DOCUMENT REVIEW
To conduct our fiscal adequacy review we collected multiple documents from the County
Emergency Medical Services (EMS) Agency, including the 2014 EMS System Modernization
report, the ambulance contract Request for Proposal (RFP), and current system performance data
the EMS Agency receives from the existing contractor, American Medical Response, West
(AMR).
Once the Alliance (comprised of the Contra Costa County Fire Protection District and AMR)
proposal was received, we examined it along with the cost of services detailed fiscal information
received. We then issued a substantial list of follow-up questions to the Alliance and met with its
representatives to reach final understanding on the fiscal components of its proposal.
2.2 CITYGATE’S PROJECT METHODOLOGY
Citygate’s review process consisted of the three critical steps described below.
First, before the proposal was received we independently built a deployment model to evaluate
the response time and geographic coverage needed. This served as a baseline from which to
compare the current system as understood by County staff with the single proposal received.
Using this method, we endeavored to understand an appropriate level of ambulance staffing and
spacing across the geography for the near term. Appropriate staffing is critical to an
economically viable system since personnel costs drive the majority of system costs. We had to
ensure that a proposal to provide fewer EMS field personnel than the number presently
contracted would not be considered only because it could appear less expensive.
Second, once the deployment model was refined, the numbers of field personnel drove our
expectations for the logistical support personnel needed, including the positions for training and
Quality Assurance (QA). We also had to understand facility, supplies, equipment, and ap paratus
costs. The RFP requested that respondents deliver a detailed logistical staffing plan and line item
budget. We compared the logistical staffing plan proposed to the estimates we independently
formed and used our own EMS Agency operating experience to make the best evaluation. Again,
the goal was to ensure that a proposal that provided fewer personnel than currently, or was
insufficiently budgeted, would not receive a passing grade.
Third, we had to understand current ambulance revenues from all sources and prepare a revenue
forecast based on the historical incident demand data for the last four years. We obtained not
only the three years of County EMS data (2011-2013) supplied by the RFP, but we also obtained
County EMS incident data from calendar year 2014 so we could use the most recent data
available to the EMS Agency. We used both a historical and a Citygate data forecast to prepare a
Section 2—Background page 8
revenue projection and assumptions that would be compared to the existing AMR system data
and to proposals received.
Thus, three views exist for evaluating data and determining staffing: the system currently
provided by AMR, the system “check model” as envisioned by Citygate, and the system
envisioned by the respondent (Alliance). As a validation test, at least two of the three views
should have reasonable agreement. If not, an explanation is necessary for the Board of
Supervisors of why the operating and economic assumptions cannot be tightly relied upon.
Section 3—Current State of Ambulance Economics page 9
SECTION 3—CURRENT STATE OF AMBULANCE ECONOMICS
3.1 THE STATE AND REGIONAL EMS PICTURE
Throughout California, Emergency Medical Services (EMS) systems, and especially ambulance
providers, are facing unprecedented economic pressures. During the past ten years, large
populations have shifted from higher-paying commercial insurance plans to lower-paying
government plans. Many commercial insurance plans are also decreasing payment rates for
ambulance transport. In total, more people are insured due to federal health care reform, but the
average insurance payment rate has significantly decreased for ambulance care, causing some of
Northern California’s largest EMS systems and ambulance providers to lose millions of dollars
annually, threatening their short- and long-term financial solvency. Three of the most significant
factors influencing aggregate ambulance reimbursement are: (1) the increase in number of Medi -
Cal insured; (2) the decreased reimbursement rates by commercial insurance companies; and (3)
the increased number of high deductible health insurance plans.
3.1.1 Medi-Cal, Medicare, Covered California, and Commercial Insurance
Medi-Cal
Medi-Cal (California’s version of Medicaid) reimburses ambulance providers at rates
significantly less than the cost of providing ambulance services. Medi-Cal’s average payment is
approximately $130 to $150, which is approximately 15% to 25% of the cost of an ambulance
transport.1, 2 California law prohibits ambulance companies from billing the patient for the
difference between the ambulance cost and Medi-Cal reimbursement, causing ambulance
companies to write off this difference as a contractual allowance to accept Medi-Cal payments.3
Throughout California, most of the newly-covered patients who received insurance through the
provisions of the Patient Protection and Affordable Care Act (PPACA or abbreviated as ACA)
are new, previously undiscovered eligible enrollees to Medi-Cal, and estimates are that now a
full 30% of Californians are covered by Medi-Cal. Across California as high as 80% of those in
Medi-Cal are enrolled in Medi-Cal Managed Care, while 20% are enrolled in Medi-Cal Fee for
Service.4 While both programs pay standard Medi-Cal rates and prohibit billing for the
difference between the billed and reimbursed amounts, ambulance services owned or operated by
public agencies who meet certain requirements can seek cost-based reimbursement for those
1 “Medi-Cal Rates as of June 15, 2015.” California Department of Health Care Services, Medi-Cal. 15 June 2015.
Web. Accessed 18 June 2015. <https://files.medi-cal.ca.gov/pubsdoco/rates/rateshome.asp>
2 “California’s Ground Emergency Ambulance Transportation (GEMT) Certfiied Public Expenditure.” California
Ambulance Assocation. 17 July 2013. Web. Accessed 7 June 2015. <www.the-caa.org>
3 Citygate interviews with numerous ambulance industry representatives.
4 “Total Monthly Medicaid and CHIP Enrollment.” Henry J. Kaiser Family Foundation. April 2015. Web. Accessed
16 June 2015. <http://kff.org/health-reform/state-indicator/total-monthly-medicaid-and-chip-enrollment/>
Section 3—Current State of Ambulance Economics page 10
patients who are covered by Medi-Cal Fee for Service through the Ground Emergency Medical
Transport (GEMT) Program. The GEMT program will be explained in Section 6.4.
Medicare
Medicare sets its allowable ambulance payment rate through the Medicare Ambulance Fee
Schedule, allowing charges only for an ambulance transport base rate and mileage charges to a
hospital. Medicare will pay 80% of its allowable rate, regardless of the charges by the ambulance
company, causing the ambulance company to write off the difference between its billed rate and
Medicare’s allowable rate. The patient or the patient’s supplemental insurance must pay the
remaining 20% balance between Medicare’s allowable rate and the Medicare payment.
Medicare’s average transport payment is approximately $540 to $600 and thus is also below the
full cost of a transport at both the Basic or Advanced Life Support (BLS or ALS) level of care.5
Commercial Insurance Plans
Historically, commercial (private) insurance companies paid 80% or greater of an ambulance
company’s billed charges, and the population covered by commercial insurance was much larger.
Thus, commercial insurance helped transport providers cover losses generated by the lower-
paying government insurance providers, such as Medi-Cal and Medicare.6
Commercial insurance rates of reimbursement are now also decreasing. Rather than paying the
traditional 80% of the rate charged by ambulance companies, many commercial insurance
companies now pay either Medicare rates, rates they unilaterally determine as “reasonable and
customary,” or charges based on a region’s average rate structure. Many insurance compan ies
also review ambulance records, routinely determine that a patient’s condition did not warrant an
ambulance, and disallow the entire charge.7
High Deductible Health Plans
Covered California, the state’s health care exchange, provides five insurance plan levels,
commonly called the “metal plans or metals” using labels such a gold, silver, and bronze. Two of
the five, along with many commercial plans, are High Deductible Health Plans (HDHP). Such
HDHP plans have a minimum individual deductible of $1,300, but the average deductible for an
individual HDHP is $2,098, and 18% of workers have a deductible of at least $3,000. Other
plans are offered with $4,000-$5,000 deductibles. Enrollment in employer-sponsored HDHP
plans has rapidly and significantly increased from 4% in 2006 to 20% of covered workers in
5 “Ambulance Fee Schedule Public Use Files.” Centers for Medicare and Medicaid Studies. April 2015. Web.
Accessed 17 June 2015. <http://kff.org/health-reform/state-indicator/total-monthly-medicaid-and-chip-enrollment/>
6 Citygate interviews with numerous ambulance industry representatives.
7 Citygate interviews with numerous ambulance industry representatives and EMS Agency Administrators.
Section 3—Current State of Ambulance Economics page 11
2014.8 The rate of growth of HDHP plans will continue to dramatically rise. Many people
purchase HDHP plans because of their less expensive premiums, but cannot pay the prohibitively
high deductible following a medical emergency.9, 10
3.2 COVERED CONTRA COSTA
3.2.1 Health Insurance Coverage in Contra Costa County
Since 2005, Contra Costa County has seen an increase in patients covered by Medi-Cal (due to
Covered California) and Medicare, and fewer patients covered by commercial insurance, private
pay, and other contract pay sources. In 2005, 41.7% of patients receiving ambulance services had
Medicare and Medi-Cal, which increased to 59.6% by 2011, and is now 69.2%. Conversely, in
2005, 36.5% of ambulance patients had commercial insurance, which decreased to 18.2% in
2011, and is now 14.4%. The percentage of ambulance patients without insurance or who have
other pay sources was 21.0% in 2005, 22.2% in 2011, and now is 16.4%.11
Through the ACA (Covered California), more people in Contra Costa County become insured
every year. However, most people’s status has changed from uninsured to underinsured, because
they now are covered through Medi-Cal Expansion rather than a Covered California exchange-
based plan. Since January 1, 2014, more than 80,000 persons in Contra Costa County received
health insurance coverage through provisions of the ACA. Of these, approximately 65,000
persons (or 81%) have Medi-Cal. As mentioned above, Medi-Cal now insures approximately
30% of all persons in Contra Costa County. In Contra Costa County, 80% of those in Medi-Cal
are enrolled in Medi-Cal Managed Care, while the remaining 20% are enrolled in Medi-Cal Fee
for Service.12
Approximately 15,500 persons in Contra Costa County have an exchange-based health insurance
plan provided through Covered California. Of those in Covered California, approximately 88%
receive subsidies to reduce the cost.13 Subsidy levels are an important proxy to predict a person’s
8 Renter, Elisabeth. “Should You Roll the Dice on a High Deductible Health Plan?” US News and World Reports. 10
November 2014. Web. Accessed 7 June 2015. <http://health.usnews.com/health-news/health-
insurance/articles/2014/11/10/should-you-roll-the-dice-on-a-high-deductible-health-plan>
9 “Understanding High Deductible Health Plans.” Fair Health Consumer. n.d. Web. Accessed 7 June 2015.
<http://fairhealthconsumer.org/reimbursementseries.php?id=48&terms=understanding-high-deductible-health-
plans>
10 “2014 Employer Health Benefits Survey.” Henry J. Kaiser Family Foundation (NORC at the University of
Chicago, and Health Research & Educational Trust). 10 September 2014. Web. Accessed 8 June 2015.
<http://kff.org/health-costs/report/2014-employer-health-benefits-survey/>
11 Citygate analysis of data and documents submitted by Contra Costa County EMS Agency and AMR.
12 Contra Costa Health Plan Chief Executive Officer Patricia Tanquary, interview by Citygate, 21 April 2015,
Martinez.
13 Contra Costa Health Plan Chief Executive Officer Patricia Tanquary, interview by Citygate, 21 April 2015,
Martinez.
Section 3—Current State of Ambulance Economics page 12
ability to pay his or her insurance deductible, and in two of the five Covered California plans
deductibles exceed $1,300 annually.14
Approximately 15% of persons in Contra Costa County remain uninsured. Uninsured persons
constitute a large, disproportionately share of high and repeat users of medical services (not just
9-1-1 ambulance service) within Contra Costa County.15
To place Medi-Cal’s average payment of approximately $130 to $150 per transport into
perspective, the Contra Costa County rates per the 2015 County Ambulance RFP for Contract
Year 1 for the base rate, plus the cost to drive 10 miles to the hospital and cost to provide oxygen
to the patient, would total $2,775. This Year 1 rate is higher than the current County equivalent
rate that would yield a charge of $2,582.
This amount does not include advanced paramedic treatment and drug rates, which are allowed
separately by many insurance companies. It is therefore not at all unreasonable that a $3,000-plus
ambulance bill can be incurred and still not reach an individual’s deductible amount in his or her
insurance coverage.
Ambulance companies have known for years that raising billed rates cannot cover the difference
between the ambulance cost billed and the reimbursement provided. The marginal return on
higher rates continually diminishes as insurance providers refuse to fully pay them. Stated this
way, the County cannot simply increase rates to resolve the problem between the amounts billed
and received.
3.3 AMR REVENUE HISTORY IN CONTRA COSTA COUNTY
To place the above observations into macro perspective for this RFP proposal analysis, Citygate
asked AMR for historical revenue projections for its existing Contra Costa County Exclusive
Operating Area (EOA) contract. We received data for all payer types, volumes, and receiv ables
for the years 2005 through 2014. The 2013 and 2014 data is not complete yet as some
receivables are aged and the books cannot be closed yet for those years. The mathematical trends
are complicated as there are multiple moving parts (e.g., payer mix changes, ambulance rate
changes, decline in receivables, and growth in incident volume). Generally, though, as
receivables declined and operating costs increased, the average patient charge increased even as
total revenues also increased due to volume growth.
To place these movements into perspective, the ambulance industry uses a measure called “Net
Revenue per Transport” or NRT. For this measure from 2005 to 2014, the NRT has fallen from
$613 to $583.
14 Covered Contra Costa Plans. Citygate analysis.
15 Contra Costa Health Plan Chief Executive Officer Patricia Tanquary, interview by Citygate, 21 April 2015,
Martinez.
Section 3—Current State of Ambulance Economics page 13
The following charts show the change over time for how payments shifted from the private pay
and private insurance to public insurance—Medicare and Medi-Cal. These six charts contain
Contra Costa County data, as provided by AMR at the request of Citygate. We received and
verified the source data and methods with AMR’s Regional Finance Officer.
Figure 1—Increase in 9-1-1 Government Payments in Contra Costa County
To place this shift into an ambulance rates perspective, as total ambulance rates have risen just
over double since 2005, the net revenue per trip has stayed relatively flat. This is why the
ambulance industry tells clients that as payer mix has changed and reimbursements have been
aggressively lowered by private pay sources, an ambulance system “can’t raise rates enough” to
fix the revenue problem:
-
5,000
10,000
15,000
20,000
25,000
30,000
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014Transports Increase in 9-1-1 Government Payments in Contra
Costa County
Medi-Caid Medicare Private Insurance Self Pay
Section 3—Current State of Ambulance Economics page 14
Figure 2—Average County Patient Charge and Net Cash Received per Transport
The next two charts show the volume trends ahead based on the last four years of system data:
Figure 3—Historical and Projected Annual Incident Volume
$-
$500
$1,000
$1,500
$2,000
$2,500
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Average County Patient Charge and Net Cash Received
per Transport
Average patient charge Net cash per trip
-
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
100,000
2011 2012 2013 2014 2015 2016 2017 2018
Historical and Projected Annual Incident Volume
Total Calls - Actual Total Transport - Actual Total Cancelled - Actual
Total Calls - Trend Line Total Transport - Trend Line Total Cancelled - Trend Line
Total Calls - RFP Forecast Total Transport - RFP Forecast Total Cancelled - RFP Forecast
Section 3—Current State of Ambulance Economics page 15
Figure 4—Historical and Projected Annual Transports
As will be discussed in the economics sections of this report (Sections 4 through 6), the Alliance
proposal took a conservative revenue approach and used flat volume growth even though the
above projection shows continuing volume increases.
The last two charts show the more variable movement month to month for incident demand and
total transports:
-
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
2011 2012 2013 2014 2015 2016 2017 2018
Historical and Projected Annual Transports
Priority 1 Transport - Actual Priority 3 Transport - Actual Priority 1 Transport - Trend Line Priority 3 Transport - Trend Line
Section 3—Current State of Ambulance Economics page 16
Figure 5—Historical and Projected Monthly Incident Volume
Figure 6—Historical and Projected Monthly Transports
-
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
Jan-11Mar-11May-11Jul-11Sep-11Nov-11Jan-12Mar-12May-12Jul-12Sep-12Nov-12Jan-13Mar-13May-13Jul-13Sep-13Nov-13Jan-14Mar-14May-14Jul-14Sep-14Nov-14Jan-15Mar-15May-15Jul-15Sep-15Nov-15Jan-16Mar-16May-16Jul-16Sep-16Nov-16Jan-17Mar-17May-17Jul-17Sep-17Nov-17Jan-18Mar-18May-18Jul-18Sep-18Nov-18Historical and Projected Monthly Incident Volume
Total Calls - Actual Total Transport - Actual Total Cancelled - Actual
Total Calls - Trend Line Total Transport - Trend Line Total Cancelled - Trend Line
-
1,000
2,000
3,000
4,000
5,000
6,000
7,000
Jan-11Mar-11May-11Jul-11Sep-11Nov-11Jan-12Mar-12May-12Jul-12Sep-12Nov-12Jan-13Mar-13May-13Jul-13Sep-13Nov-13Jan-14Mar-14May-14Jul-14Sep-14Nov-14Jan-15Mar-15May-15Jul-15Sep-15Nov-15Jan-16Mar-16May-16Jul-16Sep-16Nov-16Jan-17Mar-17May-17Jul-17Sep-17Nov-17Jan-18Mar-18May-18Jul-18Sep-18Nov-18Historical and Projected Monthly Transports
Priority 1 Transport - Actual Priority 3 Transport - Actual Priority 1 Transport - Trend Line Priority 3 Transport - Trend Line
Section 3—Current State of Ambulance Economics page 17
While monthly demand is more fluid, these monthly projections show slightly less increased
demand when compared to the annual demand trend lines. The Alliance revenue proposal is
based on 63,500 transports in Contract Year 1 (2016), which, if the monthly trend line ends up
more accurate that the annual projection, that volume may not be reached until late 2016. So
again, the Alliance took a balanced, conservative position on its transport demand numbers as
will be explained more fully in the sections to follow.
Section 4—The Business Structure of the Alliance Proposal page 18
SECTION 4—THE BUSINESS STRUCTURE OF THE ALLIANCE
PROPOSAL
4.1 AMR’S SUBCONTRACT WITH CCCFPD
In response to the Contra Costa County Local Emergency Medical Services Agency’s (LEMSA)
February 27, 2015 Request for Proposal (RFP) for Exclusive Operator for Emergency
Ambulance Service, Contra Costa County Fire Protection District (CCCFPD) and American
Medical Response, West (AMR), formed an alliance (referred to as the “Alliance”) and
submitted a single unified proposal to provide emergency ground ambulance services. No other
proposal was received. The business structure of the Alliance between the CCCFPD and AMR is
a subcontract relationship, in which the CCCFPD subcontracts with AMR to provide emergency
ground ambulance services, at CCCFPD’s direction, in the RFP’s requested Response Areas,
except for those portions that are in the jurisdiction of the Moraga-Orinda and San Ramon Valley
Fire Protection Districts.
The CCCFPD will be the billing agent of record. It has secured its own National Provider
Identification (NPI) number from the Center for Medicare and Medicaid Services and intend to
bill for the ambulance services provided by AMR. The revenue received by CCCFPD, through
patient billing and reimbursements from health insurers and other emergency ambulance
transport revenue sources, would be used to offset the cost of its contract with AMR to provide
the transport ambulance system as a complete, “turn key” operation. This billing arrangement
might also allow CCCFPD to seek Ground Emergency Medical Transport (GEMT) cost -based
reimbursement for emergency medical services provided by the CCCFPD (but this allowance is
not an absolute guarantee as will be explained in Section 6.4).
4.1.1 Deployment Plan A and B Costs to be Paid to AMR by CCCFPD
Separate from the Alliance proposal to the County, is a contract between CCCFPD and AMR
that stipulates that the CCCFPD will pay AMR for each ambulance unit/hour of emergency
ground ambulance service that AMR provides, as full compensation for all services and costs
provided or incurred by AMR in performing its obligations pursuant to the contract. According
to the Alliance response to the RFP, for Plan A, during the first year of service (January 1, 2016
through December 31, 2016), CCCFPD will compensate AMR at a rate of $135.19 per deployed
Unit Hour. During the second year of service (January 1, 2017 through December 31, 2017),
CCCFPD will compensate AMR at a rate of $139.25 per hour. During the third year of service
(January 1, 2018 through December 31, 2018), CCCFPD will compensate AMR at a rate of
$143.43 per hour. Compensation rates for year 4 and 5 were not identified; however, the
CCCFPD/AMR contract contains an escalator clause which increases unit/hour payments
beginning April 1, 2017. The amount of the escalator has not been quantified. Unless modified,
Section 4—The Business Structure of the Alliance Proposal page 19
the payment limit of the subcontract will be approximately $188,000,000 over the five years of
the subcontract.
Note: The costs in the two tables below are the contractual obligations that CCCFPD must pay
AMR, its subcontractor, regardless of the actual revenues received. Including costs in addition to
those of AMR, the total Alliance costs per year and the resultant Unit Hour costs are higher. A
comparison of total Alliance costs to total estimated revenues will be provided in a later section
of this report.
Table 4—Plan A Staffing Hours and Costs1
Plan A Year 1 Year 2 Year 3
Average Weekly Staffed Unit Hours 4,788 4,788 4,788
Average Annual Staffed Unit Hours 249,660 249,660 249,660
AMR Burdened Unit Hour Cost $135.19 $139.25 $143.43
Estimated CCFPD Payment to AMR $33,752,634 $34,765,213 $35,808,170
1 All Unit Hours and costs from AMR only Plan A costs dated July 6, 2015.
The Alliance also submitted, as required, a second deployment plan called Plan B. The summary
of that plan’s AMR staffing and costs is:
Table 5—Plan B Staffing Hours and Costs
Plan B Year 1 Year 2 Year 3
Average Weekly Staffed Unit Hours 4,6201 4,620 4,620
Average Annual Staffed Unit Hours 240,900 240,900 240,900
AMR Burdened Unit Hour Cost 135.302 $139.35 $143.54
Estimated CCFPD Payment to AMR $32,592,803 $33,570,588 $34,577,705
1 Unit Hours from Alliance updated Plan B proposal received on July 3, 2015.
2 Unit Hour Cost per AMR Plan B fiscal spreadsheet for AMR only Plan B costs dated July 6, 2015.
4.1.2 Terms of the CCCFPD and AMR Contract
The Emergency Ambulance Services subcontract between the CCCFPD and AMR begins on
January 1, 2016 and ends December 31, 2020. Through this contract AMR is responsible to
provide 24-hour/day, 365-day/year paramedic-staffed emergency ambulance service within
Contra Costa County in a manner that meets the standards articulated in the Contra Costa County
EMS Agency’s RFP and the CCCFPD’s proposed contract with AMR. This includes owning and
maintaining the ambulance fleet; employing paramedics and EMTs to staff the ambulances;
providing quality improvement, training, and community outreach programs; providing field
Section 4—The Business Structure of the Alliance Proposal page 20
supervision; and maintaining an electronic clinical care and billing records system. These
services are normally expected of an ambulance provider servicing a 9-1-1 Exclusive Operating
Area (911EOA) Emergency Ambulance contract in a metropolitan area, such as Contra Costa
County. These roles are further detailed in Section 4.3—AMR’s Role and Responsibilities in the
Alliance Proposal.
The contract also includes default provisions, providing CCCFPD the ability to take over AMR’s
stations, ambulances, and equipment if AMR cannot correct certain material deficiencies within
7 days following notice of default by CCCFPD. AMR is not prohibited from conducting non -
emergency work that does not interfere with the contract.
The contract also obligates AMR to provide equipment, programs, and services normally
expected of an ambulance provider servicing a 911EOA Emergency Ambulance contract.
4.1.3 Alliance Proposal Risk Impact to the Taxpayer
In the Alliance proposal, the CCCFPD pays AMR, its subcontractor, a predetermined unit/hour
fee to provide emergency ground ambulance services. CCCFPD will serve as the billing agent of
record, and through a subcontractor separate from AMR, will bill Medicare, Medi-Cal, insurance
companies, patients, and other potential revenue sources. In this arrangement, the financial risks
associated with operation of the ambulance service, including decreasing reimbursement rates,
accounts receivables management, and increased cost of staffing, materials, and supplies, is
transferred from AMR to the CCCFPD, putting the CCCFPD and the taxpayers of the CCCFPD,
not the balance of the taxpayers of Contra Costa County, at risk of financial loss. This risk, if
realized as a liability, becomes a general liability of the CCCFPD and its taxpayers. Citygate
believe that this financial risk is small, because the deployment plan and the revenue and expense
budgets are realistic. Nonetheless, it is important to make note of this risk, because this
subcontracting model is new and untested within California. Understanding, monitoring, and
evaluating the implications associated with ongoing taxpayer risk for ambulance systems should
be of the utmost importance to the CCCFPD management. This is especially important
considering the changing health care payment environment in America.
Citygate believes that all governmental entities that directly provide ambulance service or
subcontract for ambulance service are potentially at financial and operational risk. These risks
include decreasing rates of reimbursement, unexpected changes in volume, and increasing costs
of service, including labor, capital asset acquisition, and costs caused by regulatory changes.
Similarly, government jurisdictions that contract for ambulance services also retain some degree
(albeit probably less) of financial and operational risk, because if net revenue decreases to less
than the cost to provide the service, the jurisdiction is at risk to maintain the solvency of the
ambulance operator by raising rates, providing a subsidy, or selecting a new provider.
Further, should an ambulance provider in financial trouble discharge the contract through
bankruptcy, the governmental entity retains the responsibility of maintaining a stable ambulance
Section 4—The Business Structure of the Alliance Proposal page 21
transport system, which may entail the financial and operational risks of engaging a new
contractor or, directly at taxpayer expense, providing ambulance service, without time for a well-
planned transition.
Citygate Opinion #1 – Alliance Economic Risk: It is undisputed that 9-1-1
ambulance system revenues are falling to the point where some, if not all, systems
will no longer be able to operate without a public subsidy as many have for over
30 years. The choice before Contra Costa County is whether the Board wants to
more fully be involved in managing the contractor via the CCCFPD, and if a
revenue collapse is inevitable, be able to detect the problem with enough time to
develop and implement thoughtful mitigation measures.
The other option is to operate the existing type of contract model and hope the
private provider would provide enough notice before default. Ultimately,
taxpayers are the fallback resource to fund 9-1-1 ambulance services. If ultimately
the ambulance system needs an allocation of CCCFPD or County general
discretionary resources to stabilize ambulance services, that could force the
reduction of services in other areas. Monitoring and understanding how this issue
evolves is critical if the County is to minimize the impact of a potentially
damaging ambulance fiscal shock wave.
The CCCFPD and AMR “Alliance” is designed to provide full EMS system integration for the
communities serviced. The Alliance notes that this organizational structure will provide single-
source dispatch, integrated oversight for first response and transportation, consistent training for
all responders, common and shared language and response culture, and eliminate redundancies in
service.
4.2 CCCFPD ROLES AND RESPONSIBILITIES IN THE ALLIANCE PROPOSAL
The CCCFPD’s roles and responsibilities, as specified in the Alliance proposal, are coordinating
the overall AMR contract and ensuring close coordination with all of the first responders in the
ambulance service area. These actions do not replace, but enhance, the oversight functions
mandated by state regulations to the County EMS Agency.
The Alliance support for first responder functions is compliant with the terms of the County’s
RFP and includes costs for issues such as replacing first responder supplies and equipment, plus
group supply purchasing savings or discounts. These first responder support costs are in the
Alliance operating expense and revenue proposals.
For its coordination with AMR, CCCFPD is not adding significant personnel or costs in order to
supply both AMR contract coordination and first responder coordination functions.
Section 4—The Business Structure of the Alliance Proposal page 22
4.2.1 One Chief Officer Oversight Position
The Alliance proposal does not significantly change the number of personnel employed by the
CCCFPD or AMR. In fact, only one new position is created in the Alliance organization: an
EMS Chief, who will be employed by the CCCFPD. The EMS Chief will oversee first responder
training, the clinical manager, and clinical education services support. The EMS Chief will also
work closely with AMR’s Medical Director and the County’s EMS Medical Director and the
AMR General Manager. The fully-benefitted cost of this new fire department chief officer
position is budgeted at $400,000 annually.
4.2.2 Ambulance Billing
In the current Contra Costa County EMS System, AMR directly bills insurance providers and
patients for ambulance medical care and transport. In the Alliance proposal, the CCCFPD will
perform first responder and ambulance billing through a contract with an external billing agency.
AMR will continue to perform the “front end” billing process, which includes ensuring proper
documentation, reconciling trip information, and timely submitting billing information to the
external billing agency. CCCFPD expects to pay approximately about 5% of collections, if a
percentage collection agreement is negotiated to the external billing contractor.
Ambulance billing systems contain a hard cost. In the current contract with the County, AMR
performs the billing, the cost of which is included in its bills to patients under the County-
approved ambulance rate structure. Under the Alliance approach, its plan to try to acquire
supplemental Medi-Cal revenues known as GEMT (explained in Section 6.4 of this report)
possibly requires, under state regulations, that the billing to be performed by the CCCFPD, not
its ambulance subcontractor. Given this is not yet settled, the Alliance proposal calls for a
separate billing contractor under CCCFPD control. The cost of this is included in the Alliance
cost structure at an estimated amount of $2,078,548. Billing contracts can be priced at fixed rates
or a percent of the amount billed. Because the Alliance does not know if it will be required to
separate billing from AMR, at this time its proposal uses a cost that is closely estimated, but not
agreed to contractually.
If the Alliance proposal is approved by the Board of Supervisors and implementation begins,
Citygate hopes that the Alliance can make the case to the state that the more effective billing
approach would be to let the current and capable AMR billing process remain in one integrated
patient data system from point of dispatch to final patient destination.
In either case, the final Alliance costs cannot be determined until the billing question and costs
are firmly fixed.
Billing for Inter-Facility Transports (IFT)
Another part of the EMS system RFP for 9-1-1 ambulance services allows the 9-1-1 ambulance
operator to provide, at the request of hospitals, clinics, and others, a paramedic unit to transfer
Section 4—The Business Structure of the Alliance Proposal page 23
patients between sites. As required, the Alliance priced this option in Appendix 19 of its
response and identified a rate structure set at 50% of the Usual and Customary Rates (UCR)
charged for 9-1-1 calls. The Alliance expects that requests for these services will be extremely
low.
The billing for IFTs will be performed by the CCCFPD along with all other billing. Therefore,
the IFT revenues are part of the overall Alliance revenue submittal and any revenues in excess of
costs will remain with the CCCFPD for use within the Alliance structure.
4.2.3 Merged Dispatch
In the current Contra Costa County EMS System, the CCCFPD and AMR operate separate,
geographically-distinct dispatch centers. In the Alliance proposal, AMR will relocate its medical
dispatch personnel to the Contra Costa County Regional Fire Communications Center, allowing
CCCFPD and AMR to operate one consolidated dispatch center that will provide fire and
ambulance dispatching services. The Alliance’s communication center provides the
infrastructure, technologies, and redundancies normally associated with an emergency services
dispatch center serving an urban or suburban area. This communication center will process
medical requests for assistance using the Medical Priority Dispatch System including Medical
Dispatch Quality Assurance, both of which are considered the state-of-the-art in EMS dispatch.
Consolidated communication centers are associated with shorter call transfer and processing
times, improved inter-organizational situational awareness, and improved coordination of fire
and ambulance resources to complex incidents.
4.2.4 Separate Training/CQI for Fire Paramedics – “As Is”
The CCCFPD will not be merging or changing how it currently trains and conducts Continuous
Quality Improvement (CQI) for the paramedics on its fire engines, so there are no new costs for
these programs in the Alliance proposal.
4.3 AMR’S ROLES AND RESPONSIBILITIES IN THE ALLIANCE PROPOSAL
4.3.1 An Almost Identical AMR Effort to the Current Model
AMR’s roles and responsibilities, as specified in the Alliance proposal, are nearly identical to its
roles and responsibilities in the current Contra Costa County EMS System. AMR will have the
sole responsibility for owning, maintaining, and upgrading the ambulance fleet. AMR is
responsible to respond to all calls dispatched from the County-designated Public Safety
Answering Points (PSAPs) with Advanced Life Support (ALS (paramedic-staffed)) ambulances.
AMR is responsible to provide ALS service (paramedic-staffed ambulances), with the exception
that Basic Life Support (BLS (EMT-staffed)) ambulances may be used for response to multi-unit
responses and when BLS response is appropriate according to the Contra Costa County EMS
Agency’s policies and procedures. AMR must also provide equipment, programs, and services
Section 4—The Business Structure of the Alliance Proposal page 24
normally expected of an ambulance provider servicing a 911EOA Emergency Ambulance
contract.
The equipment, programs, and services that AMR must provide include:
Performing comprehensive data analysis and quality improvement activities,
using a dedicated quality improvement staff conducting practices according to the
County’s EMS Agency policies
Assuring all personnel are properly vetted, licensed or certified, credentialed, and
trained
Providing field supervision using trained supervisors
Providing continuing education for CCCFPD and AMR personnel
Operating a dispatch center within the CCCFPD dispatch center, maintaining
dispatch-related equipment, and dispatching ambulances to requests for
emergency ambulance services
Using and maintaining an electronic PCR system
Providing records to CCCFPD to verify clinical and operational performance
standards
Employing a full-time Community Outreach Coordinator to work towards
improving community health status and providing community education
Maintaining disaster and multi-casualty incident capability, including the ability
to recall personnel, staff a disaster response vehicle, and participate in disaster
training and exercises.
In addition to the change in ambulance billing service described above, another significant
change from the current Contra Costa County EMS System in the Alliance model is AMR’s
reporting structure to the County. In the current Contra Costa County ambulance contract, AMR
is an independent organization. The Contra Costa County EMS Agency has an EOA contract
directly with AMR, which is responsible to the EMS Agency for meeting the standards contained
in that contract.
In the Alliance model, the EMS Agency will not have a direct contractual relationship with
AMR. The EMS Agency will have a direct EOA contractual relationship with CCCFPD, which
in turn has a subcontract agreement with AMR.16
This reporting relationship is reflected in the Alliance’s organizational chart. In the Alliance, all
CCCFPD and AMR positions and functions report into CCCFPD’s command structure. The
16 The LEMSA and AMR must have a paramedic service provider agreement, pursuant to 22 CCR 100168 (b) (4).
Section 4—The Business Structure of the Alliance Proposal page 25
manager of the consolidated communications center reports to CCCFPD’s Assistant Support
Chief, the CCCFPD’s new billing contractor reports to CCCFPD’s Administrative Chief, and
AMR’s positions report through the supervisors and general managers to CCCFPD Emergency
Operations Assistant Chief. All Assistant Chief positions report to CCCFPD’s Fire Chief.
Additionally, in the field setting, AMR’s personnel are contractually placed under the authority
of the fire officer in charge.
Another significant change from the current Contra Costa County EMS System in the Alliance
model is the consolidation of AMR dispatching into the CCCFPD communication center. AMR
does experience cost savings from the dispatch merger, but these savings are already reflected in
its lowered cost per Unit Hour charge to the CCCFPD.
Section 5—Operations Review as the Cost Driver page 26
SECTION 5—OPERATIONS REVIEW AS THE COST DRIVER
5.1 DEPLOYMENT LEVELS AND RESULTANT STAFFING
Determining the number of ambulances needed at any given hour across the diverse topography
and populations of a large county is complicated. Current ambulance systems typically deploy a
mix of 24-hour and partial-day units with overlapping schedules. The highest quantity and
location of units is clustered in the hours of the day and in the communities having the greatest
demand for service. In a deployment plan, a baseline number of units is placed across the
geography to provide equitable response time to an emergency, assuming the closest assigned
area unit is available.
The County RFP requested two deployment plans labeled A and B. Plan A is what the current
system operates; the ambulance contract area is divided into four Emergency Response Zones
(ERZs) for calculation of ambulance response times and penalties.
Under Plan B, the ambulance contract area is divided into three ERZs for calculation of
ambulance response times and penalties. In aggregating performance zones from four to three,
Plan B significantly expands areas designated as “urban” instead of “rural.” While Plan B
increases the response time requirement in existing urban zones from 10:00 or 11:45
minutes/seconds to 12:45 minutes/seconds for the highest priority emergencies, the shift of the
rural areas to urban lowers response time requirements from 16:45 minutes/seconds to 12:45
minutes/seconds. Thus, Plan B changes response time requirements in multiple areas.
Both plans are fully described in the County Ambulance RFP in Appendix 3 and will not be fully
repeated here.
The calculation used to summarize a deployment plan is measured in “Unit Hours,” defined as
the total number of two-person ambulance units on duty in each hour block (24 hours per day for
a week or monthly cycle). In the case of Contra Costa County, the County is divided into
response time measurement zones as the major population clusters are separated by large open
space or rural areas.
Once the plan is set into motion, the ambulance contractor and County EMS Agency measure
response times delivered by the deployment plan against a pre-determined policy goal. If the
deployment plan under-delivers response time performance to an area, the deployment plan must
be adjusted. If the response time performance exceeds the goal, then the deployment plan can be
adjusted to save cost.
In the current system, AMR’s 2014 Unit Hour deployment plan delivered, on average, 17,140
Unit Hours per month. As a simple average, this is approximately 23 units per hour Countywide.
After 2:00 am the quantity is lower; it is highest in the afternoon and early evening hours.
Section 5—Operations Review as the Cost Driver page 27
The previous 2004 AMR contract required a minimum of 17,437 Unit Hours per month. In
September 2009, the Board of Supervisors allowed the Unit Hours to be slightly lowered to
control excessive system costs. Averaged per month for calendar year 2014, AMR’s Unit Hour
plan delivered 17,140 Unit Hours. Starting in the fall of 2014, with the closure of Doctors
Medical Center, the Unit Hours were increased because transports that could not be diverted to
less acute clinic care needed to go to hospitals further away, increasing unit out of service times
during incidents.
By January 2015, AMR’s monthly Unit Hour plan had risen to 18,172. In reviewing the 2014
incident demand data, and AMR’s Unit Hour plan by hour per week for March 2015, Citygate
finds that this early 2015 level of Unit Hours is the minimum necessary to meet system response
time goals in each of the three zones.
5.1.1 Alliance Plan A Deployment
The Alliance deployment proposal under Plan A is for 20,748 Unit Hours per month. In its
proposal the Alliance states:
“Core (lowest) deployment will be 18 ambulances, with a peak of 39 ambulances
during the highest demand. As this is a performance-based contract and call
demand is dynamic, we are committed to increasing units to match volume and
contractual requirements. Analyzing the County call volume and hot spots, we
will strategically deploy 12-hour units, with the ability of backfill, if needed.”
Citygate reviewed the proposed Unit Hour plan for one week against what AMR delivered in
March/April of 2015 and found the Alliance slightly increased hours at key parts of the day and
days of the week in the sample weekly ambulance schedule provided by the Alliance.
Citygate Opinion #2 – Plan A Deployment Hours: Citygate’s extensive review
of the incident demand data by zone, hour of the day, and day of the week found
the proposed Alliance deployment plan capable of meeting the current needs of
the requested Plan A.
5.1.2 Alliance Plan B Deployment
The Alliance deployment proposal under Plan B is for 20,020 Unit Hours per month. In its
proposal the Alliance states:
“Core (lowest) deployment will be 18 ambulances, with a peak of 37 ambulances
during the highest demand. As this is a performance-based contract and call
demand is dynamic, we are committed to increasing units to match volume and
contractual requirements. Analyzing the County call volume and hot spots, we
will strategically deploy 12-hour units, with the ability of backfill, if needed.”
Section 5—Operations Review as the Cost Driver page 28
Citygate reviewed the proposed Unit Hour plan for one week against what AMR delivered on
July 3, 2015 and found the Alliance slightly decreased Unit Hours at key parts of the day, and at
key days of the week in the sample weekly ambulance schedule provided by the Alliance.
Citygate Opinion #3 – Plan B Deployment Plan Hours: Citygate’s extensive
review of the incident demand data by zone, hour of the day, and day of the week
found the proposed Alliance Plan B insufficiently documented regarding where
the reductions and resultant reduced response times occur. As such, it is not
possible to state whether the plan will meet the response time objectives for the
cost proposed.
5.2 PLAN A LIKELY RESPONSE TIME COMPLIANCE
Contra Costa County’s current contract with AMR requires a 10-minute response 95% of the
time for calls determined to need a “lights and sirens” response in the City of Richmond, while in
the remainder of West County emergency response times are 11:45 minutes, 90% of the time
(similar to the remainder of the County). The variation in response requirements between these
communities was based on the goal of providing a paramedic within 10 minutes on scene,
established by the County as part of the 2004 ambulance service agreement for areas not served
by fire paramedic first response.
The 2015 Ambulance System RFP required, in Plan A, response time performance across four
geographic zones. The zones are the City of Richmond, the balance of the West County, the
Central County, and the East County. The response time measures are:
High Priority Emergencies – to 90% of the incidents from a low in Richmond of
10 minutes to 11:45 minutes/seconds across the mid-County and to rural East
County areas at 16:45 minutes/seconds.
In documents to the County EMS Agency, and in the Alliance proposal, response times by AMR
from March 1, 2014 through February 28, 2015 in the current five performance zones exceeded
90% in all zones ranging from a low of 91% to a high of 97%, with West County and more
specifically Richmond, typically averaging 94-95%.
Citygate Opinion #4 – Plan A Response Time: Given the historical response
time compliance reported by AMR under the current contract, as well as the
increased Unit Hours in the Alliance Deployment Plan, Citygate is of the opinion
that the Alliance can maintain the desired response time goals of the requested
Deployment Plan A.
Section 5—Operations Review as the Cost Driver page 29
5.3 PLAN B LIKELY RESPONSE TIME COMPLIANCE
The County’s RFP requested an alternative Response Plan B that reduced the response time
zones to three and increased response time for 90% of the incidents ranging from a low of 12:45
minutes/seconds in urban/suburban areas to 20:00 minutes/seconds in rural areas. The goal was
intended to allow a few less ambulances in the system for cost control given the lower severity
incidents that dominate workload across the system.
The three response time zones were West, Central, and East County, with response time
measures focused on population density areas. This plan removed the City of Richmond from
being its own performance area.
Based on a one-week, Countywide ambulance deployment schedule, and the fact that Plan B
merges Richmond into the western compliance zone, it is impossible to validate if the reductions
in Plan B are excessive, or if they will even meet the County’s lessor response time goals. There
is no way to know if one zone is more affected by reductions than another zone.
While the Alliance offered a different Unit Hour deployment exhibit for Option/Plan B, it did not
prefer its implementation. In its RFP response, the Alliance stated:
Our submission under Plan “A” provides shorter response times than provided
for under option B and we believe that is what the public wants and demands. Our
submission addresses the concerns that the LEMSA has for system sustainability,
while simultaneously providing what the public wants in their ambulance delivery
model, which is an efficient, cost-effective emergency response. Our plan is
designed to meet the public’s desire and does not require any subsidy from the
County.
We have also provided a Plan “B” that includes longer response times for
responding ambulances, thus decrease the cost of providing the service through
reduction of unit hours. We would like to highlight that this plan comes at a
significant cost to not only the patient that is required to wait longer for the
arrival of the ambulance but also the County’s first responders from all agencies
as they will be required to remain on scene until the ambulance arrives. This
includes all first responder such as fire, police, sheriff and highway patrol.
Diminished resources due to increased response times for transport providers is
not in the best interest of any of the County’s stakeholders. Our submission of
Plan “A” provides for all the needs identified in the modernization report at no
cost to the County.
In response to further Plan B questions from Citygate Associates, the Alliance stated:
The unit hours proposed under Plan A are higher than our 2014 deployment. The
difference in deployment is driven by several factors. First, the closure of Doctors
Section 5—Operations Review as the Cost Driver page 30
Medical Center earlier this year has resulted in a significant disruption to the
previous deployment model requiring the addition of unit hours to maintain West
County coverage. Next, while the current RFP does ease some response time
requirements, it also provides additional complexity and cost by initiating outlier
penalties and rolling daily compliance requirements. Lastly, both the District and
AMR felt it was necessary to build a deployment plan that would ensure success,
especially given the unknown effects of further first responder reductions in East
Contra Costa County. As such, we built a robust deployment plan that may allow
for future reductions once the system is stable.
Given these numerous system dynamics outlined above, the Alliance felt it would
be imprudent to propose unit hour reductions under Plan B. Unit hour reductions
would result in longer on-scene times for our local fire departments at a time
when their resource capabilities are already stretched thin. In addition, such unit
hour reductions would provide for less flexibility to address the recent system
changes and those new requirements outlined in the RFP.
Citygate also observes that the deployment hours for Plan B are estimated from a software model
used by AMR and, due to the changes in response zones, the deployment hour estimations are
new. No software model estimates are perfect, and different mathematical approaches yield
different results.
Even with historical incident data to model from, the 9-1-1 system demand is a chaotic
mathematical model; it is not simply linear. There are many simultaneous and sometimes
unexpected factors that generate 9-1-1 demand. The emergency system is not like a supermarket
where a large volume of data supports how many checkout registers to have open on busy
afternoons. In that scenario, the volume of use over time is very predictable. In a 9-1-1 system,
an event such as a wildland fire, multi-patient auto accident, a heat wave, or hazardous materials
leak can throw unexpected hourly demands on the system. It is preferable to have some reserve
capacity in a system for such moments. Proposed Plan A has proven historically positive
response times, and the Alliance has offered that plan in a cost-to-revenue structure that is
positively balanced.
Citygate Opinion #5 – Plan B Response Time: The response time compliance
for Plan B cannot be benchmarked to current system compliance given the change
from four to three zones and a relaxation of response time measures. Citygate
would strongly encourage the County not to implement Plan B all at once, if at
all. If chosen for implementation, the Alliance should be allowed to test some
reductions in some areas and then, based on closely-observed metrics, make
adjustments. This measured, incremental approach is consistent with the values of
Continuous Quality Improvement (CQI).
Section 5—Operations Review as the Cost Driver page 31
5.4 STAFFING FOR ADMINISTRATIVE, TRAINING, DISPATCH, AND COMMUNITY EDUCATION
SUPPORT
The ambulance deployment plan drives the total number of paramedics and EMTs needed. Each
of these types of employees needs state- and County-mandated training and quality assurance
clinical oversight. Additionally, any ambulance operation needs support staff to provide
administration, fiscal, supply, and ambulance fleet repair. An all-encompassing term for these
positions and resultant costs would be administration and logistical support. The Alliance
staffing proposal for Plan A requires 114 paramedics and 114 EMTs, totaling 228 personnel.
Deployment Plan B only requires 8 fewer field personnel, so the following logistical support
analysis only uses proposed Plan A, and there is a negligible decrease to oversight position costs
under Plan B.
To provide the needed support for these field positions, AMR’s portion of the Alliance will
provide 47 full- and part-time positions across these categories:
Table 6—Administrative and Logistical Support
Position Title
Number of
Positions
General Manager 1
Clinical Manager 1
Operations Manager 1
Data Analyst 1
Community Outreach 1
Clinical Education Specialist 1
Clinical Education Coordinator 1
Deputy Operations Manager 1
Logistics Supervisor 1
Administrative Supervisor 1
Administrative Assistant 1
Scheduling 2
EMS Operations Supervisor 9
Vehicle Service Technicians 7
Lead Mechanic 1
Vehicle Mechanic 3
Pre-billing Staff 3
Dispatchers 10
Assistant Medical Director 1
Total AMR Positions 47
Section 5—Operations Review as the Cost Driver page 32
In the Alliance proposal for administration, there is only one (CCCFPD) position added and
expensed from ambulance revenues: an EMS Chief Officer to oversee the Alliance operations on
behalf of CCCFPD. This position would presumably be the key liaison between AMR, fire
operations staff, and the County’s EMS Agency.
5.4.1 Community Education
The Ambulance RFP required the contractor to allocate $100,000 under Plan A, and $300,000
under Plan B, annually for community education and improvement activities. The Alliance
proposal allocated $300,000 under Plan A, exceeding the RFP requirement, and $300,000 under
Plan B, as required by the RFP.
This amount is shown in the proposed Alliance budget in two locations: (1) personnel costs,
because people provide community training; and (2) a separate line item of $50,000 for outreach
supplies and publications. Personnel include a dedicated Community Education Coordinator that
will be dedicated to providing support to the Community Education programs. In addition,
members of the management team, Paramedics, and EMTs will be used to staff high volume
community outreach programs, and those wages also are included in the Alliance budget.
5.4.2 Quality Control and Overall Logistical Positions Needs and
Appropriateness
Quality emergency medical care and transport services are dependent upon an effective
Continuous Quality Improvement (CQI) program that is tied to a living training plan and
calendar. The CQI program focuses on both the individual care provider (EMT or paramedic) as
well as on the system as a whole. It is both internal to the Department and external to the EMS
community at large. Trend analysis through consistent data review, as well as individual run
review (patient care report audits), are used to identify training needs. The four positions
identified on the Alliance’s organization chart (Community Outreach, Continuing Education
Specialist, Continuing Education Coordinator, and Data Analyst) will provide the fundamentals
for an effective CQI and training program.
Citygate Opinion #6 – Alliance Logistical Staffing Expense: Given the staffing
provided by AMR, and a verbal confirmation that AMR support services staffing
will remain the same as in the current contract, the CQI, training, and community
education staff appears appropriate for the size of the projected AMR operation.
CCCFPD will continue to separately manage the training and CQI for its
firefighter/paramedics, as it does currently.
Section 6—Alliance Economic Proposal page 33
SECTION 6—ALLIANCE ECONOMIC PROPOSAL
6.1 TRANSPORT VOLUME OVER TIME
An ambulance system’s revenues are fundamentally driven by total transports. Citygate’s review
of County EMS-provided raw data found that, in the calendar year of 2014, there were a total of
79,358 AMR initial responses in all zones in the County. This was an increase of about 5,000
response incidents over 2013.
These incidents resulted in a total of 63,488 transports to the region’s hospitals. Over four years
the number of transports has grown steadily:
Table 7—Number of Transports in Contra Costa County
Year Transports
2011 57,590
2012 60,751
2013 60,804
2014 63,488
In Contract Year 1 (2016), the Alliance proposal has estimated total transports to be 63,500, or a
growth rate of essentially zero. Citygate sees this flat-line projection as conservative and
reasonable given the slight increase in overall incident demand from 2012 to 2014. Even given
the closure of Doctors Medical Center, the Alliance believes that transport demand under the
health care reform impacts will be flat for several years. In response to question s from Citygate
about the demand for service assumptions, the Alliance stated:
In reviewing transport history, 2014 had considerably higher transport growth
(4.4%) than the previous year growth (1.8%). The historic growth rates included
years with both positive as well as negative transport growth rates. We identified
2014 as a higher than average year as the Affordable Care Act (ACA) was
implemented and more patients had access to insurance and therefore utilized
ambulance service. Based upon this information, we took a conservative
approach to forecasting transport growth to ensure system stability and kept 2015
and 2016 projections flat.
Citygate Opinion #7 – Number of Transports Volume: Given the conservative
projection of total transports for at least Contract Year 1 (2016), we find that the
Alliance proposal had not inflated transport projections upon which to base
revenues. If anything, the projections could end up being slightly low, thus
providing a possible economic cushion by 2017.
Section 6—Alliance Economic Proposal page 34
6.2 BILLING BY PAYER TYPE
Table 2 on page 9 of the RFP provided the current breakdown of pa yer types for AMR in Contra
Costa County:
Table 8—Payer Types from AMR in Contra Costa County
Payer Type
RFP Percent of
Payer Type 2014 Actual
Alliance
Proposal
Medicare and Medicare HMO 42.9% 43.2% 42.9%
Medi-Cal and Medi-Cal HMO 26.3% 26.8% 26.3%
Insurance 14.4% 14.5% 14.4%
Private Pay & Other 16.4% 15.5% 16.4%
Total 100.0% 100.0% 100.0%
In its revenue projections for the bid response, the Alliance assumed that the payer mix would
remain the same for all three years of the projection period (2016-2018). In response to a
question regarding why it assumed a constant payer-type mix, the Alliance stated:
It is AMR’s practice in developing cost projections to keep payer mix steady,
unless there are known factors that would result in a material change. At this
point, the 2015 payer mix appears stable. The majority of the changes associated
with the ACA occurred in 2014. With the future of the ACA uncertain at this time,
we assumed the status quo was the most prudent approach to take.
Consequently, while the payer mix has clearly changed over time, Contra Costa County already
has a much higher proportion of Medicare and Medi-Cal customers, a much lower proportion of
Commercial Insurance than AMR’s contracts in other regions, and supports AMR’s response
that much of the changes associated with ACA have already been reflected in the 2014 payer
mix.
As discussed in Section 3, the trend in recent years has been a shift from higher-paying
commercial insurance plans to lower-paying governmental plans. From the most recent 10-K for
Envision Healthcare Holdings, Inc., the parent holding company for AMR, the payer breakdown
for AMR in total (including all regions, not just Contra Costa County) was as follows:
Section 6—Alliance Economic Proposal page 35
Table 9—AMR National Payer Experience
Payer 2012 2013 2014
Medicare 28.6% 32.1% 30.4%
Medicaid (Medi-Cal) 6.3% 7.4% 8.8%
Insurance 41.4% 39.2% 36.8%
Self-pay & Other 23.7% 21.3% 24.0%
Total 100.0% 100.0% 100.0%
6.3 ALLIANCE REVENUE ESTIMATE MODEL
Regarding the revenue projection for Total (Gross) Charges, the Alliance appropriately used the
stipulated ambulance rates for rate Contract Year 1, as required in Appendix 10 of the RFP, as
well as the annual 3% rate increase specified on page 55 of the County’s Ambulance RFP.
Table 10—County RFP Ambulance Rates
Charge Type Charge Amount
Emergency Base Rate $2,100.00
Mileage Rate (per loaded mile) $50.00
Oxygen $175.00
Treat and Refused Transport $450.00
The Alliance assumed 6 miles per transport, and oxygen usage on 60% of transports, resulting in
an Average Patient Charge (APC) of approximately $2,505. The Alliance took a conservative
position related to “Treat and Refused Transport” charges. Given the unfavorable political
considerations, and historically low net collection experience for Treat and Refused Transport
fees, at this time AMR does not intend to pursue such fees even though the RFP and proposed
contract would permit them to do so.
In terms of expected net collections by payer type, the Alliance again took a conservative
approach to its revenue projections compared to AMR’s experience in 2014:
Section 6—Alliance Economic Proposal page 36
Table 11—AMR Contra Costa County Net Cash Collections by Type
Payer 2014 Actual 2016 Projected 2017 Projected 2018 Projected
Medicare 22.7% 18.8% 18.6% 18.4%
Medi-Cal 6.5% 5.5% 5.4% 5.2%
Insurance 92.0% 91.2% 91.2% 91.2%
Self-pay & Other 13.1% 12.1% 11.9% 11.7%
Average 27.1% 24.6% 24.5% 24.3%
This lower projected collection percentage is prudent given the recent trend in high deductible
health plans, as well as the stipulated rate increases specified in the RFP, which will increase
Total (Gross) Charges, but will not necessarily increase the amount collected, especially for
Medicare and Medi-Cal customers.
Citygate Opinion #8 – Net Collections: The Alliance’s approach in projecting
Average Patient Charges (APC) and expected net collections by payer type is both
conservative and prudent. The question of payer mix is one of the most difficult
aspects of this projection given the uncertainties surrounding health care reform.
AMR believes that much of the change resulting from the ACA has already been
reflected in the 2014 payer mix data and that projecting the status quo is the most
prudent course of action at this time. While this approach is reasonable, we
believe that continued deterioration of net collections due to changes in payer mix
and increases in the number of high deductible health plans remains one of the
largest risks going forward, and one that will need to be evaluated in light of other
risks and opportunities in the Alliance projections (see Section 6.5).
6.4 GEMT ABSENCE, NEAR-TERM FORECAST, AND THE WIDE VARIANCE OF POSSIBLE
REVENUES
6.4.1 Description of GEMT Program
The Ground Emergency Medical Transportation (GEMT) supplemental reimbursement program
is a supplemental program designed to compensate governmental providers of GEMT services
for up to 50% of the uncompensated cost of providing GEMT services to Medi-Cal Fee for
Service beneficiaries. The GEMT program uses Certified Public Expenditures (CPE) for
payment of the federal share of the supplemental reimbursement. The GEMT statute was enacted
as California Welfare and Institution Code, Section 14105.94 on October 2, 2011, and approved
in a State Plan Amendment by the Centers for Medicare and Medicaid Services (CMS) on
September 4, 2013. The program is retroactive to January 30, 2010.
Section 6—Alliance Economic Proposal page 37
To qualify for GEMT program reimbursement, an EMS provider must meet the following
criteria: (1) provide GEMT services to Medi-Cal beneficiaries; (2) be enrolled as a Medi-Cal
provider for the period being claimed; and (3) be owned or operated by the state, a city, a county,
a city and county, a fire protection district, a health care district, a community services district, a
special district, or a federal Indian tribe. Eligible providers must also enter into a Provider
Participation contract with the California Department of Health Care Services (DHCS) and agree
to reimburse DHCS and the fiscal intermediary for their administrative expenses.
To receive supplemental reimbursement pursuant to the GEMT program, service providers
submit an annual cost report to DHCS. The payment is based on claiming federal financial
participation in CPEs that have been incurred by the public GEMT provider during the preceding
fiscal year. Expenses that may be submitted in the cost report include direct and indirect costs,
such as capital assets, including depreciation of buildings and equipment; salaries and benefits
for line and management staff; and administrative and general expenses, such as operations and
maintenance, insurance, and materials and supplies.
In the GEMT program, the participating provider is subject to retrospective audit after
reimbursement is provided, creating a potential liability for the participating agency.
Representatives of some fire departments that have received audits of their GEMT programs
described the audit as being very thorough and detailed, more “like preparing to go to court.”
This potential liability can be minimized by maintaining complete and original records justifying
all claims made pursuant to the GEMT program.
6.4.2 CCCFPD’s Intent to Seek GEMT Reimbursement
The CCCFPD has stated that it intends to submit for GEMT reimbursement in the future, but has
not included GEMT revenue in its budget. Citygate agrees with this decision, because there are
numerous variables that make it difficult to quantify current and future benefits of the GEMT
reimbursement for the Alliance. These variables include: (1) whether the GEMT program will
expand to cover Medi-Cal Managed Care (HMO) beneficiaries; (2) characteristics of CCCFPD’s
contracted billing services agreement; and (3) DHCS’s determination of CCCFPD’s allowable
expenses.
6.4.3 The GEMT Program, Medi-Cal Fee for Service, and Medi-Cal Managed Care
The GEMT supplemental reimbursement program, as currently defined in statute, provides
supplemental reimbursement for the federal share of providing GEMT services to Medi-Cal Fee
for Service beneficiaries. The GEMT program does not provide supplemental reimbursement for
GEMT services provided to Medi-Cal Managed Care beneficiaries. During the past two years,
there have been two attempts at legislation to expand GEMT supplemental reimbursement to
include Medi-Cal Managed Care beneficiaries, but those attempts have not been successful. It is
likely these attempts will continue in the next legislative year.
Section 6—Alliance Economic Proposal page 38
In Contra Costa County, approximately 26% of ambulance transports are Medi-Cal beneficiaries.
Also in Contra Costa County, only 20% of Medi-Cal beneficiaries are in Fee for Service
programs. The majority of Medi-Cal beneficiaries (80%) are in Medi-Cal Managed Care Plans.
Thus, the CCCFPD would be eligible to claim cost-based GEMT supplemental reimbursement
on only approximately 5.2% of all ambulance transports.
6.4.4 Characteristics of Contracted Billing Service Agreement
Because CCCFPD has not entered into an agreement with a contracted billing service, it is not
possible to determine whether DHCS would determine whether this expense would qualify for
GEMT reimbursement. DHCS, in Policy and Procedure Letter 14 -001, issued on December 18,
2014, clarified allowable reimbursement of GEMT contracted billing and accounting service
costs. DHCS stated that expenditures for contracted billing services would be allowable for
supplemental GEMT reimbursement only if those billing services are paid fees, based on a flat
rate per transport or for the time of work rather than paid fees based on the amount collected,
amount billed, or historical costs.
6.4.5 DHCS’s Determination of the CCCFPD’s Allowable GEMT Expenses
The GEMT statute requires, to be eligible for GEMT supplemental reimbursement, that the
public provider “own and operate” the GEMT service. The GEMT statute also restricts
reimbursable costs to those costs incurred by the public provider. On September 30, 2013, DHCS
issued Policy and Procedure Letter 13-001, which clarified the meaning of “owns and operates”
by explaining the intent of “costs incurred by the public provider” in the GEMT statute. DHCS
stated:
Eligible Contracting Arrangements - satisfying "owns or operates"
Eligible public providers that contract for the provision of GEMT services to a
private provider, and the public provider directly bills the Department of Health
Care Services (DHCS) for GEMT services, satisfies the "owns or operates"
requirement in Welfare and Institutions Code section 14105.94, subdivision (b),
paragraph (3), and the public provider is eligible to participate in the GEMT
program. However, the public provider may claim supplement reimbursement
only for the costs the public provider incurs, not the contracted provider's costs.
Therefore, costs eligible for reimbursement under this program would be the
public provider's contract costs attributed only to providing GEMT services to
Medi-Cal beneficiaries, billing costs, and the public provider's overhead costs
allocated to the Medi-Cal GEMT services program, as allowed by State Plan
Amendment (SPA) 09-024. The public provider may not claim supplemental
reimbursement for any other cost incurred by the contracted private provider.
Eligible public providers that contract for the provision of GEMT services to a
private provider, and the public provider also contracts out its billing activities to
Section 6—Alliance Economic Proposal page 39
a billing agent that bills DHCS on the public provider's behalf, satisfies the "owns
or operates" requirement in Welfare and Institutions Code section 14105.94,
subdivision (b), paragraph (3), and the public provider is eligible to participate in
the GEMT program. However, the public provider may claim supplemental
reimbursement only for its contract costs. Therefore, costs eligible for
reimbursement under this program would be the public provider's contract costs
attributed only to providing GEMT services to Medi-Cal beneficiaries, and the
public provider's overhead costs (including the public provider's billing agent
costs) allocated to the Medi-Cal GEMT services program, as allowed by SPA 09-
024. The public provider may not claim supplemental reimbursement for any
other cost incurred by the contracted private provider and the billing agent.
Non-Eligible Contracting Arrangements
If a public provider contracts for the provision of GEMT services and its billing
activities to a private provider, and such private provider or its billing agent
directly bills DHCS, then the public provider is not eligible to participate in the
GEMT program because it does not satisfy the "owns or operates" requirement in
Welfare and Institutions Code section 14105.94, subdivision (b), paragraph (3).
Under this scenario, it is the private provider who "owns or operates" as the
provider of GEMT services rather than the public provider. A public provider that
contracts for the provision of GEMT services and its billing activities, and allows
the contracted private provider or the private provider's billing agent to use the
public provider's National Provider Identification number for billing to DHCS,
does not satisfy the "owns or operates" requirement in Welfare and Institutions
Code section 14105.94, subdivision (b), paragraph (3), and the public provider is
not eligible to participate in the GEMT program.
If CCCFPD applies to DHCS for GEMT reimbursement, DHCS will evaluate the business, legal,
and organizational structure between CCCFPD and AMR. DHCS will also assess CCCFPD’s
relationship with its separate contracted billing agency. DHCS will then determine which of
CCCFPD’s costs, incurred directly or through contract, are eligible for reimbursement pursuant
to the GEMT program guidelines.
Citygate Opinion #9 – Fee for Service GEMT Availability: Citygate will not
attempt to predict which of CCCFPD’s costs DHCS will or will not allow for
GEMT reimbursement, as the scope of the Fire Department / Ambulance
Company / Billing Contractor hybrid has not been tried yet in California, to our
knowledge, since the inception of the GEMT program. Therefore, given that the
CCCFPD has just obtained DHCS’s national provider number and must still apply
to DHCS, the Alliance approach to not assume any GEMT reimbursement in its
fiscal pro-forma was the correct, conservative approach.
Section 6—Alliance Economic Proposal page 40
6.4.6 Potential Expansion of the GEMT Program to Medi-Cal Managed Care
It is difficult to accurately predict the future of GEMT program reimbursement. GEMT
advocates will likely continue to attempt to expand the GEMT program to include supplemental
reimbursement for GEMT services provided to Medi-Cal Managed Care beneficiaries. Because
approximately 80% to 85% of Medi-Cal beneficiaries statewide are in Medi-Cal Managed Care
plans, expansion of GEMT services to these beneficiaries would significantly increase the cost-
based reimbursement for eligible GEMT providers.
Should the GEMT program reimbursement be approved in law for Medi-Cal Managed Care
beneficiaries, the cost-based reimbursement would be facilitated through Intergovernmental
Transfers (IGTs) rather than certified public expenditures. IGTs are a mechanism used to secure
federal funds for use by local or state government. IGTs do not require the use of a cost report. In
the federal Medicaid program, the quantities of funds that can be transferred through IGTs are
capped at the state and local level. The difference between the local cap and the amount already
received through other IGTs is called “headroom.” Each county must assess whether it has
adequate headroom within its local Medicaid IGT-based cap. If it does not have adequate
headroom under the local cap, GEMT IGT claims will result in IGT revenue being reallocated
from other existing in-county IGT programs, or denied due to the importance of other programs
or the headroom cap. There is an approved pilot program in one other county that has open
headroom, but it is unknown if IGT permission for EMS will be allowed statewide.
Citygate Opinion #10 – HMO GEMT: There is no near-term assurance in
Contra Costa County that the IGT program for Medi-Cal Managed Care
beneficiaries will become available. As such, the Alliance decision to not depend
on GEMT funds for Medi-Cal Managed Care is correct.
6.5 PLAN A AND B REVENUE AND COST PROJECTION ANALYSIS
As the incumbent operator for Emergency Ambulance Service in Contra Costa County, AMR
has unique insight into the factors that drive revenues and costs, and the recent trends in those
factors. AMR has managed to continue to meet service obligations while maintaining
profitability through very adverse trends in payer mix and net collection rates in recent years.
The County Ambulance RFP stipulated ambulance rate for Contract Year 1 provides for a net
increase of approximately 7.4% over existing rates in Contra Costa County. That increase
enabled the Alliance to conservatively estimate a reduction in net collections and maintain
profitability.
Clearly, one of the largest risks facing the Alliance and Contra Costa County is the uncertainty
surrounding health care reform and the potential continuing shift of payer mix and deteriorating
net collections below the already conservative Alliance revenue projection. While the Alliance
Section 6—Alliance Economic Proposal page 41
projected declines in net collections from 27.1% to 24.6%, such declines could actually exceed
that forecast if recent trends of rising deductibles and rejected claims continue.
In considering the overall strength and weakness of the revenue projection, there are several
potential opportunities that could offset the risks associated with payer mix and net collections.
As described in Section 6.1 previously, the Alliance took a conservative approach to projecting
transport volume over time. If transport volumes exceed the levels in the Alliance projection,
there should be a positive impact to profit margins. This is because revenues should generally
grow in proportion to transport volume increases, while costs will not likely grow as quickly due
to certain fixed costs, and the improved economies of scale.
Similarly, the Alliance took the conservative approach of not projecting any incremental
revenues associated with two potential new sources of revenue. The RFP would permit the
contractor to charge for “Treat and Refused Transport” services, which the Alliance says it does
not plan to do, at least initially. In addition, as described in Section 6.4 previously, the potential
for supplemental reimbursement under the GEMT program could be a source of incremental
revenue. While both “Treat and Refused Transport” and GEMT revenues could have some
incremental billing costs associated with them, their net collections would still contribute to the
bottom line.
Cost projections are driven by the deployment plan, and a detailed analysis of the deployment
plan, staffing levels, and operations is contained in Section 5 of this report. The resulting cost
per Unit Hour provided by the Alliance for the first three years of the contract is as follows,
including a projection of 3% increases each year to cover increases in the collective bargaining
agreement, merit increases, and inflation:
Table 12—Plan A and B Cost per Unit Hour
Plan Year 1 (2016) Year 2 (2017) Year 3 (2018)
Plan A
Cost per Unit Hour $148.89 $153.36 $157.96
Plan B
Cost per Unit Hour $152.52 $157.09 $161.80
Section 6—Alliance Economic Proposal page 42
Combining the revenue and cost projections by year with the projected transport volumes yields
the following results:
Table 13—Deployment Plan A
Description Year 1 (2016) Year 2 (2017) Year 3 (2018)
Transport Volume 63,500 64,450 65,418
Net Revenue / Transport $617.08 $631.62 $646.51
Expenses / Transport $586.00 $594.69 $603.46
Gross Profit / Transport $31.08 $36.94 $43.05
Gross Profit Percentage 5.0% 5.8% 6.7%
The potential for supplemental reimbursement under the GEMT program is the largest
opportunity, and growth in transport volumes above currently-projected levels could also provide
a cushion. The strategies in Section 7 regarding risk control will further help the County manage
risk over the life of the contract.
Table 14—Deployment Plan B
Description Year 1 (2016) Year 2 (2017) Year 3 (2018)
Transport Volume 63,500 64,450 65,418
Net Revenue / Transport $617.08 $631.62 $646.51
Expenses / Transport $578.60 $587.18 $595.84
Gross Profit / Transport $38.48 $44.45 $50.67
Gross Profit Percentage 6.2% 7.0% 7.8%
The only major cost difference between the two plans is that in Plan B there are eight less field
employees and a small reduction in logistical expenses, such as insurance. There are no
meaningful administrative and logistical personnel expense deductions.
Plan B contains a new and significant required annual payment of $750,000 to the County EMS
Agency for system administration uses. This charge is, in theory, to be funded from operational
savings due to longer response times. The cost shifts between Plans A and B can be summarized
as:
Section 6—Alliance Economic Proposal page 43
Table 15—Cost Differences Between Plans A and B
Plan Difference Amount
Plan B Cost Reductions ~ ($1,220,000)
Plan B EMS Agency Fee ~ $750,000
Plan B Net Reductions ~ ($470,000)
Given the comparison of Plan A and Plan B provided by the Alliance, and the fact that the cost
savings for Plan B are only $470,000 due to the charge for County EMS administration, it is
obvious that Plan A provides better response times and compliance at a lower Unit Hour cost. In
both Alliance Plan A and Plan B proposals, the total system costs per Unit Hour are:
Table 16—Total System Costs per Unit Hour for Plans A and B
Plan Unit Hour Cost
Plan A $148.89
Plan B $152.52
Thus, the reduced coverage in Plan B actually costs more per Unit Hour than Plan A due to the
EMS Agency fee mandated in Plan B.
Plan A also maintains a response time compliance zone in Richmond, which Citygate believes is
positive due to the unique workload demands in that city. It does not make sense to Citygate to
include a very busy area such as Richmond with adjoining areas that are far less busy. The result
could well be that the high call volume areas either suffer slow response times as units are
outside the city, or the low call volume areas suffer as their units are inside the city. It would be
preferable to require the contractor to balance Richmond for compliance separate from the rest of
the West County.
6.5.1 Total Expense to Revenue Performance for Plan A and B
It must be remembered that the Alliance projected declines in net collections from 27.1% to
24.6%. Net collection declines could actually exceed that forecast if recent trends of rising
deductibles and rejected payment claims continue. What also makes the projected 24.6% net
revenue disturbing is that, in the decades preceding the last recession and federal health care
reform, a “low” ambulance collection rate was 66%. Some communities collected more;
however, no communities collected more than 90%. Because private providers may not be able
to run a regional ambulance system for a profit of only 3-5%, the EMS industry is openly
discussing the question, “At what net collection rate will a public subsidy be required?”
Section 6—Alliance Economic Proposal page 44
In summary, for total revenue to expense, the two plans project:
Table 17—Plan A and B Economics
PLAN A PLAN B
Description Year 1 (2016) Year 2 (2017) Year 3 (2018) Year 1 (2016) Year 2 (2017) Year 3 (2018)
Revenue $39,184,619 $40,707,971 $42,293,630 $39,184,619 $40,707,971 $42,293,630
Expenses $37,211,143 $38,327,477 $39,477,301 $36,741,220 $37,843,457 $38,978,760
Gain $1,973,476 $2,380,494 $2,816,329 $2,443,399 $2,864,514 $3,314,870
Based on the above analysis, and our experience, Citygate offers the following:
Citygate Opinion #11 – Plan A Economics: The economic proposal for Plan A
submitted by the Alliance is based on reasonable and generally conservative
assumptions. Projected costs are less than conservatively estimated revenues.
While there is no way to completely address the risks that are faced in the
industry regarding the impact of health care reform, and trends of declining
collections from insurance carriers, Plan A has a revenue safety cushion without
the receipt of any GEMT supplemental revenues.
Citygate Opinion #12 – Plan B Economics: Given that Plan B provides a system
with longer response times for a few less Unit Hours and small revenue cushion
for the uncertainties in ambulance revenue trends, Citygate does not see a reason
to implement a significant system change to, for the most part, simply generate
new revenues to the County’s EMS Agency. Citygate would rather see the
Alliance build a larger revenue-to-cost projection to build its reserves first.
6.6 ESTIMATE OF AMR PROFIT AND REASONABLENESS
During our meeting with representatives from the Alliance, Citygate confirmed that the provision
for profit for AMR under the contract with CCCFPD is contained in the Expense Budgets in
Appendix 16 of the bid response under the line item titled “AMR Contract Administration Fees.”
Citygate compared the Administration Fee to total AMR expenses before the Fee and then total
expenses, including CCCFPD expenses, which are presented in the table below:
Section 6—Alliance Economic Proposal page 45
Table 18—Deployment Plan A Expenses
Description Year 1 (2016) Year 2 (2017) Year 3 (2018)
AMR Contract Admin Fee $3,375,263 $3,476,521 $3,580,517
Total AMR Expenses Fee $33,752,634 $34,765,213 $35,808,170
Fee as a % of AMR Expenses 10.0% 10.0% 10.0%
Total Alliance Expenses Fee $37,211,143 $38,327,477 $39,477,301
Fee as a % of Total Expense 9.1% 9.1% 9.1%
Based on discussions with representatives from AMR, this profit percentage effectively
represents Earnings Before Interest and Taxes (EBIT), and actually also covers a small am ount
of Depreciation and Amortization for certain AMR non-field assets which were not included in
the expense budgets.
Table 19—Deployment Plan B Expenses
Description Year 1 (2016) Year 2 (2017) Year 3 (2018)
AMR Contract Admin Fee $3,259,280 $3,357,059 $3,457,771
Total AMR Expenses Fee $32,592,803 $33,570,588 $34,577,705
Fee as a % of AMR Expenses 10.0% 10.0% 10.0%
Total Alliance Expenses Fee $36,741,220 $37,843,457 $38,978,760
Fee as a % of Total Expense 8.9% 8.9% 8.9%
Citygate Opinion #13 – AMR Profit: The AMR profit component is segregated
as a separate line item in the Alliance Expense Budget, providing a level of
transparency. Also, AMR allocated a reasonable 10.0% of total expenses to cover
non-field Depreciation and Amortization, Interest, Taxes, and leave a reasonable
level of Net Profit for AMR.
6.7 AMR FISCAL HEALTH/CORPORATE REVIEW
AMR is the nation’s largest medical transportation company. AMR is a wholly owned subsidiary
of Envision Healthcare Holdings, Inc. (ticker symbol EVHC). In addition to AMR, EVHC also
owns a subsidiary called EmCare. EmCare is a leading provider of integrated facility-based
physician services, including emergency, anesthesiology, hospitalist/inpatient care, radiology,
tele-radiology, and surgery. EmCare also offers physician -led care management solutions outside
the hospital.
Section 6—Alliance Economic Proposal page 46
The following are some facts about AMR obtained from its company website:
Number of employees: 18,000+
Number of vehicles: 4,200
Number of states served: 40, plus the District of Columbia
Number of communities served: 2,100
Number of patient transports in 2014: 3 million +
Citygate reviewed the 10-K reports for EVHC as submitted with the Alliance proposal and as
filed with the U.S. Securities and Exchange Commission for the years ended December 31, 2012,
2013, and 2014. Selected liquidity and profitability ratios for EVHC are shown on the following
table:
Table 20—Envision Healthcare Holdings, Inc. (EVHC) Fiscal Health Measures
Item 2012 2013 2014
Days Sales Outstanding 69.1 78.4 78.9
Net revenue $3,300,121 $3,728,312 $4,397,644
Trade accounts receivable, net $625,144 $801,146 $950,115
Current Ratio 1.57 2.40 2.36
Current assets $753,259 $1,082,283 $1,363,239
Current liabilities $478,694 $451,329 $576,868
Quick Ratio 1.48 2.29 2.26
Cash and cash equivalents $57,832 $204,712 $318,895
Securities (insurance collateral) $24,481 $29,619 $32,828
Trade accounts receivable, net $625,144 $801,146 $950,115
Current liabilities $478,694 $451,329 $576,868
Debt Ratio 0.87 0.63 0.62
Total liabilities $3,492,146 $2,690,264 $2,934,712
Total assets $4,036,833 $4,300,017 $4,703,753
Long-Term Debt-to-Equity Ratio 4.86 1.18 1.15
Long-term debt $2,647,098 $1,895,381 $2,025,877
Total equity $544,687 $1,609,753 $1,769,041
Interest Coverage Ratio 1.41 1.48 3.52
Income from operations $256,742 $276,755 $388,486
Interest expense $182,607 $186,701 $110,505
Section 6—Alliance Economic Proposal page 47
Item 2012 2013 2014
Operating Margin 7.8% 7.4% 8.8%
Income from operations $256,742 $276,755 $388,486
Net revenue $3,300,121 $3,728,312 $4,397,644
Net Profit Margin 1.2% 0.3% 2.7%
Net income $41,185 $11,495 $119,866
Net revenue $3,300,121 $3,728,312 $4,397,644
Return on Equity 5.6% 1.1% 7.1%
Net income $41,185 $11,495 $119,866
Average equity $729,089 $1,077,220 $1,689,397
Return on Assets 1.0% 0.3% 2.7%
Net income $41,185 $11,495 $119,866
Average assets $4,036,833 $4,168,425 $4,501,885
Citygate Opinion #14 – AMR Fiscal Strength: Citygate notes that AMR
national liquidity ratios stayed very consistent between 2013 and 2014, and the
profitability ratios improved from 2013 to 2014. Given the diversity of ambulance
costs and declining payer type payments across the country, for AMR to have
stable liquidity and profit ratios showing slight improvement, it suggests AMR is
weathering the ambulance industry revenue decline as well as, if not better than,
the other large national providers.
6.8 CCCFPD FISCAL HEALTH / CORPORATE REVIEW
6.8.1 CCCFPD Financial Capacity
Citygate conducted a preliminary review of CCCFPD’s last three financial statements. The
CCCFPD provides fire and emergency medical service activities to nine cities and certain
unincorporated areas in the County. The CCCFPD is principally financed by property taxes and
services, such as fire prevention plan review and inspections.
Citygate’s initial review showed that the finances of the CCCFPD have been improving over the
past three years, with steady increases in the unassigned fund balance as well as cash. From FY
2012/13 to FY 2013/14, the cash balance increased by approximately $4.0 million. This is due to
both an increase in property tax revenue and decrease in expenses.
Section 6—Alliance Economic Proposal page 48
The following tables 21 and 22 provide a snapshot of the CCCFPD balance sheet over the past
three years as reported in the County’s Comprehensive Annual Financial Reports (CAFR) for
Fiscal Years 11-12, 12-13, and 13-14:
Table 21—CCCFPD “Balance Sheet” by Fiscal Year
Item FY 2011-12 FY 2012-13 FY 2013-14
Assets
Cash and investments $23,851,000 $27,519,000 $31,508,000
Accounts receivable and accrued revenue
(net) $940,000 $689,000 $1,135,000
Inventories $551,000 $760,000 $666,000
Due from other funds $59,000 $51,000 $48,000
Notes receivable
Prepaid items, deposits land held for resale $1,355,000 $1,127,000 $1,614,000
Restricted cash and investments
Total Assets $26,756,000 $30,146,000 $34,971,000
Liabilities, Deferred Inflows of Resources, and Fund Balances
Liabilities:
Accounts payable and accrued liabilities $4,593,000 $4,335,000 $4,294,000
Due to other funds $157,000 $106,000 $118,000
Welfare program advances
Unearned/deferred revenue $41,000 $51,000
Total Liabilities $4,791,000 $4,492,000 $4,412,000
Deferred Inflows of Resources:
Unavailable Revenue $59
Fund Balances:
Nonspendable $1,906,000 $1,887,000 $1,614,000
Restricted $12,393,000 $10,092,000 $10,623,000
Committed
Assigned $7,666,000 $13,675,000 $18,263,000
Unassigned
Total fund balances $21,965,000 $25,654,000 $30,500,000
Total Liabilities, Deferred Inflows of
Resources, and Fund Balances $26,756,000 $30,146,000 $34,971,000
Over the past three years, tax revenue has grown by approximately $8.0 million, or a 10%
increase. This reflects a significant growth in income and is an indication of the recovery of the
Section 6—Alliance Economic Proposal page 49
property tax revenue post-recession. It does not show how much of the tax base recovery is
related to increased assessed value and how much is related to new property tax base. This can
be an important distinction because new property tax base may mean housing growth that will
translate into service level requirements over time.
Table 22—CCCFPD Statement of Revenues, Expenditures, and Change in Fund Balance
Item FY 2011-12 FY 2012-13 FY 2013-14
Revenue
Taxes $77,270,000 $80,202,000 $85,274,000
Licenses, permits and franchise fees
Fines, forfeitures
Use of money and property $31,000 $16,000 $2,000
Intergovernmental $7,122,000 $8,226,000 $3,342,000
Charges for services $5,372,000 $6,380,000 $6,119,000
Other revenue $226,000 $1,541,000 $123,000
Total Revenue $90,021,000 $96,365,000 $94,860,000
Expenditures
Current
Public safety $93,978,000 $92,700,000 $90,033,000
Total Expenditures $93,978,000 $92,700,000 $90,033,000
Excess of revenues over expenditures ($3,957,000) $3,665,000 $4,827,000
Other Financing Sources
Transfers in $164,000 $24,000 $19,000
Transfers out
Capital lease financing
Total Other Financing Sources $164,000 $24,000 $19,000
Net Changes in Fund Balance ($3,793,000) $3,689,000 $4,846,000
Fund Balance at Beginning of Year $25,758,000 $21,965,000 $25,654,000
Fund Balance at End of Year $21,965,000 $25,654,000 $30,500,000
Although the CCCFPD appears to be making significant strides on both the revenue and
expenditure fronts, there are also areas with will present significant long-term financial
challenges. These include retirement contribution rates and other post-employment benefits
(OPEB) primarily due to retirement health care cost underfunding and increasing health care
costs.
Section 6—Alliance Economic Proposal page 50
Citygate Opinion #15 – Fire District Economic Health: Given CCCFPD’s
current reserves, and inclusion in the overall County tax distribution system, the
CCCFPD has the funds to begin monthly payments to AMR for several months
and fund other start-up costs until new ambulance billing revenue catches up to
expenditures. At that point, the CCCFPD must first repay its cash advances and
then build the recommended ambulance enterprise reserves before it can true up
revenue to ambulance rates.
Section 7—Fiscal Risk Control Strategies page 51
SECTION 7—FISCAL RISK CONTROL STRATEGIES
7.1 RISK CONTROL STRATEGY #1: ESTABLISH ALLIANCE CONTRACTS AS AN ENTERPRISE
OPERATION
The Contra Costa County Fire Protection District (CCCFPD) is accounted for as a special
revenue fund. Property taxes are the primary income source for CCCFPD’s fire and emergency
medical service activities. CCCFPD serves nine cities and certain unincorporated areas in the
County. CCCFPD’s financial activities are reported as a major fund in the County’s
comprehensive annual financial statement.
It is important to consider how CCCFPD will account for and manage the financial arrangement
with AMR. It is beneficial to distinguish that CCCFPD’s property taxes are the core revenue
source for the fire and emergency medical services. Ideally, ambulance service expenses would
be fully funded by transport fees. When governments engage in business-type activities where
their intent is to either fully or partially recover the cost of the service, an enterprise accounting
and management structure is a suitable approach.
General governmental funds often provide a focus that is proper for the flow of resources, while
an enterprise fund provides a structure closely resembling a business orientation in which cost
recovery is the focus. Ambulance services are financed and operated in a manner similar to a
private business in which the intent of the governing body is to recover the cost (including
depreciation) of goods and services to beneficiaries on a continuing basis, primarily through user
fees.
Using the enterprise approach provides financial and management information that can be
valuable from a public policy perspective:
Measuring and monitoring business activity performance
Analyzing the impact of financial and operational decisions
Determining the full cost of providing the service
Identifying any cost subsidy from the CCCFPD operating fund for providing the
service
Documenting short- and long-term financial inter-fund advances.
In practice, these types of governmental business funds are routinely used to account for
activities where costs are fully recovered through user fees and charges (such as water, trash
collection, and wastewater operations). They are also used for activities in which the primary
source of financing comes from subsidies rather than user charges (such as transit operations).
Section 7—Fiscal Risk Control Strategies page 52
Enterprise funds are reported using a flow of economic resource measurements as well as a full
accrual basis accounting system. These are the same financial measurements used in commercial
enterprises. Revenues are recognized when they are earned and expenditures are recognized as
soon as the liability is incurred. This approach provides a proper platform for cost recovery
purposes. In most cases the use of enterprise funds is permitted rather than required; however;
Citygate believes, in this case, its usage would represent a best practice from a perspective of full
cost recovery and transparent public policy accountability.
7.2 RISK CONTROL STRATEGY #2: ESTABLISH A SIGNIFICANT RESERVE FUND OF 6 MONTHS
OF REVENUES PLUS A CAPITAL EQUIPMENT REPLACEMENT RESERVE
Reserve policies are a critical element in any business plan. The most critical questions are
always, “What level of reserve is adequate to meet the needs of a particular type of reserve?
When are reserves either too high or too low?” Insufficient reserve levels could jeopardize
CCCFPD’s long-term financial sustainability, and unwarranted levels of reserves could impact
the cost-effectiveness of services and ultimately undermine constituent confidence.
There are a variety of reasons to establish reserves, including:
To handle cash flow challenges
To provide insulation from economic impacts
To maintain equipment and infrastructure (deferred maintenance)
To meet bond/debt-related requirement
To fund liabilities
To bolster emergency preparedness
To provide fee/rate stabilization for business activities
To fund investments/opportunities in the future.
Evaluating reserve policies is a continual process, and reserve policies should be evaluated
annually as part of the budget plan. These policies are closely tied with the economy and service
delivery environment. Reserve policies cannot be adequately developed without a complete
understanding of the CCCFPD’s core service requirements and significant cost and revenue
drivers. It is particularly important that the reserve policies be continually evaluated and refined
as additional operations, performance, revenue, and cost information are developed.
CCCFPD’s cash flow needs are similar to many special districts that derive their primary funding
from property tax revenue. This source of funding is the typical means for supporting special
district public safety-related activities, including fire protection services. CCCFPD receives the
first property tax payment in late December. The lag time between the start of the fiscal year
Section 7—Fiscal Risk Control Strategies page 53
(July 1st) and the first property tax payments received leaves a six -month dry financing period.
Most of CCCFPD’s employee-related expenses are consistently spread over the fiscal year. For
CCCFPD to be a self-sustaining financial entity, it needs enough available cash to make it
through the end of the fiscal year to the first property tax payment, assuming that it does not
want to utilize restricted fund balances.
To monitor cash flow, an understanding of the month-to-month timing of revenue receipts and
expenditure patterns is required. Fortunately, during the “dry period financing,” between the
receipt of property taxes, the County can simply charge the CCCFPD its pooled cash investment
rate for short-term borrowing in order to meet typical cash flow needs.
The projected January 2016 start date in the Alliance proposal will provide a fiscal advantage
because the CCCFPD will have received its first property tax payment. This will provide an
additional cash flow cushion. A successful billing and collection process will be a critical factor
in the cash flow requirements. Cash flow must be able to fund the difference between the
monthly CCCFPD payments to AMR and received and accumulated transport revenue.
Given these anticipated cash flow challenges due to the periodic nature of revenue, the unknown
financial risks associated with ambulance billing, and the changing and uncertain economics of
the health care landscape, the Alliance should build a 6-month reserve for cash flow purposes.
While monitoring cash flow will be a critical element of managing the AMR contract, it appears
that the transport revenue collection model provides a reasonable starting point to understand the
fiscal relationship between revenue collections and AMR contract payment.
Another critical component is equipment and infrastructure replacement funds. This component
of the business plan should also have adequate reserve levels to meet the future needs of
CCCFPD and should be supported by a multi-year capital replacement programs that details
these future needs. From a long-term financial sustainability perspective, this represents a best
practice.
Several other liabilities are important considerations for CCCFPD fire protection cost to revenue
balance; those include equipment and infrastructure replacement, liabilities for pension related
costs, sick leave, vacation, and other post-employment benefits (OPEB). To CCCFPD’s credit, it
has made progress on OPEB and pension liabilities and has improved its funding payments to
these obligations annually.
CCCFPD’s primary operating fund, and the Alliance enterprise fund, need established reserve
policies. Initially, CCCFPD may be required to subsidize the Alliance enterprise fund, but this
subsidy can be reimbursed at a later time. These subsidies need to be booked on each fund’s
balance sheet.
Section 7—Fiscal Risk Control Strategies page 54
7.3 RISK CONTROL STRATEGY #3: EVENTUALLY CALIBRATE TRANSPORT FEES TO TRUE
COSTS THROUGH AUDITS OF EXPENSES AND ADHERENCE TO STIPULATED CONTRACT
PROVISIONS
With the enterprise fund established, the Alliance can better understand its costs. It should take
the time to carefully determine its direct and indirect costs, including equipment and
infrastructure. Because this can be even more complicated if costs are part of a General Fund
operation, it may be beneficial to hire a firm to conduct a Cost of Service Fee Study.
7.4 RISK CONTROL STRATEGY #4: WHEN REVENUES EXCEED NEEDED RESERVES,
CONSIDER LOWERING TRANSPORT FEES, NOT CROSS-SUBSIDIZING NON-ALLIANCE
CCCFPD OR COUNTY EMS AGENCY OPERATIONS
The CCCFPD operation is primarily financed by property tax revenue and fees from fire
prevention plan review and fire inspections. CCCFPD is a special revenue fund and is accounted
for in the Contra Costa County comprehensive annual financial statements as a major fund. An
enterprise fund established to account for transport services would be a separate and distinct
accounting entity with a separate balance sheet, revenue budget, and expense budget. There may
be certain CCCFPD employee costs that are allocated to the Alliance enterprise fund for direct
and indirect services. These charges need to be carefully documented and justified because they
may be eligible to become part of the transport fees base. Costs that are part of the basic/core fire
protection operations should not be part of the ambulance fee structure. This cross-subsidization
would violate the basis for establishing proper fees and charges in an enterprise fund. Any such
inter-fund activity needs to be thoughtfully accounted for and budgeted.
Citygate believes it would be imprudent to, under the decreased deployment capacity in Plan B,
pay $750,000 up front to support County EMS Agency functions instead of saving for a reserve
fund and then, if fiscally secure, lowering rates to individuals and insurance companies. The
older systems that removed revenues for County EMS, dispatch, and first responder fire
department functions are now under the worst economic stress. Additionally, the insurance
company payers simply will not support $2,500+ ambulance bills. The revenues in the system
should first offset a medically necessary transport system, not other community health services
or EMS agency oversight services.
If a subsidy is needed for a county EMS oversight operation, a public policy debate is needed to
determine the funding source (several are available for a county to use). Additional non-transport
costs should not be placed on the ambulance provider, and a new public subsidy should not be
considered the fault of the ambulance company. With good fiscal practices for the ambulance
contract, if for direct costs the ambulance provider cannot stay solvent, then a county can make a
straightforward case to the public for a transport subsidy.
Section 7—Fiscal Risk Control Strategies page 55
7.5 RISK CONTROL STRATEGY #5: ESTABLISH A COUNTY BOARD OF SUPERVISORS AND
CCCFPD “COMPASSIONATE” SET OF BILLING POLICIES FOR CCCFPD-MANAGED
FIRST RESPONDER AND AMBULANCE REVENUE COLLECTION TO INCLUDE A WRITE-
DOWN AND WRITE-OFF POLICY
Through the AMR Compassionate billing program, a patient requesting a Compassionate billing
discount applies to AMR, which then verifies the applicant’s income level and insurance
coverage. If the applicant meets AMR’s criteria for a Compassionate billing discount, the
applicant is informed as to the amount of the discount. In Contra Costa County and other
services areas, AMR’s Compassionate billing policies have been well regarded by members of
the Board of Supervisors, EMS agencies, and the public.
The County EMS Agency currently informs the public about the effective AMR Compassionate
billing policy. However, since that program is AMR’s, not County Board of Supervisors policy,
if the Alliance proposal is implemented, CCCFPD, as the billing entity, should adopt its own
policy to legally guide its billing contractor.
Citygate recommends the County policy to be identical or similar to the one AMR currently uses.
Section 8—Opinions Summary and Implementation Recommendations page 56
SECTION 8—OPINIONS SUMMARY AND IMPLEMENTATION
RECOMMENDATIONS
8.1 CITYGATE’S OPINIONS
Listed here for ease of summary reading are Citygate’s Opinions:
Citygate Opinion #1 – Alliance Economic Risk: It is undisputed that 9-1-1 ambulance system
revenues are falling to the point where some, if not all, systems will no longer be able to operate
without a public subsidy as many have for over 30 years. The choice before Contra Costa County
is whether the Board wants to more fully be involved in managing the contractor via the
CCCFPD, and if a revenue collapse is inevitable, be able to detect the problem with enough time
to develop and implement thoughtful mitigation measures.
The other option is to operate the existing type of contract model and hope the private provider
would provide enough notice before default. Ultimately, taxpayers are the fallback resource to
fund 9-1-1 ambulance services. If ultimately the ambulance system needs an allocation of
CCCFPD or County general discretionary resources to stabilize ambulance services, that could
force the reduction of services in other areas. Monitoring and understanding how this issue
evolves is critical if the County is to minimize the impact of a potentially damaging ambulance
fiscal shock wave.
Citygate Opinion #2 – Plan A Deployment Hours: Citygate’s extensive review of the incident
demand data by zone, hour of the day, and day of the week found the proposed Alliance
deployment plan capable of meeting the current needs of the requested Plan A.
Citygate Opinion #3 – Plan B Deployment Plan Hours: Citygate’s extensive review of the
incident demand data by zone, hour of the day, and day of the week found the proposed Alliance
Plan B insufficiently documented regarding where the reductions and resultant reduced response
times occur. As such, it is not possible to state whether the plan will meet the response time
objectives for the cost proposed.
Citygate Opinion #4 – Plan A Response Time: Given the historical response time compliance
reported by AMR under the current contract, as well as the increased Unit Hours in the Alliance
Deployment Plan, Citygate is of the opinion that the Alliance can maintain the desired response
time goals of the requested Deployment Plan A.
Citygate Opinion #5 – Plan B Response Time: The response time compliance for Plan B
cannot be benchmarked to current system compliance given the change from four to three zones
and a relaxation of response time measures. Citygate would strongly encourage the County not
to implement Plan B all at once, if at all. If chosen for implementation, the Alliance should be
allowed to test some reductions in some areas and then, based on closely-observed metrics, make
Section 8—Opinions Summary and Implementation Recommendations page 57
adjustments. This measured, incremental approach is consistent with the values of Continuous
Quality Improvement (CQI).
Citygate Opinion #6 – Alliance Logistical Staffing Expense: Given the staffing provided by
AMR, and a verbal confirmation that AMR support services staffing will remain the same as in
the current contract, the CQI, training, and community education staff appears appropriate for the
size of the projected AMR operation. CCCFPD will continue to separately manage the training
and CQI for its firefighter/paramedics, as it does currently.
Citygate Opinion #7 – Number of Transports Volume: Given the conservative projection of
total transports for at least Contract Year 1 (2016), we find that the Alliance proposal had not
inflated transport projections upon which to base revenues. If anything, the projections could end
up being slightly low, thus providing a possible economic cushion by 2017.
Citygate Opinion #8 – Net Collections: The Alliance’s approach in projecting Average Patient
Charges (APC) and expected net collections by payer type is both conservative and prudent. The
question of payer mix is one of the most difficult aspects of this projection given the
uncertainties surrounding health care reform. AMR believes that much of the change resulting
from the ACA has already been reflected in the 2014 payer mix data and that projecting the
status quo is the most prudent course of action at this time. While this approach is reasonable, we
believe that continued deterioration of net collections due to changes in payer mix and increases
in the number of high deductible health plans remains one of the largest risks going forward, and
one that will need to be evaluated in light of other risks and opportunities in the Alliance
projections.
Citygate Opinion #9 – Fee for Service GEMT Availability: Citygate will not attempt to
predict which of CCCFPD’s costs DHCS will or will not allow for GEMT reimbursement, as the
scope of the Fire Department / Ambulance Company / Billing Contractor hybrid has not been
tried yet in California, to our knowledge, since the inception of the GEMT program. Therefore,
given that the CCCFPD has just obtained DHCS’s national provider number and must still apply
to DHCS, the Alliance approach to not assume any GEMT reimbursement in its fiscal pro-forma
was the correct, conservative approach.
Citygate Opinion #10 – HMO GEMT: There is no near-term assurance in Contra Costa County
that the IGT program for Medi-Cal Managed Care beneficiaries will become available. As such,
the Alliance decision to not depend on GEMT funds for Medi-Cal Managed Care is correct.
Citygate Opinion #11 – Plan A Economics: The economic proposal for Plan A submitted by
the Alliance is based on reasonable and generally conservative assumptions. Projected costs are
less than conservatively estimated revenues. While there is no way to completely address the
risks that are faced in the industry regarding the impact of health care reform, and trends of
declining collections from insurance carriers, Plan A has a revenue safety cushion without the
receipt of any GEMT supplemental revenues.
Section 8—Opinions Summary and Implementation Recommendations page 58
Citygate Opinion #12 – Plan B Economics: Given that Plan B provides a system with longer
response times for a few less Unit Hours and small revenue cushion for the uncertainties in
ambulance revenue trends, Citygate does not see a reason to implement a significant system
change to, for the most part, simply generate new revenues to the County’s EMS Agency.
Citygate would rather see the Alliance build a larger revenue-to-cost projection to build its
reserves first.
Citygate Opinion #13 – AMR Profit: The AMR profit component is segregated as a separate
line item in the Alliance Expense Budget, providing a level of transparency. Also, AMR
allocated a reasonable 10.0% of total expenses to cover non-field Depreciation and Amortization,
Interest, Taxes, and leave a reasonable level of Net Profit for AMR.
Citygate Opinion #14 – AMR Fiscal Strength: Citygate notes that AMR national liquidity
ratios stayed very consistent between 2013 and 2014, and the profitability ratios improved from
2013 to 2014. Given the diversity of ambulance costs and declining payer type payments across
the country, for AMR to have stable liquidity and profit ratios showing slight improvement, it
suggests AMR is weathering the ambulance industry revenue decline as well as, if not better
than, the other large national providers.
Citygate Opinion #15 – Fire District Economic Health: Given CCCFPD’s current reserves,
and inclusion in the overall County tax distribution system, the CCCFPD has the funds to begin
monthly payments to AMR for several months and fund other start-up costs until new ambulance
billing revenue catches up to expenditures. At that point, the CCCFPD must first repay its cash
advances and then build the recommended ambulance enterprise reserves before it can true up
revenue to ambulance rates.
8.2 IMPLEMENTATION RECOMMENDATIONS
Based on our Opinions and Fiscal Risk Control Strategies, Citygate recommends the CCCFPD,
AMR, and the County EMS Agency pursue final implementation contracts, and offers the
following best practice-based recommendations to guide this process:
1. Fully identify the fiscal relationship between the parties, their separate fiscal
exposure for each other’s decisions (such as staffing levels), and start-up capital
costs.
2. Board policy should require that ambulance loss risk only be transferred to the
taxpayer for unforeseen, catastrophic losses, as would be the case in the current
system if the ambulance contractor were to fail.
3. Fine the contractor only for material breach, not small, per-minute fines.
4. Rather than fine for small response time misses, require that the deployment plan
account for equitable response time coverage for similar land use and population
Section 8—Opinions Summary and Implementation Recommendations page 59
densities. Then if the Alliance delivers the required response time performance,
only gross neglect to deploy or respond should trigger a fine and/or lead to
default.
5. Define in the contract between the County EMS Agency and the CCCFPD a clear
delineation of roles, responsibilities, and authorities as it pertains to operational
authority and regulatory oversight.
6. Require the CCCFPD to report to the Board of Supervisors quarterly on response
times, payer mix, and a rolling revenue-to-date report and near-term revenue-to-
expense forecast.
7. Annually require an independent audit of the revenues to expenses and the
viability going forward of the contract terms. Once ambulance reimbursements
settle under health care reform, the formal audits could possibly move to two-year
cycles.
Appendix A—List of Acronyms page 60
APPENDIX A—LIST OF ACRONYMS
The following list of acronyms occurs throughout the report:
911EOA 9-1-1 Exclusive Operating Area
Sometimes referred to as Exclusive Operating Area or EOA
ACA Affordable Care Act
Sometimes referred to as PPACA, and sometimes called Covered California
ALS Advanced Life Support
AMR American Medical Response, West
APC Average Patient Charges
BLS Basic Life Support
CCCFPD Contra Costa County Fire Protection District
CMS Centers for Medicare and Medicaid Services
CPE Certified Public Expenditures
CQI Continuous Quality Improvement
EBIT Earnings Before Interest and Taxes
EMS Emergency Medical Services
EMT Emergency Medical Technician
EOA Exclusive Operating Area
ERZ Emergency Response Zone
EVHC Envision Healthcare Holdings, Inc
GEMT Ground Emergency Medical Transport
HDHP High Deductible Health Plan
HMO Health Maintenance Organization
IFT Inter-Facility Transfers
IGT Intergovernmental Transfers
LEMSA Local Emergency Medical Services Agency
NPI National Provider Identification
NRT Net Revenue per Transport
OPEB Other Post-Employment Benefits
PPACA Patient Protection and Affordable Care Act
Sometimes referred to as ACA, and sometimes called Covered California
PSAP Public Safety Answering Points
QA Quality Assurance
RFP Request for Proposal
SPA State Plan Amendment
UCR Usual and Customary Rates
17/16/2015 www.citygateassociates.com | (916) 458www.citygateassociates.com | (916) 458--51005100
Independent Economic Review of the Ambulance Transport RFP Result
Board of Supervisors Briefing
County of Contra Costa
Presented on July 21, 2015
2
What This Review Contains
•The background on current ambulance economics
•The structure of the Alliance business partnership
•Operational measures, since they drive costs
(ambulance staffing)
•The reasonableness of the Alliance revenue
estimations
•Citygate’s Opinions, Fiscal Risk Control Strategies, and
Implementation Recommendations, should the
Alliance approach be approved by the Board of
Supervisors
3
•It is undisputed that 9-1-1 ambulance system
revenues are falling nationally to the point
where some systems will no longer be able to
operate without a public subsidy.
•If there are not enough health care system
payments to cover the costs of ambulance
care, the taxpayers in every community are
the fallback resource to fund 9-1-1 ambulance
services.
Citygate’s Capstone Opinions
4
•The Alliance proposal shifts the ultimate economic
responsibility from the ambulance contractor (which
will be guaranteed a fixed payment) to the taxpayers of
the Contra Costa County Fire Protection District
(CCCFPD).
•Even if this is an acceptable policy alternative, the
CCCFPD is smaller in service area than the area covered
by the ambulance contract.
•Consequently, the taxpayers in some non-CCCFPD
service areas would have less exposure to ambulance
fiscal risk in the case of system default.
Risk Shift to the Fire District Taxpayer
5
•Costs and estimated revenues are conservative and consistent with the system demand for ambulances.
•As such, the Alliance Plan A offers similar services to the current system in a positively balanced economic model.
•To the Alliance’s credit, its proposed Plans A and B are not reliant on using new revenue sources, such as Ground Emergency Medical Transport (GEMT) revenues on some types of Medi-Cal transports.
Alliance Proposal Economics
6
•The Alliance’s approach in projecting Average Patient
Charges (APC) and expected net collections by payer
type are both conservative and prudent.
•While this approach is reasonable, we believe that
continued deterioration of net collections due to
changes in payer mix remains one of the largest risks
going forward.
•To shield against this, Citygate has made several
contractual implementation recommendations to
separate and ensure, to the degree possible, the
economic solvency and sustainability of the system.
Alliance Proposal Economics (cont.)
77
Expense to Revenue Comparisons
8
Economic Assumptions
•The Alliance projected declines in net collections from the
recent past of 27.1% to 24.6% and a flat incident demand.
PLAN A PLAN B
Description Year 1 (2016)Year 2 (2017)Year 3 (2018)Year 1 (2016)Year 2 (2017)Year 3 (2018)
Revenue $39,184,619 $40,707,971 $42,293,630 $39,184,619 $40,707,971 $42,293,630
Expenses $37,211,143 $38,327,477 $39,477,301 $36,741,220 $37,843,457 $38,978,760
Gain $1,973,476 $2,380,494 $2,816,329 $2,443,399 $2,864,514 $3,314,870
9
Deployment Plan A vs. B
•The only major cost difference between the two plans is eight
field employees and a small reduction in operating costs.
•There are no overhead personnel expense reductions.
•There is an addition in Plan B for a required annual payment
of $750,000 to the County EMS Agency for EMS system
enhancement uses.
Plan B Difference Amount
Plan B Cost Reductions ~ ($1,220,000)
Plan B EMS Agency Fee ~ $750,000
Plan B Net Reductions ~ ($470,000)
10
The Fiscal Health of AMR
•The AMR profit component is segregated as a
separate line item in the Alliance Expense Budget,
providing a level of transparency.
•AMR allocated a reasonable 10% of total expenses to
cover non-field Depreciation and Amortization,
Interest, Taxes, thus leaving a reasonable level of Net
Profit for AMR in the range of 3 to 6%.
•We note that AMR national liquidity ratios stayed
very consistent between 2013 and 2014, and the
profitability ratios improved from 2013 to 2014.
11
The Fiscal Health the CCCFPD
•Given the CCCFPD’s current reserves and inclusion in
the overall County tax distribution system, the
CCCFPD has the funds to begin monthly payments to
AMR for several months and fund other start-up
costs, until new ambulance billing revenue catches
up to expenditures.
•At that point, the CCCFPD must first repay its cash
advances and then build the recommended
ambulance enterprise reserves before it can true up
revenue-to-ambulance rates or system
enhancements.
1212
Risk Control Strategies
13
Key Risk Control Strategies
1.Establish Alliance contracts as an Enterprise
Operation, similar to other local governmental fee-
for-service programs, such as water and sewer
operations.
2.Establish a significant reserve fund of 6 months of
revenues plus a capital equipment replacement
reserve; also establish best practice financial policies.
3.Eventually calibrate transport fees to true costs
through audits of expenses and adherence to
stipulated contract provisions.
14
Key Risk Control Strategies (cont.)
4.When revenues exceed needed reserves, consider
lowering transport fees, not cross-subsidizing non-
Alliance CCCFPD or County EMS Agency operations.
5.Establish a County Board of Supervisors and CCCFPD
“Compassionate” set of billing policies for CCCFPD-
managed first responder and ambulance revenue
collection to include a write-down and write-off
policy.
1515
Implementation Recommendations
16
1.Identify the fiscal relationship between the parties,
their separate fiscal exposure for each other’s
decisions (such as staffing levels), and start-up
capital costs.
2.Board policy should require that ambulance loss risk
only be transferred to the taxpayer for unforeseen,
catastrophic losses, as would be the case in the
current system if the ambulance contractor were to
fail.
3.Fine the contractor only for material breach, not
small, per-minute fines.
Recommendations Should the Alliance
Proposal Move Forward
17
4.Rather than fine for small response time misses,
require that the deployment plan account for
equitable response time coverage for similar land use
and population densities. Then if the Alliance delivers
the required response time performance, only gross
neglect to deploy or respond should trigger a fine
and/or lead to default.
5.Define in the contract between the County EMS
Agency and the CCCFPD a clear delineation of roles,
responsibilities, and authorities as it pertains to
operational authority and regulatory oversight.
Recommendations Should the Alliance
Proposal Move Forward (cont.)
18
6.Require the CCCFPD to report to the Board of
Supervisors quarterly on response times, payer
mix, and a rolling revenue-to-date report and
near-term revenue-to-expense forecast.
7.Annually require an independent audit of the
revenues to expenses and the viability going
forward of the contract terms. Once ambulance
reimbursements settle under health care
reform, the formal audits could possibly move to
two-year cycles.
Recommendations Should the Alliance
Proposal Move Forward (cont.)
1919
Questions?
Page i
Request for Proposals
Exclusive Operator for Emergency Ambulance Service
Contra Costa County, California
Release Date: 27 February 2015
Proposal Due Date: 21 May 2015
Time: 4:00 PST
Return Location:
Contra Costa County EMS Agency
1340 Arnold Drive, Suite 126
Martinez, CA 94553
Attention: Patricia Frost
Page i
Table of Contents
SECTION I. EMS SYSTEM SUMMARY ________________________________________________________ 1
A. OVERVIEW _______________________________________________________________________________ 1
B. EXCLUSIVE OPERATING AREAS (EOAS) _____________________________________________________________ 2
C. PROPOSALS MUST INCLUDE RESPONSE TO TWO SERVICE PLANS _____________________________________________ 2
D. BACKGROUND ____________________________________________________________________________ 3
E. OVERVIEW OF EMS SYSTEM ____________________________________________________________________ 4
F. LOCAL EMS AGENCY RESPONSIBILITIES ____________________________________________________________ 7
G. CONTRA COSTA EMS SYSTEM IMPROVEMENTS ________________________________________________________ 7
1. Call Transfer and Dispatch _______________________________________________________________________________ 7
2. Call Density Response Zones, Response Time Requirements and Non-performance Penalties
Established ________________________________________________________________________________________________ 8
3. Provider Fatigue __________________________________________________________________________________________ 8
4. No Subsidy System ________________________________________________________________________________________ 8
H. RELEVANT INFORMATION REGARDING SERVICE AREAS ____________________________________________________ 8
1. Historical Service Volume ________________________________________________________________________________ 9
2. Current Ambulance Service Rates _______________________________________________________________________ 9
3. ALS Ground Ambulance Transports Not Originating from 9-1-1 _______________________________________ 9
4. Payer Mix__________________________________________________________________________________________________ 9
SECTION II. PROCUREMENT INFORMATION _________________________________________________ 10
A. PERFORMANCE-BASED CONTRACT _______________________________________________________________ 10
B. NOTICE TO PROPOSERS ______________________________________________________________________ 10
C. USE OF OWN EXPERTISE AND JUDGMENT ___________________________________________________________ 11
D. PROCUREMENT TIME LINE ____________________________________________________________________ 11
E. PROCUREMENT PROCESS ____________________________________________________________________ 11
1. Pre-proposal Process ____________________________________________________________________________________ 11
2. Mandatory Proposers’ Conference ______________________________________________________________________ 11
3. Proposal Submission _____________________________________________________________________________________ 12
4. Public Proposal Opening ________________________________________________________________________________ 12
5. Additional Proposer Responsibilities ___________________________________________________________________ 12
6. Notice of Intent to Award _______________________________________________________________________________ 13
F. PROPOSAL INSTRUCTIONS ____________________________________________________________________ 13
1. Proposal Format _________________________________________________________________________________________ 13
2. Required Proposal Format ______________________________________________________________________________ 13
G. PROPOSAL EVALUATION PROCESS _______________________________________________________________ 14
1. Proposal Review Panel __________________________________________________________________________________ 14
2. Proposal Review Process ________________________________________________________________________________ 15
3. Method for Competitive Scoring of Price Proposals ____________________________________________________ 17
4. Independent Financial Analysis _________________________________________________________________________ 17
5. Post-submission Presentation ___________________________________________________________________________ 18
6. Investigation _____________________________________________________________________________________________ 18
7. Notification ______________________________________________________________________________________________ 18
8. Debriefing ________________________________________________________________________________________________ 18
9. Protest ____________________________________________________________________________________________________ 19
10. Withdrawal of Proposals ________________________________________________________________________________ 20
11. Canceling the Procurement Process after Opening ____________________________________________________ 20
12. Award ____________________________________________________________________________________________________ 20
13. Scoring Criteria __________________________________________________________________________________________ 21
Table of Contents
Page ii
14. RFP Governed by Its Terms ______________________________________________________________________________ 22
H. SCORING MATRIX _________________________________________________________________________ 22
SECTION III. MINIMUM QUALIFICATIONS ___________________________________________________ 23
A. ORGANIZATIONAL DISCLOSURES ________________________________________________________________ 23
1. Organizational ownership and legal structure _________________________________________________________ 23
2. Continuity of business ___________________________________________________________________________________ 23
3. Licenses and permits ____________________________________________________________________________________ 23
4. Government investigations ______________________________________________________________________________ 23
5. Litigation _________________________________________________________________________________________________ 23
B. EXPERIENCE AS SOLE PROVIDER ________________________________________________________________ 24
1. Demonstrate Capability in Lieu of Experience _________________________________________________________ 24
2. Comparable experience _________________________________________________________________________________ 24
3. Government contracts ___________________________________________________________________________________ 24
4. Contract Compliance ____________________________________________________________________________________ 24
C. DEMONSTRATED RESPONSE TIME PERFORMANCE ______________________________________________________ 25
D. DEMONSTRATED HIGH LEVEL CLINICAL CARE ________________________________________________________ 25
SECTION IV. CORE REQUIREMENTS _______________________________________________________ 26
A. TWO SERVICE PLANS ARE TO BE ADDRESSED _________________________________________________________ 26
B. CONTRACTOR’S FUNCTIONAL RESPONSIBILITIES _______________________________________________________ 26
1. Basic Services ____________________________________________________________________________________________ 26
2. Services Description _____________________________________________________________________________________ 27
C. CLINICAL ______________________________________________________________________________ 27
1. Clinical Overview ________________________________________________________________________________________ 27
2. EMS System Medical Oversight__________________________________________________________________________ 28
3. Minimum Clinical Levels and Staffing Requirements __________________________________________________ 29
D. OPERATIONS ____________________________________________________________________________ 32
1. Operations Overview ____________________________________________________________________________________ 32
2. Transport Requirement and Limitations _______________________________________________________________ 33
3. Response Time Performance Requirements ____________________________________________________________ 34
4. Modifications During the Term of Agreement __________________________________________________________ 36
5. Response Time Measurement Methodology ____________________________________________________________ 37
6. Response Time Exceptions and Exception Requests ____________________________________________________ 39
7. Response-time Performance Reporting Procedures and Penalty Provisions _________________________ 41
8. Fleet Requirement _______________________________________________________________________________________ 45
9. Coverage and Dedicated Ambulances, Use of Stations/Posts __________________________________________ 45
E. PERSONNEL _____________________________________________________________________________ 45
1. Treatment of Incumbent Work Force ___________________________________________________________________ 45
2. Character, Competence and Professionalism of Personnel ____________________________________________ 46
3. Internal Health and Safety Programs __________________________________________________________________ 46
4. Evolving OSHA & Other Regulatory Requirements _____________________________________________________ 47
5. Discrimination Not Allowed _____________________________________________________________________________ 47
F. MANAGEMENT ___________________________________________________________________________ 47
1. Data and Reporting Requirements _____________________________________________________________________ 47
G. EMS SYSTEM AND COMMUNITY ________________________________________________________________ 51
1. Participation in EMS System Development _____________________________________________________________ 51
2. Accreditation ____________________________________________________________________________________________ 51
3. Multi-casualty/Disaster Response ______________________________________________________________________ 51
4. Mutual-aid and Stand-by Services ______________________________________________________________________ 53
5. Permitted Subcontracting _______________________________________________________________________________ 53
6. Communities May Contract Directly for Level of Effort ________________________________________________ 53
7. Supply Exchange and Restock ___________________________________________________________________________ 54
Table of Contents
Page iii
8. Handling Service Inquiries and Complaints ____________________________________________________________ 54
H. ADMINISTRATIVE PROVISIONS __________________________________________________________________ 54
1. Contractor Payments for Procurement Costs, County Compliance Monitoring, Contract Management,
and Regulatory Activities (Plan B only) ________________________________________________________________ 54
2. No System Subsidy _______________________________________________________________________________________ 54
3. Contractor Revenue Recovery ___________________________________________________________________________ 55
4. Federal Healthcare Program Compliance Provisions __________________________________________________ 55
5. State Compliance Provisions ____________________________________________________________________________ 56
6. Billing/Collection Services ______________________________________________________________________________ 56
7. Market Rights ____________________________________________________________________________________________ 57
8. Accounting Procedures __________________________________________________________________________________ 58
9. County Permit ____________________________________________________________________________________________ 58
10. Insurance Provisions ____________________________________________________________________________________ 59
11. Hold Harmless / Defense / Indemnification / Taxes / Contributions _________________________________ 59
12. Performance Security Bond _____________________________________________________________________________ 59
13. Term of Agreement ______________________________________________________________________________________ 60
14. Earned Extension to Agreement ________________________________________________________________________ 60
15. Continuous Service Delivery _____________________________________________________________________________ 60
16. Annual Performance Evaluation ________________________________________________________________________ 60
17. Default and Provisions for Termination of the Agreement ____________________________________________ 61
18. Termination ______________________________________________________________________________________________ 62
19. Emergency Takeover ____________________________________________________________________________________ 62
20. Transition Planning _____________________________________________________________________________________ 64
21. LEMSA's Remedies _______________________________________________________________________________________ 64
22. Provisions for Curing Material Breach and Emergency Take Over ____________________________________ 65
23. "Lame-duck" Provisions _________________________________________________________________________________ 66
24. General Provisions _______________________________________________________________________________________ 66
SECTION V. COMPETITIVE CRITERIA _______________________________________________________ 70
A. CLINICAL ______________________________________________________________________________ 70
1. Competitive Criterion: Quality Improvement___________________________________________________________ 70
2. Competitive Criterion: Clinical and Operational Benchmarking ______________________________________ 73
3. Competitive Criterion: Dedicated Clinical Oversight Personnel _______________________________________ 75
4. Competitive Criterion: Medical Direction _______________________________________________________________ 76
5. Competitive Criteria: Focus on Patients and Other Customers ________________________________________ 77
6. Competitive Criterion: Continuing Education Program Requirements _______________________________ 78
B. OPERATIONS ____________________________________________________________________________ 78
1. Competitive Criterion: Dispatch and Communications ________________________________________________ 78
2. Competitive Criterion: Vehicles _________________________________________________________________________ 81
3. Competitive Criterion: Equipment ______________________________________________________________________ 81
4. Competitive Criterion: Vehicle and Equipment Maintenance _________________________________________ 82
5. Competitive Criterion: Deployment Planning __________________________________________________________ 83
C. PERSONNEL _____________________________________________________________________________ 84
1. Competitive Criterion: Field Supervision _______________________________________________________________ 84
2. Competitive Criterion: Work Schedules _________________________________________________________________ 85
3. Competitive Criterion: Internal Risk Management/Loss Control Program ___________________________ 86
4. Competitive Criterion: Workforce Engagement ________________________________________________________ 86
D. MANAGEMENT ___________________________________________________________________________ 87
1. Competitive Criterion: Key Personnel __________________________________________________________________ 87
E. EMS SYSTEM AND COMMUNITY ________________________________________________________________ 88
1. Competitive Criterion: Supporting Improvement in the First Response System _____________________ 88
2. Competitive Criterion: Health Status Improvement and Community Education _____________________ 90
F. INTEGRATION WITH HEALTHCARE PROVIDERS _________________________________________________________ 92
1. Competitive Criterion: Collaboration with Healthcare Providers ____________________________________ 92
Table of Contents
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SECTION VI. FINANCIAL CRITERIA ________________________________________________________ 93
A. FINANCIAL STRENGTH AND STABILITY _____________________________________________________________ 93
B. FINANCIAL SITUATION DOCUMENTS ______________________________________________________________ 93
1. Financial Statements ____________________________________________________________________________________ 93
2. Audited Statements ______________________________________________________________________________________ 93
3. Financial Commitments _________________________________________________________________________________ 93
4. Working Capital _________________________________________________________________________________________ 93
5. Performance Security ___________________________________________________________________________________ 94
6. Financial Interests _______________________________________________________________________________________ 94
C. FINANCIAL PROJECTIONS _____________________________________________________________________ 94
1. Revenue projections _____________________________________________________________________________________ 94
2. Revenue Flow Projections _______________________________________________________________________________ 94
3. Expense Projections _____________________________________________________________________________________ 94
4. One-Time Start Up and Capital Items ___________________________________________________________________ 95
5. Pro Forma Summary ____________________________________________________________________________________ 95
D. PRICING _______________________________________________________________________________ 95
TABLE 1. CONTRA COSTA COUNTY POPULATION CENTERS ______________________________________________________________ 4
TABLE 2. ESTIMATED PAYER MIX _____________________________________________________________________________________ 9
TABLE 3. SCORING ALLOCATION ______________________________________________________________________________________ 21
TABLE 4. PROPOSAL REVIEW SCORING ALLOCATIONS _________________________________________________________________ 22
TABLE 5. RESPONSE TIME COMPLIANCE REQUIREMENTS FOR PLAN A ALL CONTRA COSTA COUNTY EMERGENCY RESPONSE
ZONES _________________________________________________________________________________________________________ 36
TABLE 6. RESPONSE TIME COMPLIANCE REQUIREMENTS FOR PLAN B _________________________________________________ 36
TABLE 7. COUNTY RESPONSE TIME PENALTIES _______________________________________________________________________ 42
TABLE 8. OUTLIER RESPONSE TIME PENALTIES _______________________________________________________________________ 43
TABLE 9. BREACH EVENTS AND PENALTIES ___________________________________________________________________________ 44
AAPPENDICES:
1. Mandatory Table of Contents
2. Map of Exclusive Operating Area
3. Emergency Response Zone Maps
4. County Ambulance Ordinance
5. Current Ambulance Zones Map
6. Call Density Response Areas in EOA
7. Current Ambulance Rates
8. Procurement Timeline
9. Required Forms
10. Stipulated Ambulance Charges
11. Subsidy Request Form
12. Insurance Requirements
13. Sample Standard County Contract
14. Basis for Revenue Projections Template
15. Revenue Flow Projection Template
16. Expense Budget Templates
17. One-Time Expense and Capital Budget
Template
18. Pro Forma Budget Summary Template
19. ALS Interfacility Price Sheet
Page 1
SECTION I. EMS SYSTEM SUMMARY
A. Overview
Request for Proposals: The County of Contra Costa (County) is a political subdivision of the State of
California. State law confers on the county’s Local Emergency Medical Services Agency (LEMSA) the
authority to designate exclusive operating areas (EOA) and to select its emergency ambulance
service providers through a competitive process. (California Health and Safety Code, Section
1797.224). Contra Costa County is conducting this procurement and is seeking a qualified ambulance
service provider to deliver these and certain related services in accordance with the expectations set
forth in this Request for Proposals (RFP).
Each entity responding to this RFP (Proposer) shall submit a written response (Proposal) setting
forth the Proposer’s qualifications and plans for meeting or exceeding the performance expectations
set forth in this RFP. Proposals must be organized to address each of the items and in the exact order
shown in the “Mandatory Table of Contents for Proposals” in Appendix 1.
The outcome of this RFP will be the selection of a Proposer (Contractor) with whom the County will
execute an exclusive, performance-based agreement (Agreement) for the provision of 1) a ground
emergency medical transportation system at a “paramedic Advanced Life Support” (ALS) level of
service; and 2) non-emergency interfacility paramedic ALS ambulance transports originating in
Contra Costa County. This includes the exclusive right and obligation to (i) respond to all ALS calls
originating from 9-1-1 or other telephone numbers and other emergency or urgent medical call
requests made through the County PSAPs public safety agencies, and other sources (Emergency
Ambulance Requests), (ii) provide care and/or transport patients within the emergency medical
services (EMS) system, and (iii) provide care and/or transport other patients requiring ALS
ambulance service, when the transports originate in the EOA.
The performance expectations set forth in this RFP and the performance commitments set forth in
the selected Proposal will be incorporated in the Agreement as mandatory performance standards.
Policy Goals of the Procurement: The County’s overarching goals in the conduct of this procurement
process are to: (1) promote public health and safety by preventing the loss of life; (2) minimize the
physical pain of patients; (3) reduce the costs associated with catastrophic injury or illness; and (4)
ensure good value in return for the investments of the customer and the community.
To achieve these overarching goals, the County is working to promote a quality EMS system that
includes the following essential elements:
Prevention and early recognition
Bystander action/system access
Medical Dispatch
Telephone protocols and pre-arrival instructions
First responder and ambulance dispatch
First responder services
Page 2
Transport ambulance services
Exchange of health information among providers
Integration of healthcare providers to improve survival and recovery
Direct (on-line) medical control
Receiving facility interface
Indirect (off-line) medical control
Independent monitoring
The County is taking a comprehensive systems approach to the overall EMS system of which
ambulance services are one important part. The RFP accordingly identifies geographic and density-
based response time zones and calls for the Contractor to meet specified response times within
defined timeframes in each of these zones.
This approach also calls for the County to maintain EMS coordination, oversight, and accountability,
while allowing the Contractor the flexibility to use its expertise and entrepreneurial talent to manage
its day-to-day operations. This model is intended to promote high-quality clinical care, efficiency,
economy, reliability, and operational and financial stability.
B. Exclusive Operating Areas (EOAs)
Proposers shall submit a Proposal for the designated Exclusive Operating Area (EOA). The
Designated EOA covers most of the territory of Contra Costa County. Not included in the Designated
EOA for this procurement are two smaller EOAs covering the territories of the San Ramon Valley and
the Moraga-Orinda Fire Protection Districts where paramedic ambulance services are provided by
the respective fire districts. (See Map of EOA in Appendix 2)
Proposers must agree to provide the services referred to above for the EOA without any qualification
or variation other than as expressly set forth in this RFP.
C. Proposals Must Include Response to Two Service Plans
The LEMSA has determined that the interests of the County can best be met by including two (2)
service plans for the provision of emergency medical services within the EOA. These plans are
designated Plan A and Plan B.
Plan A includes minor changes in the current system design, performance requirements, and
measurement zones. Plan B incorporates more changes as proposed in the March 2014 “EMS
Modernization Project Report” (available at http://www.cchealth.org/ems/system-
review.php#simpleContained4 ) to respond to operational, financial, and clinical trends and findings.
Each proposer is required to respond to both of the Plans.
Page 3
D. Background
The County has historically designated five ambulance zones. Plan A consolidates two of the Zones in
East County (D & E) while Plan B consolidates two additional Zones (A & B) in West County. The Zone
maps are included in Appendix 3.
The County has established an ambulance ordinance (83-28) that establishes broad standards for the
operations, equipment, and personnel of pre-hospital emergency care services. A copy of the
ordinance that may be amended is attached hereto in Appendix 4.
Additionally, requirements that are more specific can be found in the County’s policies, which are
incorporated into the provider agreements. Any successful proposer will be required to have a
provider agreement administered by the LEMSA. The County Policies and Procedures can be
downloaded at http://www.cchealth.org/ems/policies.php.
The EOA is a mix of urban, rural, and wilderness areas. Table 1 (below) lists the county cities and
communities with their population.
Page 4
Table 1. Contra Costa County Population Centers1
Community
Population
2013 estimate U.S.
Census
ER Zone (*) Notes Rural
Response Area
Requirements Included
Richmond 107,571 A
San Pablo 29,685 B
El Cerrito 24,086 B
El Sobrante 12,669 B
Kensington 5,077 B
Pinole 18,902 B
Hercules 24,848 B
Rodeo 8,679 B
Crockett 3,094 B
Port Costa 190 Rural B
Concord 125,880 C
Martinez 37,165 C
Pleasant Hill 34,127 C
Pacheco 3,685 C
Clayton 11,505 C
Clyde 678 C
Walnut Creek 66,900 C
Lafayette 25,053 C
Orinda 18,681 MOFD
Moraga 16,771 MOFD
Canyon 842 MOFD
Alamo 14,570 SRFD
Danville 43,341 SRFD
Diablo 1,158 SRFD
San Ramon 72,313 SRFD
Blackhawk 9,354 SRFD
Antioch 107,100 D
Pittsburg 66,695 D
Bay Point 21,349 D
Oakley 38,194 E
Bethel Island 2,137 Rural E
Knightsen 1,568 Rural E
Brentwood 55,000 E
Discovery Bay 13,352 Rural E
Byron 1,277 Rural E
Unincorporated 70,509 NA
Total 1,094,205
In conducting a competitive process for the provision of emergency ambulance services, Contra Costa
County is meeting the mandates of the California EMS Act and the Health and Safety Code, Division
2.5, available at www.emsa.ca.gov.
E. Overview of EMS System
Contra Costa County's LEMSA, as designated by the County Board of Supervisors pursuant to the
California EMS Act, is the Contra Costa Health Services Department. The governing body of the
LEMSA is the Board of Supervisors and the Chief Executive Officer, or Director, is the County Health
Services Director. Day-to-day activities and oversight of the County's EMS system is carried out by
the County EMS Agency, which is a division of Contra Costa Health Services. Key positions within the
County EMS Agency include the County EMS Director, who oversees County EMS activities, and the
1 Ibid
Page 5
County EMS Medical Director, who provides EMS medical oversight pursuant to State law. Both these
positions report to the Health Services Director, who is the LEMSA director.
A County ambulance ordinance regulates both emergency and non-emergency ambulance service.
Emergency ambulance service is further regulated through exclusive operating agreements in each of
the County’s three EOAs. First responder services are provided by six fire districts and three
municipal fire departments. Most first responder services are provided at the paramedic level in
accordance with County first responder agreements. Eight hospitals within the county are licensed to
provide Basic Emergency Services and designated as emergency ambulance receiving centers. One of
these, John Muir Medical Center in Walnut Creek, is a County-designated Level II Trauma Center. The
County also has five designated ST-elevation myocardial infarction (STEMI) receiving centers and six
stroke receiving centers. Two air ambulances (CalSTAR and REACH) are based in Contra Costa
County.
Requests for assistance to medical emergencies typically are made through the 9-1-1 phone system.
These calls are answered at a primary Public Safety Answering Point (PSAP) and, when identified as
involving a medical emergency, transferred to one of three County-designated medical
communications centers located at San Ramon Valley Fire (serving San Ramon Valley Fire),
Richmond Police (serving Richmond and El Cerrito Fire Departments), and Contra Costa County Fire
(serving Contra Costa County Fire, East Contra Costa County Fire, Rodeo-Hercules Fire, Pinole Fire,
Crockett-Carquinez Fire, and Moraga-Orinda Fire).
Personnel at the medical communications centers identify the caller’s needs in accordance with EMS
priority dispatch protocols, dispatch and/or request appropriate EMS resources, and provide pre-
arrival instructions when appropriate. For the areas covered by this RFP, dispatch information,
including the ambulance request, is transferred to the ambulance service from Contra Costa County
Fire dispatch or Richmond Police dispatch via the Message Transmission Network (MTN), a direct
microwave linkage between the medical communications center and ambulance dispatch computer
systems. The ambulance contractor is responsible for establishing and maintaining the necessary
hardware and software at the contractor’s dispatch center to integrate with the County MTN. The
ambulance contractor is also responsible for the actual dispatch of requested ambulance resources
(specification is available at http://www.cchealth.org/ems/pdf/mtnspec_v1.5.pdf).
The initial response to a potentially life threatening incident includes both a first response unit and a
paramedic-staffed ambulance. Most fire first response is at the paramedic level. Richmond, East
Contra Costa County, and Crockett-Carquinez Fire provide first response at the Basic Life Support
(BLS) level.
Emergency ambulance service is currently provided by the County's three emergency ambulance
contractors, American Medical Response in the areas covered by this RFP covering about 90 percent
of the County and by San Ramon Valley Fire and by Moraga-Orinda Fire in their respective districts.
All ambulances responding on emergency calls are required to have one paramedic and one
Emergency Medical Technician (EMT) as minimum staffing. Ambulances may be dispatched Code 3
Page 6
(lights and siren) or Code 2 (immediate response without lights or siren) depending on the priority
assigned by the medical communications center.
Currently, the Designated EOA is divided into five (5) Emergency Response Zones (ERZ’s) for
calculation of ambulance response times and penalties. The zones, shown in Appendix 5, are:
ERZ A—The City of Richmond
ERZ B – West County including the Cities of El Cerrito and Pinole Fire Departments, Rodeo-
Hercules Fire Protection District, Kensington Fire Protection District, Crockett-Carquinez
Fire Protection District, the portion of the Contra Costa County Fire Protection district
covering San Pablo, El Sobrante, North Richmond, and surrounding unincorporated areas.
ERZ C—Central County including the area of Contra Costa County Fire Protection District
covering the Cities of Clayton, Concord, Lafayette, Martinez, Pleasant Hill, and Walnut Creek
and surrounding unincorporated areas served by Contra Costa County Fire.
ERZ D—East County including Antioch, Bay Point and Pittsburg and surrounding
unincorporated areas served by Contra Costa County Fire.
ERZ E—Far East County including Oakley and Brentwood and unincorporated areas served
by East Contra Costa County Fire Protection District.
Patient treatment and transport are carried out under State laws and regulations, as well as County
EMS Agency policies and procedures. These policies may include, in the case of paramedics, making
contact with a mobile intensive care nurse (MICN) or physician at a designated base hospital to
obtain direction in management of the patient. Patients are transported to appropriate receiving
facilities. Hospital destination is based upon patient preference and County EMS protocols. Critical
patients are normally transported to a nearby emergency department or to a specialty care center
(trauma, STEMI, stroke), as appropriate. Non-critical patients may be transported to hospitals of
choice within reasonable travel time. Note that County EMS protocols may require transport of
certain patients to out-of-county specialty centers or hospital emergency departments. Medical
helicopter service is available to transport critical patients when ground ambulance transport time
would be excessive and patients meet helicopter transport criteria.
As a part of the STEMI Receiving Center system, the County, in 2011, began implementation of 12-
lead EKG transmission from the field to receiving hospital. The ambulance contractor will be
responsible for the continued support of this system.
Further information regarding Contra Costa's EMS system can be found in the Contra Costa County
Emergency Medical Services Agency's "2013 Annual Program Report" and in the "Emergency Medical
Services System Plan" approved by the Emergency Medical Care Committee and adopted by the
County Board of Supervisors. Both of these documents are available at the Emergency Medical
Services Agency and on the County EMS website at http://cchealth.org/ems/documents.php.
Page 7
F. Local EMS Agency Responsibilities
It is the LEMSA’s responsibility to:
Select and enter into an Agreement with the Contractor;
Provide contract administration and management services for the Agreement;
Monitor the EMS system’s performance and compliance with the performance based
specifications applicable to the Contractor;
Commit to the continued collaboration to provide high quality first response service on life-
threatening incidents;
Provide medical direction for the system;
Develop and modify EMS system protocols and procedures;
Create and sustain coordinated specialty systems of care e.g. Trauma, STEMI, Stroke, Cardiac
Arrest, etc.;
Contract with base hospitals to provide on-line medical control; and
Secure or provide, in the event of Contractor’s default, an alternative EMS delivery system.
G. Contra Costa EMS System Improvements
Changes and improvements in EMS have occurred during the last 10 years and healthcare has
changed considerably as has EMS. Numerous studies have been undertaken to ascertain which
practices will produce the best patient outcomes and what actions will have minimal positive
impacts. Technology has allowed EMS to improve response times and productivity and to provide
data for identifying practices that will deliver positive results for the patients and the system.
In preparation for this RFP, the County conducted a review of current practices in collaboration with
system stakeholders. The process identified improvement opportunities in the Contra Costa EMS
System. Although it is not the LEMSA’s intent or desire to create the most expensive, high-
performance EMS system in the country, the LEMSA is committed to ensuring that EMS services are
delivered at the comparable level of quality and performance enjoyed by users in other good quality
and reliably performing EMS systems.
The LEMSA is pursuing its overall goal to update the local EMS system through incorporating system
improvements in this RFP and its resulting Agreement.
Changes to the Contra Costa County EMS system are designed to strategically match emergency
ambulance resource to patient need, and improve care to patients without undue financial or
operational hardship on the Contractor.
1. Call Transfer and Dispatch
The goal for the EMS system is that all Emergency Ambulance Requests for medical assistance be
promptly transferred (within 60 seconds) from the medical communications centers to the
Contractor. The goal is also for all calls to be prioritized as to acuity level according to protocols
approved by the LEMSA. When appropriate, all callers will receive emergency medical pre-arrival
instructions according to protocols approved by the LEMSA.
Page 8
2. Call Density Response Zones, Response Time Requirements and Non-performance
Penalties Established
Call Density Response Zones are defined within the EOA. The requirements are based on an analysis
of the historical volume and density of calls, as well as population density and city boundaries.
Performance requirements are based on call location and call acuity (Priority 1, 2 or 3) as
determined through emergency medical dispatch protocols. The details of the response time
requirements are provided in detail in Section IV.C.3.
The Contractor’s response time clock begins when the call is time stamped as received by the
Contractor’s dispatch center.
Response time compliance is to be maintained on 90% of all calls. Failure to perform will result in
financial penalties and may cause the replacement of the Contractor as described in Section IV.C.7.
Appendix 6 includes maps indicating the Call Density Response Zones within the EOA.
3. Provider Fatigue
Provider fatigue and the impairment associated with the fatigue pose a significant safety risk for
patients, partners, and others in the community. Crewmembers working on ambulances in Contra
Costa County shall not be scheduled to work shifts longer than 24 consecutive hours and shall not
remain on duty for longer than 36 consecutive hours due to late calls or unscheduled holdovers. A
rest period of at least 12 consecutive hours between shifts is required. The only exception will be a
County declared disaster.
4. No Subsidy System
The Contra Costa County EMS system operated for years without subsidy to ambulance providers. It
is the LEMSA’s desire that Contra Costa County emergency ambulance providers will continue to
operate within the system without additional subsidy, but the financial and operational trends
identified in the “EMS Modernization Report” indicate that the operational status quo may require
funding support. Plan A includes the opportunity for quantifying additional funds needed by the
Contractor during the term of the Agreement, if necessary. Plan B assumes no subsidy from the
County or LEMSA.
H. Relevant Information Regarding Service Areas
The LEMSA makes no representations, promises, or guarantees concerning the actual number of
emergency and non-emergency calls or transports, number of patients or distance of transports
associated with this procurement. Every effort has been made to provide accurate information, but
Proposers will need to use their professional judgment and expertise to develop estimates, economic
models and operational plans and proposals.
Page 9
1. Historical Service Volume
Call volume in the EOA are included in the EMS Agency’s annual report and can be downloaded
at http://cchealth.org/ems/pdf/annual-report-2013.pdf. Three years of call data including date and
time of call, priority of call, longitude/latitude, location, and city are available at the LEMSA website.
The location information has been altered to mask actual response locations by randomly adding or
subtracting a number between one (1) and four (4) from the numerical portion of the street address.
There has been no independent validation of this data and Proposers are encouraged to use their
own means to analyze the information to determine response and transport volumes. The LEMSA
does not guarantee any number of responses or transports.
2. Current Ambulance Service Rates
Current providers are required to receive approval of rates from the LEMSA and County. The current
ambulance service rates are included in Appendix 7.
3. ALS Ground Ambulance Transports Not Originating from 9-1-1
Ground ALS ambulance transports originating within the EOA that are not routed through the
Emergency Ambulance Request (9-1-1) system – specifically the ALS interfacility transports staffed
with at least one paramedic– are included in the EOA scope of services. These transports were not
previously included in the EOA’s exclusivity and the quantity, origins, destinations, and time of calls
are not available. The Agreement will include such transports, granting the Contractor the exclusive
right to provide these services and the Proposers should use their own expertise while conducting
their due diligence to quantify the ALS interfacility transports.
4. Payer Mix
The current provider reports the following transport volume and payer mix information in Table 2.
Table 2. Estimated Payer Mix
Payer Percent of Transports
Medicare & Medicare HMO 42.9%
Medi-Cal & Medi-Cal HMO 26.3%
Insurance 14.4%
Private Pay & Other 16.4%
Total 100.0%
Since the payer mix determines potential revenue recovery and anticipated healthcare changes may
have a significant impact on the payers, the Agreement will provide that should the Contractor
demonstrate to the LEMSA’s satisfaction that the insured category is at least three (3) percentage
points lower than listed or that the MediCal or self pay category is at least three (3) percentage points
higher than identified, the variation will be grounds for a rate adjustment as provided in Section
IV.G.3.b. For example, if Medi-Cal transport percentages exceed 29.3% the Contractor can request a
rate adjustment.
Page 10
SECTION II. PROCUREMENT INFORMATION
A. Performance-based Contract
The result of this procurement will be the award of a performance-based contract. The Agreement
will require the Contractor to achieve and maintain high levels of performance and reliability. The
demonstration of effort, even diligent and well-intended effort, will not suffice to meet the
requirements of the Agreement with respect to prescribed performance requirements. Failure to
meet specified service standards will result in financial penalties and may lead to termination of the
Agreement.
The essential areas where performance must be achieved include:
Ambulance response times;
Ambulance equipment and supply requirements;
Ambulance staffing levels including personnel with current and appropriate levels of
certification/licensure;
Clinical performance consistent with approved medical standards and protocols;
Management and field supervision;
On-going training and continuing education;
Collaboration with other emergency responders and medical personnel;
Comprehensive quality improvement and compliance activities and results;
Accurate and timely reporting; and
Customer and community satisfaction with the services provided.
The Agreement is not a level-of-effort contract. In submitting its Proposal, the Proposer is agreeing to
employ whatever level of effort is necessary to achieve the clinical, response time, customer
satisfaction, quality improvement, and other performance results required by the EMS System
Specifications.
B. Notice to Proposers
The issuance of this RFP does not commit the LEMSA to accept proposals, complete the selection
process, award a contract, or pay any costs incurred in the preparation of a Proposal responding to
this RFP. The LEMSA reserves the right to reject all Proposals, reject any Proposal that is not
responsive to or conforms to the requirements of this RFP, or to cancel the procurement process at
any time.
Submission of a proposal by a Proposer shall constitute an agreement to the provision for public
announcement. The LEMSA intends to post the Proposals within twenty-four hours (24) of the public
opening.
Submission of a Proposal to this RFP constitutes a complete waiver of any claims whatsoever against
the LEMSA or the County that it has violated a Proposer's right to privacy, disclosed trade secrets or
caused any damage by allowing the Proposal to be made publically available.
Page 11
C. Use of Own Expertise and Judgment
Each Proposer must use its own best expertise and judgment in deciding on the methods to be
employed to achieve and maintain the performance required under the resulting Agreement. As used
here, “methods” includes, without limitation, compensation programs, shift schedules, personnel
policies, asset acquisition, supervisory structure, deployment plans, and other business matters that
comprise the organizations strategies and activities.
D. Procurement Time Line
The Procurement Time Line is included in Appendix 8 (the Procurement Time Line). Any changes to
the Procurement Time Line will be published on the LEMSA website and organizations requesting
the RFP will be notified by the LEMSA.
E. Procurement Process
Administrative support for this process will be provided to the LEMSA by county Health Services
Department (HSD).
1. Pre-proposal Process
Questions regarding this RFP should be submitted in writing to:
Patricia Frost,
EMS Director
Contra Costa County EMS Agency
1340 Arnold Drive, Suite 123
Martinez, CA 94553
Facsimile (925) 646-4379
Patricia.Frost@hsd.cccounty.us
Questions or requests for clarification regarding the RFP will be accepted prior to the Proposers’
Conference, but no later than 4:00 p.m. on the date specified in the Procurement Time Line
(Appendix 8).
2. Mandatory Proposers’ Conference
A Proposers’ conference will be held on the date identified in the Procurement Time Line (Appendix
8) to allow County staff and consultants to discuss all relevant issues associated with the Request for
Proposal and to permit Proposers an opportunity to ask questions. Each Proposer will be limited to
not more than four (4) representatives in attendance.
Proposers shall submit, in writing, any questions about the RFP that they would like answered at the
Proposers’ Conference no later than three (3) working days before the conference. This will allow for
a more thorough response.
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The Proposers’ Conference may be taped and answers to questions will be posted to the LEMSA
website following the conference. Oral answers at the conference will not be binding on the LEMSA.
Any changes or clarifications to the Request for Proposal made following the Proposers’ Conference
will be distributed to all potential Proposers who attend the Proposer’s Conference and will be
posted on the LEMSA website. The Proposers’ conference is mandatory.
3. Proposal Submission
Each Proposer must submit one (1) original and ten (10) copies of its Proposal by 4:00 p.m., Pacific
Time on the date specified in the Procurement Time Line (the Deadline). A CD-ROM, or other
electronic storage device, of the Proposal and attachments in Microsoft Word or PDF format shall
accompany each Proposal. Any Proposals received after the deadline will not be considered.
Proposals shall remain in effect for a period of one hundred and twenty (120) days after the Deadline.
Proposals shall be submitted in a sealed container. The outside of the container and each Proposal
shall be labeled “Exclusive Operator for Emergency Ambulance Service Proposal For Contra Costa
County, California”and the Proposer’s name.
One (1) original and five (5) copies of the required Financial Documents shall be included in the
sealed container but placed in a separate, sealed envelope marked with the Proposer’s name and
labeled “Financial Documents.” The Financial Documents are described in Section VI.
Proposals shall be delivered to:
Contra Costa County EMS Agency
1340 Arnold Drive, Suite 126
Martinez, CA 94553
Attention: Patricia Frost
4. Public Proposal Opening
All proposals received prior to the Deadline shall be marked with a proposal number (EMS-1, EMS-2,
etc.) and the date and time of receipt and kept unopened and secured in a locked area. Such
Proposals shall be publicly opened at 1340 Arnold Drive, Suite 126, Martinez, CA 94553, at the time
and date specified in the Procurement Time Line. The RFP number, submission date, general
description of service being requested, and name of each Proposer will be recorded and read aloud to
the persons present. The contents of the Proposals shall not be reviewed or disclosed at the public
opening.
5. Additional Proposer Responsibilities
At any time following the opening of Proposals, the LEMSA may request a Proposer to provide
additional information or documentation for clarification of its Proposal. Proposers will also be
requested to make a formal oral presentation to the proposal review panel (the Review Panel) and to
respond in person to questions from the panel. Such requests must be fulfilled by the Proposer or its
Proposal may be rejected.
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6. Notice of Intent to Award
The LEMSA will issue a “ Notice of Intent to Award.” At the time of the issuance of the Notice of Intent
to Award, non-winning proposers’ right to protest will become ripe, and LEMSA staff will begin the
process of placing the contract award on a future agenda of the Board of Supervisors for
recommendation. Although the Notice of Intent to Award may tentatively identify a Board of
Supervisors meeting date upon which the award recommendation will be considered, such date
selection shall not be binding upon the LEMSA or the County. If there are any delays in the
procurement timeline, all Proposers will be notified by the LEMSA.
F. Proposal Instructions
1. Proposal Format
Proposals should be concise and directly respond to the required information in this RFP. To
facilitate the evaluation process, Proposals shall be limited in size.
The entire Proposal and exhibits shall be contained within two (2) 2-inch, three-ring binders. One
binder shall contain the narrative (Proposal Narrative) and the second the exhibits (Proposal
Exhibits). Excepted from these restrictions are any information submitted in response to Sections
III.A.4 and 5, below.
The Proposal Narrative shall adhere to the following specifications:
Easily readable font, no smaller than 10 point;
Line spacing no smaller than 1 ½ lines;
Single sided page printing;
Standard 8 ½” by 11” paper;
Pages must be numbered sequentially; and
Pages are limited to 250 pages per binder excluding title page, table of contents, and
dividers
All attachments and exhibits shall be inserted in the second binder. Each exhibit and attachment shall
be labeled and referenced in the narrative.
2. Required Proposal Format
a) Mandatory Table of Contents
The Proposal Narrative shall respond to each topic listed in the Mandatory Table of Contents
in the exact sequence that the topics appear in the Mandatory Table of Contents. The
Proposal must utilize the stipulated section and heading titles and numbering set forth in the
Mandatory Table of Contents. The response to each item must contain all of the information
that the Proposer is providing with respect to that topic. The response may incorporate by
reference information contained in the Proposal Exhibits, but may not incorporate by
reference any information contained in other portions of the Proposal Narrative. With the
exception of information appearing in a Proposal Exhibit that is expressly referenced in a
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response, information not set forth in the portion of the Proposal Narrative clearly identified
as responding to a specific topic on the Mandatory Table of Contents may be disregarded in
the rating of the Proposal. Reviewers may disregard information submitted in the Proposal if
it is not included in the mandated location defined by the Mandatory Table of Contents.
b) Required Proposal Sections
The Proposal Narrative shall be divided into the following five sections:
Section I Executive Summary.
Section II Required Forms as specified in Appendix 9 of this RFP
Section III Proposer’s demonstration of the appropriate credentials and ability to meet
the minimum qualifications set forth in Section III of this RFP
Section IV Proposer’s response to the basic performance and operational
requirements set forth in Section IV of this RFP (the Core Requirements).
Failure to commit to each of the Core Requirements may result in the
Proposal being disqualified and deemed unresponsive.
Section V Proposer’s response to the competitive criteria set forth in Section V of this
RFP (the Competitive Criteria). The Competitive Criteria will be reviewed,
evaluated, and scored in the Proposal review process.
Proposals shall provide all information requested in this RFP in the order that it is requested.
Performance standards for emergency ambulance service are identified in multiple sections
of this RFP and shall be addressed in the manner stipulated for each standard. Proposers
may elect to use reference "exhibits" or "attachments" in the Proposal Narratives to provide
additional detail.
G. Proposal Evaluation Process
1. Proposal Review Panel
The Proposal review process shall be managed by the LEMSA through its Consultant. A multi-
disciplinary panel of four (4) independent EMS professionals shall be selected by the Consultant with
approval of the LEMSA to evaluate and rank Proposals. A fifth member of the Review Panel will be
selected by the County and be an independent resident of the County. Meetings of the Review Panel
will be closed to the public, with the exception of the “observers” provided for below. The outcome of
the deliberations of the Review Panel shall be submitted to the LEMSA. The LEMSA shall review the
submission and may consider any and all other pertinent information.
To assure a fair process, members of the Review Panel will be instructed to avoid discussing any
Proposal or the RFP process with any Proposer or other individual not present during the evaluation
prior to the public announcement of the outcome of the deliberation. Until the outcome of the
deliberations of the Review Panel has been submitted to the Health Services Director, Proposers shall
avoid any communications regarding Proposals or the RFP process with any member of the Review
Panel, observers, Board of Supervisors, LEMSA or County staff outside of the formal procurement
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process during the period commencing with the release of the RFP until either the expiration of the
protest period or the resolution of any protest that may be filed. The names of the Review Panel
members will not be disclosed prior to the RFP submission deadline. If it is determined that a
Proposer attempted or had such precluded communications, or otherwise at any time attempted to
unduly influence the selection process except in a manner explicitly approved in the RFP, Proposer’s
Proposal may be disqualified.
The County will invite two (2) local observers (the Observers) to attend the meetings of the Review
Panel at which the Proposals will be reviewed and scored. Observers will be provided copies of the
Proposals to follow discussions during the review process but will not remove the Proposals from
the premises. The Observers will not participate in the discussion or scoring process or act in any
way to influence the outcome of the RFP. They will be present to ensure the integrity of the process
and to provide information to the public about the rating of Proposals after the process has
concluded. Observers shall not have a conflict of interest, shall be able to confirm that they are
supportive of an objective and fair competitive procurement, and must agree not to take any action
to influence the outcome of the procurement process. Observers shall agree to keep the deliberations
of the Review Panel confidential until they have been completed and the Review Panel’s scoring
results have been forwarded to the Health Services Director.
2. Proposal Review Process
The review of the proposals will determine whether the Proposers meet minimum requirements and
qualitifications, verify that the Proposers agree to meet all of the Core Requirements, and score each
of the Competitive Criterion resulting in points being assigned to each Proposal.
The detailed proposal evaluation process will encompass three stages.
a) The Review Panel will review the documentation provided in each Proposal to
determine if the Proposer meets the Minimum Qualifications. Each criterion will be
scored on a pass/fail basis. If the Reviewers identify a Proposal that does not meet
Minimum Qualifications, the Proposal or Proposals not meeting all Minimum
Qualifications will be referred to the LEMSA. The LEMSA will make a recommendation to
the Health Services Director for final determination. Proposals that, in the judgment of
the Health Services Director, do not meet the minimum requirements for experience,
qualifications, and financial capabilities will be considered unresponsive and
disqualified.
b) The Review Panel will then review the documentation in the Proposals related to the
Core Requirements. The Proposals must include an affirmative statement agreeing to
each Core Requirement without qualification. If any Proposer fails to include affirmative
agreement to the Core Requirements or with the minimum requirements listed in
Section V (the Minimum Requirements), the Review Panel will refer the nonconforming
Proposal or Proposals to the LEMSA. The LEMSA will confer with the Health Services
Director and the Health Services Director will make a final determination. If the
exceptions to the Core Requirements and Minimum Requirements in the Proposal(s) are
deemed material in the sole opinion of the Health Services Director, the Proposal will be
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considered unresponsive and disqualified. If the exceptions are not deemed material, the
Health Services Director may waive the irregularity and allow the proposal review to
continue or may request additional information from the Proposer to resolve the
exception.
c) The Review Panel will then evaluate, compare, and score the Competitive Criteria.
d) After completion of the Review Panel’s review and scoring of the Proposals, the
consultants will calculate the points and combine with the pricing points ALS
interfacility transports and will present the results to the LEMSA for consideration.
The responses to the Competitive Criteria set forth in the Proposals shall be reviewed and rated
as follows:
Each member of the Review Panel shall read each Proposal prior to the convening of the
panel.
The Review Panel will convene and be provided with an overview of the review and
rating process.
The information provided to document the Minimum Qualifications will be reviewed
and scored as either pass or fail.
The responses to the Core Requirements and Minimum Requirements will be reviewed
to confirm an affirmative and unqualified acceptance of the provisions.
Each criterion of the Competitive Criteria will be evaluated separately (e.g. Clinical
Offerings, Operational Proposals, etc.). After a full discussion is completed for a specific
Competitive Criterion, each Review Panel member will complete the individual ranking
sheet for that Competitive Criterion using the scoring guidelines set forth below.
The ranking sheet completed by each reviewer will be collected by the Consultant, who
will enter the ratings into the master score sheet that will be used to calculate the total
points awarded to each Proposal.
The scores applicable to pricing will be calculated by the Consultant and combined with
the scores resulting from the panel’s review.
Subsequent to the Proposers’ presentations to the Review Panel, the Review Panel will
reconvene and each Reviewer will be allowed to view and modify any scores awarded to
a Proposal if he or she believes that information presented or answers received in
response to Review Panel member inquiries would, in the Reviewer’s sole opinion,
justify a scoring change for specific criteria.
After the Review Panel has completed the review of all Proposals, the scores of the
reviewers will be averaged to determine the total points awarded to each Proposal for
the Competitive Criteria.
The Competitive Criteria will include separate scores for each of the two Plans (A and B)
when applicable.
The results of the Review Panel and the rankings of the Proposals will be combined with
the scores derived from the Financial Analysis conducted by a separate, independent
organization. The combined scores will be forwarded to the Health Services Director.
The Health Services Director will, after consideration of the Review Panel rankings and
scores and any other relevant factors, make his or her recommendation to the County
Board of Supervisors (Board). The Health Services Director shall identify to the Board, as
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the tentative awardee, the Proposal receiving the highest score from the Review Panel
unless the Health Services Director: (i) identifies a material procedural error in the
procurement process; (ii) determines that the procurement process has failed to achieve
the LEMSA’s goals as set forth in this RFP; or (iii) subsequent investigation of Proposer
receiving the highest score reveals material information for the Health Services Director
to reasonably conclude that the recommendation would not be in the best interests of
Contra Costa County and its residents. . In the event of any such exception, the Health
Services Director shall set forth in writing the basis for his or her tentative decision.
The final decision regarding an award shall rest with the Board.
The consulting firm shall observe and serve as staff to the Review Panel.
3. Method for Competitive Scoring of Price Proposals
Prices for all calls originating from the 9-1-1 system are predetermined and presented in Appendix
10.
Points will be awarded only for the proposed pricing of ALS interfacility transports and based on the
following calculation:
ALS non-emergency transports (not originating from 9-1-1)
ALS Non-emergency Base Charge $____X
Mileage Charge: multiply the proposed per-mile charge times 12 miles
____
$____Y
Oxygen Charge: multiply the proposed oxygen charge times 90 percent
____
$____Z
___
Weighted Charge $_X+Y+Z
_
The proposal with the lowest weighted charge will receive the maximum available score assigned to
pricing under the RFP. Other proposals will be scored by multiplying the percentage by which their
weighted charge exceeds the lowest proposed weighted charge and subtracting that amount from the
maximum available score.
For example, the RFP is structured to allow 50 points for price. If the Weighted Charge for Proposal
#1 is $1,000, for Proposal #2 is $1,100, and for Proposal #3 is $1,500. Proposal #1 has the lowest
charges, so it receives 50 points for pricing. Proposal #2 exceeds Proposal #1 by 10%, so it receives
45 points for pricing. Proposal #3 exceeds Proposal #1 by 50%, so it receives 25 points for pricing.
4. Independent Financial Analysis
The County has engaged an independent entity to analyze, express an opinion, and provide a
supplemental report regarding the financial aspects of Proposals. This will include expressing an
opinion on the Proposers’ financial strength, pro forma projections (including revenue and expense
projections), the ability of the Proposers to identify and fund initial startup costs and the on-going
ability of the Proposers to fund losses if projections are underestimated.
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The supplemental report containing the financial analysis of the Proposers’ submissions will be
provided to the Health Services Director for consideration in determining the firm to be notified of
the Intent to Award.
The Review Panel will not review or even see the financial documents in order to ensure that the
evaluation of the technical and quality aspects of the proposals are not influenced by financial issues.
5. Post-submission Presentation
Proposers will be asked to meet with the Review Panel to present a brief overview of their Proposals
and answer questions. The date of the Proposers’ presentations is included in the Procurement
Timeline.
6. Investigation
Upon completion of Review Panel evaluations, the Consultant may undertake additional investigation
to verify claims made by the recommended Proposer during the Proposal evaluation process. Such
additional investigation may include, without limitation, site visits, reference checks, financial
inquiry, or any other reasonable means of determining the accuracy and completeness of information
supplied by the Proposer.
The LEMSA reserves the right to continue its investigation of representations made by a Proposer
after contract award and throughout the term of the Agreement. The furnishing of false or misleading
information during the procurement process may constitute a major breach of the Agreement even if
discovered after contract award.
7. Notification
Proposers will be notified of the status of their Proposal (recommended for selection, not
recommended for selection, or disqualified) following completion of the proposal review process.
Notification will be by electronic mail to the address listed in the Proposal.
If a Proposal is disqualified, the Proposer will be notified, in writing, of the specific reason that
caused the disqualification.
At the completion of the Review Panel’s evaluation process and the Health Services Director’s receipt
and consideration of the panel’s deliberations and the supplemental financial analysis report, the
Health Services Director will issue a Notice of Intent to Award.
8. Debriefing
A debriefing shall be held before the award of the Contract upon the timely request of an
unsuccessful Proposer for the purpose of receiving information concerning the evaluation of the
Proposer’s submission. The request must be in writing, dated, signed either by the Proposer or a
legally authorized individual on behalf of the Proposer and be received by the County’s EMS Agency
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at 1340 Arnold Drive, Suite 126, Martinez, CA 94553, within three (3) working days following the
County’s issuance of the “Notice of Intent to Award”. Each requesting Proposer will be allotted a
maximum of one hour for any debriefing conference. The information provided by the County will be
based on the Review Panel determinations of the company’s submitted proposal as it relates to the
evaluation criteria as stated herein. The debriefing may be held, in the discretion of the County, by
telephone conference call. The debriefing is not the forum to challenge the proposal’s specification,
requirements, or the selection criteria.
9. Protest
Within fourteen (14) calendar days following issuance of the Notice of Intent to Award, non-
successful Proposers shall have the right to file a protest (the Protest). A Proposer filing a Protest
(Protester) must follow the procedures set forth herein. Protests that do not follow these procedures
shall not be considered. Notwithstanding any other protest or appeal procedures, the protest
procedures herein constitute the sole administrative remedy available to the Protesters under this
RFP. Only entities which were non-successful Proposers shall have standing to file Protests. Any
Protest not filed and received by the Health Services Director within the fourteen (14) day period
shall be conclusively deemed waived.
a) Filing a Protest
The Protest of the Notice of Intent to Award must be in writing. The written Protest must be
hand delivered, electronically transmitted, or mailed to:
Contra Costa County EMS Agency
Patricia Frost, EMS Director
1340 Arnold Drive, Suite 126
Martinez, CA 94553
Facsimile (925) 646-4379
Patricia.Frost@hsd.cccounty.us
Protests will be considered filed when they have been received at the above address. Upon
the filing of any protest, the full contents of the protest will promptly be made available to all
proposers by LEMSA staff.
b) Contents of Protest
The written Protest must contain the following information: 1) the name, street address,
electronic mail address, and telephone and facsimile number of the Protester; 2) signature of
the Protester or its authorized representative; 3) grounds for the Protest; 4) copies of any
relevant documents; 5) the form of relief requested; and 6) the method by which the
Protester would like to receive the initial written Protest decision. The written Protest must
clearly state the grounds for the Protest. Protests should be concise and logically arranged.
c) Grounds for Protest
Protests shall be based only on the following grounds: The Protester believes that its
proposal should have been selected had the LEMSA followed the procedures and adhered to
requirements set forth in the RFP.
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d) Protest Resolution Process
(1)
The initial review of any protest will be conducted by the Health Services Director. Upon
receipt of the Protest, the Health Services Director will schedule, at the earliest possible
convenience, meeting(s) between the Protester and appropriate county staff to clarify
the issues and/or attempt to seek informal resolution. The Health Services Director will
notify the protesting party and all Proposers of his or her decision in writing.
Informal Meeting with Health Services Director
(2)
The Protestor may request a review of the Health Services Director’s decision by
submitting a written notice of appeal to the Health Services Director, or his designee, no
later than five (5) business days after the date of the written decision. Within five (5)
business days after the Health Services Director receives the Protestor's request for
review he will forward the notice of appeal and written protest to the Office of the
County Administrator for review and final decision. The County Administrator will base
his decision on the information contained in the original written protest and the written
decision of the Health Services Director, but he may request additional information from
the Protestor, the LEMSA, the Health Services Director, or others, for clarification if he
deems it appropriate to do so. The decision of the County Administrator on the merits
and remedies, if any, is final
Appeal of Health Services Director’s Decision
(3)
A final award shall not be made while a Protest is pending. However, LEMSA staff may
otherwise proceed with developing the contract provided for in this RFP; subject to the
resolution of any Protest. Once the County Administrator has issued his/her decision on
the Protest, if the Protest is denied the procurement process may proceed as though no
Protest was filed. In addition, in the event that a Protest substantially delays this
procurement process, the LEMSA may, in its discretion, engage in contracting activities
for interim ambulance service until the procurement process can move forward and a
permanent Agreement can become effective.
Stay of Procurement Action during a Protest
10. Withdrawal of Proposals
Once submitted, Proposals may be withdrawn by the Proposer at any time prior to the Deadline by
written notice to the LEMSA.
11. Canceling the Procurement Process after Opening
The LEMSA may, in its discretion, cancel this procurement process at any time up to the formal
approval and execution of the Agreement. In the event the LEMSA cancels the procurement, it shall
set forth the reasons in writing why the public interest is best promoted by such cancellation.
12. Award
The decision on contract award will be made by the Contra Costa County Board of Supervisors
following the recommendation from the Health Services Director. If for any reason the selected
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Proposer is unable to enter into the Agreement in a timely manner in accordance with the time
interval identified in the Procurement Time Line for contract negotiation, the Health Services
Director, upon direction from the Board, may proceed toward selection of an alternate Proposal,
cancel the process, or otherwise proceed as may be required in the public interest and consistent
with applicable law. However, the above action does not eliminate the fact that if the initial awarded
party is in breach of the contract, the County is entitled to seek any and all damages for such breach,
including loss of time, cost of resources and attorney fees.
13. Scoring Criteria
The goal of this procurement is to select the Contractor based on clinical and operational quality of
service, while also containing service costs to the public and ensuring financial stability. To achieve
this end, the Proposals will be scored on three categories; first, Competitive Criteria, which are
designed to objectively identify Proposals that will provide for higher service quality and cost
effectiveness. Second, Proposals will be scored based on the service charges to be imposed by the
Proposer for the ALS interfacility transports. In addition, the financial strength of the Proposer and
the reasonableness of its financial projections will be considered independently.
Since this process is focused on a comparison of the Proposers’ responses to the Competitive Criteria,
the review and scoring of the proposals will be based on comparing responses of Proposers to each
of the criterion. Each criterion will be allocated a specific number of maximum available points.
During the deliberations of the Review Panel, minimum requirements for each of the Competitive
Criterion will be described to the reviewers and the reviewers will then discuss the item and any
offerings that have been presented to exceed minimum requirements. Once the discussion is
completed, each Reviewer will independently evaluate the criterion and mark the rating sheet in the
applicable category described below.
The points awarded for the criterion will be based on the reviewer’s opinion of each proposal’s
commitment to the relevant item being reviewed. Five potential ratings will be available for the
reviewer. They are:
Table 3. Scoring Allocation
Rating Poor Adequate Good Very Good Excellent
Percentage of total
points for criterion 0% 25% 50% 75% 100%
Each of the Competitive Criteria stipulates minimum requirements that must be addressed and
accepted by the Proposers. Failure to address and commit to the minimum requirements may result
in the disqualification of the Proposal as being unresponsive. No points will be awarded to the
Proposal that offers to only meet the minimum requirements. Points are awarded only to Proposals
that exceed minimum requirements for a specific criterion.
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14. RFP Governed by Its Terms
This RFP shall be conducted in accordance with the terms set forth within it. It shall be construed in a
manner consistent with applicable law and rules including, but not limited to, the California State
Emergency Medical Services Act, Contra Costa County Ordinances, and published procurement
guidelines of the California State EMS Authority. Such authorities may be consulted for the resolution
of ambiguities and to provide terms not expressly provided herein.
H. Scoring Matrix
The Competitive Criteria are organized in Section V into categories. The maximum points available
for each category of Competitive Criteria are set forth below.
Table 4. Proposal Review Scoring Allocations
Category Title Total Points
1 Credentials and Qualifications Pass/Fail
2 Core Requirements Agree/Exception
3 Competitive Criteria-Minimum Requirements Agree/Exception
4 Competitive Criteria-Commitment to Clinical Quality 300
5 Competitive Criteria-Operations Management 300
6 Competitive Criteria-Commitment to Employees 250
7 Competitive Criteria-Management and Administration 175
8 Competitive Criteria-Commitment to EMS System and
Community
300
9 Competitive Criteria-Healthcare Integration 250
10 ALS Interfacility Pricing 75
11 Financial Qualifications Pass/Fail
12 Financial Strength and Projections Acceptable/Not
Acceptable
TOTAL POSSIBLE POINTS 1,650
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SECTION III. MINIMUM QUALIFICATIONS
A. Organizational Disclosures
The Proposer must be a single legally established entity, but there are no preclusions of multiple
organizations forming an entity to respond to this RFP. If such a “joint venture” is proposing on this
RFP, questions regarding experience, organizational structure, financial strength, and other items in
this RFP must be answered for each member of the “joint venture.” The Proposer must provide the
following information about its organization, experience, litigation, licenses, investigations, and other
items:
1. Organizational ownership and legal structure
The Proposer shall describe its legal structure including type of organization, its date, and state of
formation.
2. Continuity of business
The Proposer shall provide the organization’s background and number of years under present
business name, as well as prior business names.
3. Licenses and permits
The Proposer shall provide copies of business or professional licenses, permits or certificates
required by the nature of the contract work to be performed. If Proposer does not have a local
operation, examples of state licenses, and local permits for other operational locations may be
submitted to fulfill this requirement.
4. Government investigations
The Proposer shall provide a listing of all federal, state, or local government regulatory investigations,
findings, actions or complaints and their respective resolutions for the Proposer’s organization and
any parent or affiliated organization within the last three (3) years. THIS ITEM MAY BE SUBMITTED
SEPARATELY IN AN ELECTRONIC FORMAT SUCH AS COMPACT DISK OR USB DRIVE and will not
count against the limits on Proposal length set forth in Section II.F.2.
Proposer must provide documentation that it has resolved all issues arising from government
investigations including any continued obligations of the Proposer or describe status and expected
outcome of open investigations.
5. Litigation
The Proposer shall provide a listing of all resolved or ongoing litigation involving the Proposer’s
organization including resolution or status for the last five (5) years. This listing shall include
litigation brought against the Proposer’s organization or affiliated organization and any litigation
initiated by the Proposer’s organization or affiliated organization against any governmental entity or
competing ambulance service. THIS ITEM MAY BE SUBMITTED SEPARATELY IN AN ELECTRONIC
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FORMAT SUCH AS COMPACT DISK OR USB DRIVE and will not count against the limits on Proposal
length set forth in Section II.F.2.
Proposer must provide documentation that it has resolved all issues arising from litigation or
describe status of open litigation.
B. Experience as Sole Provider
The Proposer must demonstrate its experience as a sole provider of paramedic emergency
ambulance services for a specified area comparable in size and population to the Exclusive Operating
Area defined in this RFP. A population greater than 300,000 in a service area is acceptable as a
comparable service area. Documentation shall include:
1. Demonstrate Capability in Lieu of Experience
If the Proposer does not have direct comparable experience in being the sole provider of paramedic
emergency ambulance service, the Proposer must document in detail how it intends to fulfill its
obligations specified in this RFP. This may be done by providing a comprehensive deployment plan
identifying the ambulance locations, unit-hour distribution, and procedures for redeploying
resources based on demand. Alternatively, the Proposer may delineate personnel who have such
experience and that these individuals will be actively and directly involved in the delivery of services
in the EOA.
2. Comparable experience
The Proposer must document the areas in which it has provided comparable services (as described
above) in the past five (5) years, the locations of these services, population, description of services
and a jurisdictional contact. This documentation shall include a letter from a government official
confirming the ability to provide exclusive emergency paramedic ALS ambulance service and the
length of time such services have been provided. Proposer shall document that it currently provides
comparable services for a minimum of three (3) consecutive years. Letters and documentation of sole
provider status are limited to three jurisdictions.
3. Government contracts
The Proposer shall provide a list of exclusive service area emergency ambulance service contracts
completed or ongoing during the last five (5) years including the term or date of termination of the
agreement, the services provided, the dollar amount of the agreement and the contracting entity.
4. Contract Compliance
The Proposer shall detail any occurrence of its failure or refusal to complete a contract with a
governmental entity for which the Proposer was providing emergency ambulance services. This shall
specifically state whether the Proposer or affiliated organization was found in material breach of the
contract and the reasons why the contract was terminated. If the Proposer has been found in
material breach of a governmental contract or if the Proposer “walked away” from its obligations
Page 25
under a governmental contract within the last five (5) years, the Proposal may be rejected as not
complying with Minimum Qualifications.
C. Demonstrated Response Time Performance
The Proposer must provide documentation of its demonstrated ability to meet response time
requirements similar to those required in this RFP.
Documentation may include reports provided to government oversight entities and letters
confirming compliance with mandated response times. Internal reports with adequate supporting
documentation of the methodology used to create the reports may also be submitted.
If the Proposing organization does not have mandated response times in its exclusive emergency
ambulance service area, the Proposer must submit adequate documentation of plans, procedures,
and deployment strategies to demonstrate the organization has the knowledge and expertise to
comply with mandated response times.
D. Demonstrated High Level Clinical Care
The Proposer must provide documentation of its demonstrated ability to provide high-level clinical
care.
Documentation may include descriptions of clinical sophistication and high levels of performance in
systems in which it operates. The organization should describe how it ensures consistent, high-
quality clinical care and how it is able to verify and document its clinical competency and
performance improvement activities. This should include clinical protocol compliance, skills
verification, training methodology and minimum commitments per provider including systematic
assessment of EMS core performance metrics and clinical guidelines as defined by the Local EMS
Agency 2, California EMS Authority 3 and National Association of EMS Officials.4
.
2 http://cchealth.org/ems/quality.php
3 http://www.emsa.ca.gov/CEMSIS
4 http://www.nasemso.org/
Page 26
SECTION IV. CORE REQUIREMENTS
A. Two Service Plans are to be Addressed
This RFP includes two separate Service Plans – Plan A and Plan B. Plan A includes minimal changes to
the current EMS System and Plan B incorporates most of the recommendations found in the EMS
Modernization Report. The separate requirements of the Service Plans are noted in this Section, Core
Requirements, and in the Competitive Criteria, and in the Pricing and Financial sections.
The Proposer must respond to and complete all attestations and requirements for each Plan. The
County will make the determination of which Plan will be used by the EMS System after the selection
of the highest scoring Proposal.
Each of the elements of the separate Plans are highlighted by using differing font colors in this
document to facilitate the Proposers’ responses.
Plan A will be highlighted in “PURPLE”
Plan B will be highlighted in “GREEN”
B. Contractor’s Functional Responsibilities
Contractor shall provide all emergency ambulance services originating in the EOA. Emergency
Ambulance Services are defined as all requests for an immediate paramedic ambulance response
from 9-1-1, radio communications, other phone numbers, observation, or any other source within
the EOA. Such Emergency Ambulance Services shall be provided in accordance with the
requirements of State Health and Safety Code Sections 1797 et seq., Division 48 and of the Contra
Costa County Ordinance 83-28, and all regulations promulgated there under including any
amendments or revisions thereof. In performing services under the Agreement, Contractor shall
work cooperatively with the LEMSA and its EMS Director as the contract administrator (Contract
Administrator). All references to the Contract Administrator herein shall be construed to also include
the EMS Director and/or any other LEMSA employee or representative that the EMS Director may
designate.
1. Basic Services
In consideration of the LEMSA's referral to Contractor of Ambulance Service requests originating in
the EOA, Contractor shall perform the following services to the complete satisfaction of LEMSA:
a) Contractor shall provide continuous, around-the-clock, emergency ambulance services,
without interruption throughout the term of the Agreement.
b) Contractor shall provide emergency ambulance services without regard to any illegally
discriminatory classification, including without limitation: the patient's race, color,
national origin, religious affiliation, sexual orientation, age, sex, or ability to pay.
c) The Proposal will be retained and incorporated into the Agreement by reference, except
that in the case of any conflicting provisions, the provisions contained in the Agreement
shall prevail.
Page 27
d) Contractor shall participate in pilot or research programs that the EMS Medical Director
(defined below) and Contract Administrator may authorize from time to time. The
Contract Administrator may waive standards contained in the Agreement in the event
that conflicting standard(s) are established for a pilot program. Any such pilot program
must be approved by the EMS Medical Director. Contractor agrees that Contractor's
participation in the pilot projects shall entail no additional cost to the County or the
LEMSA. Contractor further agrees that Contractor's services provided under pilot
projects shall be in addition to the other services described in the Agreement.
2. Services Description
Contractor shall be responsible for furnishing all emergency ambulance services for all residents and
other persons physically present in the EOA. Such emergency ambulance services shall be provided
at the paramedic level.
Contractor shall be the sole ground ambulance organization authorized by the LEMSA in the awarded
service area covered under this RFP to provide Emergency Ambulance Services and ALS interfacility
ambulance services. All requests for EMS originating in the EOA and processed through the County
designated medical communication centers will be referred to Contractor or its subcontractor, as
provided herein. Contractor may subcontract services only as provided herein and with the prior
written approval of the LEMSA director.
C. Clinical
1. Clinical Overview
The LEMSA’s goal is to provide a clinically sophisticated system that achieves contemporary
benchmarks of clinical excellence and can continue to do so in a sustainable fashion. The following
system specifications are drawn from applicable reference sources and are generally consistent with
the direction provided in the National Highway Traffic Safety document, The EMS Agenda for the
Future, and the core recommendations of the Institute for Medicine report on EMS: Emergency Medical
Services: At the Crossroads,5 and the ACEP Stategy for a National EMS Culture of Safety 6
.
The clinical goals of progressive EMS systems are guided by the broad outcome measures established
by the US Public Health Service. These include discomfort is minimized, disability is reduced, death is
minimized, destitution eliminated, disfigurement is reduced and disease is identified and reduced. In
addition, there is a focus on meeting the six aims of the Institute of Medicine report on healthcare
quality, Crossing the Quality Chasm: A New Health System for the 21st Century, which stresses that
systems should be: safe, effective, patient-centered, timely, efficient, and equitable.78
5. National Highway Traffic Safety Administration. (1996). Emergency Medical Services Agenda for the Future. Washington, DC:
United States Department of Transportation.
Institute of Medicine. (2006). Emergency medical services: At the crossroads. Washington, DC: National Academies of Science.
6 http://www.emscultureofsafety.org/wp-content/uploads/2013/10/Strategy-for-a-National-EMS-Culture-of-Safety-10-03-
13.pdf
7 Institute of Medicine. (2001). Crossing the Quality Chasm: A new Health System for the 21st Century. Washington, DC: National
Academies of Science.
Page 28
2. EMS System Medical Oversight
The LEMSA shall furnish medical control services, including the services of a system EMS Medical
Director (EMS Medical Director) for all system participants’ functions in the EMS System (e.g. medical
communications, first responder agencies, transport entity, online control physicians). The LEMSA’s
EMS Medical Director does not relieve the Contractor from employing its own medical director as
mandated by state and LEMSA requirements.
a) Medical Protocols
Contractor shall comply with medical protocols and administrative policies established by
the LEMSA, as well as other requirements and standards established by the EMS Medical
Director.
Contractor shall document compliance with system of care operational and medical
protocols. This documentation shall describe the performance of Contractor as a whole, its
component parts (e.g. communications and transport), and individual system participants
(personnel).
Medical protocols shall be reviewed and updated by the LEMSA on a periodic basis with
input from system participants. Current Medical Protocols are available at the LEMSA
website.
b) Direct Interaction with Medical Control
Contractor personnel functioning under these specifications have the right and professional
responsibility to interact directly with the system's medical leadership (EMS Medical
Director, base hospital physicians and LEMSA clinical oversight staff) on all issues related to
patient care. This personal professional responsibility is essential.
c) Medical Review/Audits
The Contractor is required to participate in LEMSA’s continuous quality improvement (CQI)
program. The goal of the patient safety and medical audit process is to inspect and assure
compliance of the care delivered with the system’s established clinical care guidelines.
Evaluation of trends, system variation and random sampling of patient contacts provides
mechanisms to measure the clinical care provided and enables the EMS Medical Director to
identify the need for a more targeted or detailed audit. The process also assists in validating
the effectiveness of ongoing process and outcome measures in monitoring and improving
care. It is the Contractor's responsibility to comply with the EMS Medical Director
audit/review process and initiate process measurement and improvement activities based
on the results of the audit/review.
As part of LEMSA CQI processes or incident investigation, the EMS Medical Director may
require that any employee of the Contractor attend a medical audit when deemed necessary.
8 Institute of Healthcare Improvement Open School as we are a member organization
http://www.ihi.org/education/IHIOpenSchool/Courses/Pages/OSInTheCurriculum.aspx#California
Page 29
Employees, at their option and expense, may attend any audit involving any incident in
which they were involved that is being formally reviewed, but must maintain the
confidentiality of the medical audit process. Attendance of every license holder involved in a
case being reviewed is not required, unless mandated by the EMS Medical Director.
3. Minimum Clinical Levels and Staffing Requirements
a) Ambulance Staffing Requirements
All Ambulances rendering Emergency Ambulance Services under the Agreement shall be
staffed and equipped to render paramedic level care and transport with a minimum of one
(1) state licensed and locally accredited Paramedic and one (1) California certified EMT to
respond to requests from the County designated PSAPs. The paramedic shall be the
caregiver with ultimate responsibility for all patients.
An “Emergency Ambulance” is defined as a transport ambulance responding to requests for
emergency medical services staffed with at least one paramedic and one EMT.
b) Personnel Licensure and Certification and Training Requirements
All of Contractor's ambulance personnel responding to emergency medical requests shall be
currently and appropriately licensed, accredited and credentialed, as appropriate, to practice
in Contra Costa County. Contractor shall retain on file at all times copies of the current and
valid licenses and/or certifications of all emergency medical personnel performing services
under this Agreement. LEMSA certification/licensure requirements may be downloaded
from the LEMSA website. At a minimum, the Contractor shall ensure that ambulance
personnel receive in addition to the required training defined in State and LEMSA policies,
the following training and/or certifications.
(1)
Contractor shall staff each ALS ambulance with a minimum of one paramedic certified in
PreHospital Trauma Life Support (PHTLS), International Trauma Life Support (ITLS), or
the Contractor shall document that each paramedic has satisfactorily completed
comparable training adequate to ensure competency in the skills included in the PHTLS
or ITLS curriculum and approved by the EMS Medical Director. Contractor shall retain
on file at all times, copies of the current training documentation and valid certifications
of all PHTLS or ITLS qualified paramedics performing services under this Agreement.
Required Trauma Training
All paramedics shall be required by Contractor to obtain certification in PHTLS, ITLS, or
have completed a comparable program within three (3) months of hire or execution of
the Agreement.
(2)
Contractor shall staff each ALS ambulance with a minimum of one paramedic certified in
pediatric Education for Prehospital Personnel (PEPP) or Pediatric Advanced Life
Support (PALS). All paramedics shall be required by Contractor to complete training
within six (6) months of hire. Contractor shall retain on file at all times, copies of the
Required Pediatric Training and Performance
Page 30
current training documentation and valid certifications of all PEPP or PALS qualified
paramedics performing services under this Agreement.
Contractor will supplement required PEPP or PALS training with annual infant and
pediatric simulation training focused on early recognition and management of pre-
arrest and other life threatening conditions.
Contractor will require all field personnel to review prehospital procedures for Safely
Surrendered Baby Program.
(3)
Contractor Quality, Clinical and Supervisory personnel shall complete an IHI Open
School online certificate in Patient Safety, Quality and Leadership within 18 months of
hire. Contractor shall retain on file at all times, copies of the current training
documentation and valid certifications for specified personnel under this Agreement.
Required Institute of Healthcare Improvement (IHI) Certificate of Patient Safety, Quality and
Leadership
(4)
Contractor shall properly orient all field personnel before assigning them to respond to
emergency medical requests. Such orientation shall include at a minimum, provider
agency policies and procedures; EMS system overview; EMS policies and procedures;
radio communications with and between the provider agency, base hospitals, receiving
hospitals, and County communications centers; map reading skills including key
landmarks, routes to hospitals and other major receiving facilities within the County and
in surrounding areas; and ambulance and equipment utilization and maintenance. In
addition, all frontline personnel must receive continual orientation to customer service
expectations, cultural awareness, performance improvement and the billing and
reimbursement process.
Company and EMS System Orientation and On-Going Preparedness
(5)
Contractor shall train all ambulance personnel and supervisory staff in their respective
roles and responsibilities under the Contra Costa Multi-Casualty Incident Plan, which is
on file at the LEMSA, and prepare them to function in the medical portion of the Incident
Command System. The specific roles of the Contractor and other Public Safety personnel
will be defined by the relevant plans and command structure.
Preparation for Multi-casualty Incident
(6)
Contractor shall provide ambulance personnel with the training, knowledge,
understanding, and skills to effectively manage patients with psychiatric, drug/alcohol
or other behavioral or stress related problems, as well as difficult or potentially difficult
scenes on an on-going basis. Emphasis shall be on techniques for establishing a climate
conducive to effective field management and for preventing the escalation of potentially
volatile situations.
Required Assaultive Behavior Management Training
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(7)
Contractor shall maintain an on-going driver-training program for ambulance personnel.
The program, the number of instruction hours, and the system for integration into the
Contractor's operations (e.g., accident review boards, impact of accidents on employee
performance reviews and compensation, etc.) will be reviewed and is subject to
approval by the LEMSA initially and on an annual basis thereafter. Training and skill
proficiency is required at initial employment with annual training refresher and skill
confirmation.
Driver Training
(8)
Contractor shall create a culture focused on infection prevention that focuses on
aggressive hygiene practices; personal protective equipment and competency-based
training in donning and doffing PPE (e.g. eye protection, gloves, etc). The Contractor
shall develop and strictly enforce policies for infection control, cross contamination and
soiled materials disposal to decrease the chance of communicable disease exposure.
Infection Control
Contractor will comply with county local infectious disease reporting program and
strictly enforce polices for infection prevention and control. These policies shall conform
to all Federal, State and local statutes, directives and guidelines including, but not
limited to, CALOSHA and the CDC. It is the county expectation that the Contractor will
adopt procedures that meet or exceed all requirements for dealing with these matters.
(9)
Contractor shall establish a repetitive stress and critical incident stress action plan.
Included shall be an ongoing stress reduction program for its employees and access to
trained and experienced professional counselors. Plans for these programs shall be
submitted to the Contract Administrator for approval.
Critical Incident Stress Management
(10)
Contractor and Contractor’s employees shall participate in and receive training in
Incident Command System (ICS) and Homeland Security issues, including participating
in existing programs available within the County for dealing with terrorist events,
weapons of mass destruction and other Homeland Security issues.
Homeland Security
(11)
Contractor shall provide initial and ongoing training for all personnel regarding
compliance with the Health Insurance Portability and Accountability Act of 1996 and the
current rules and regulations enacted by the U.S. Department of Health and Human
Services.
HIPAA Compliance
(12)
Contractor shall provide initial and ongoing compliance training for all personnel. This
training shall be in accordance with the OIG Compliance Program Guidance for
Compliance
Page 32
Ambulance Suppliers.9
This training is one component of the Compliance Plan required
of the Contractor.
Proposer shall describe how it intends to comply with the above training and certification
requirements. The Proposer will delineate how these programs will be provided, by whom,
where, and other information to help the LEMSA understand the Proposer’s commitment to
meet these Core Requirements.
D. Operations
1. Operations Overview
The performance specifications set forth in this RFP encourage continuous improvements in the level
of service provided in Contra Costa County. The RFP provides clarification of expectations and
accountability. The following provisions define these expectations, core requirements, and activities
required of the Contractor.
a) Emergency Response Zones
The Emergency Response Zones (ERZ) are separately delineated areas, which have two
levels of ambulance call density. The call density designations are defined as high
density/urban-suburban and low density/rural. The call density designations within the ERZ
are distinguished by response times. The Call Density area designations of the ERZ are
included in Appendix 6.
As previously described, the current system utilizes five (5) ERZ, A through E. The two Plans
to be addressed in the response to this RFP have four (4) ERZ in Plan A, and three (3) ERZ
for Plan B.
Under Plan A, the Designated EOA is divided into four (4) Emergency Response Zones
(ERZ’s) for calculation of ambulance response times and penalties. The zones, shown in
Appendix 3, are:
Zone A – City of Richmond
Zone B—West County, not including the City of Richmond (Cities of El Cerrito,
San Pablo, Kensington, Rodeo, Hercules, and Pinole and surrounding
unincorporated areas, including areas served by Rodeo-Hercules Fire and
Crockett-Carquinez Fire)
Zone C—Central County (Cities of Clayton, Concord, Lafayette, Martinez, Pleasant
Hill, and Walnut Creek and surrounding unincorporated areas served by Contra
Costa County Fire)
Zone D—East County (Cities of Antioch and Pittsburg and surrounding
unincorporated area served by Contra Costa County Fire, Cities of Brentwood
and Oakley and unincorporated areas served by East Contra Costa County Fire)
9 Federal Register / Vol. 68, No. 56 / Monday, March 24, 2003
Page 33
Under Plan B, the Designated EOA is divided into three (3) Emergency Response Zones
(ERZ’s) for calculation of ambulance response times and penalties. The zones, shown in
Appendix 3, are:
Zone A—West County (Cities of Richmond, El Cerrito, San Pablo, Kensington,
Rodeo, Hercules, and Pinole and surrounding unincorporated areas, including
areas served by Rodeo-Hercules Fire and Crockett-Carquinez Fire)
Zone B—Central County (Cities of Clayton, Concord, Lafayette, Martinez,
Pleasant Hill, and Walnut Creek and surrounding unincorporated areas served
by Contra Costa County Fire)
Zone C—East County (Cities of Antioch and Pittsburg and surrounding
unincorporated area served by Contra Costa County Fire, Cities of Brentwood
and Oakley and unincorporated areas served by East Contra Costa County Fire)
b) All Emergency and Non-emergency ALS Ambulance Calls
The RFP is to result in a contract assigning an exclusive operating area provider for all
Emergency Ambulance Requests originating within the EOA and received through the 9-1-1
system as well as those emergency calls received through means other than 9-1-1. The RFP
also includes ALS interfacility transports originating in Contra Costa County.
c) Primary Response to Isolated Peripheral Areas of the EOA
While the Contractor has the exclusive right to all emergency calls originating in the EOA,
there are areas on the periphery of the County where the nearest paramedic-staffed
ambulance may be located in an adjacent jurisdiction. In the interest of getting the quickest
ambulance to the patient, LEMSA requires the Contractor to make a good faith effort to
execute a satisfactory mutual aid agreement with the agencies responding from a
neighboring jurisdiction. The LEMSA will approve an appropriately structured agreement to
use the closer ambulances.
d) Substantial Penalty Provisions for Failure to Respond
The Contractor is to deploy and staff ambulances in a manner that allows for a response to
all medical emergency dispatches. In the event the Contractor does not respond with an
ambulance to an emergency medical call, the penalty assessed is substantial, beginning at
$10,000 per incident. These are rare and isolated events that may never occur and should
not be confused with late or outlier responses. Examples of Failure to Respond include the
failure of dispatch to notify a crew to respond to a request for ambulance services, failure of
a crew to respond to a request from dispatch, and diversion of an ambulance crew to
another call without reassigning and sending an ambulance to the initial request.
2. Transport Requirement and Limitations
As outlined in greater detail in other sections, Contractor has an obligation to respond to all
emergency medical requests in the County and provide ambulance transport. However, there are
limitations and flexibilities as described herein.
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a) Destinations
Contractor shall be required to transport patients from all areas of the County, in accordance
with the LEMSA Medical Control Destination Protocols included in LEMSA’s policy manual.
b) Prohibition against Influencing Destination Decisions
Contractor personnel are prohibited from attempting to influence a patient’s destination
selection other than as outlined in the destination policy.
3. Response Time Performance Requirements
“Response times,” as defined in Section IV.D.5 below (Response Time Measurement
Methodology), are a combination of dispatch, operations, and field operations. Because this
Agreement is performance based, the LEMSA will not limit Contractor’s flexibility in the methods
of providing ambulance service. This is based upon Contractor's commitment to conform to the
Response Time standards set forth below (the Response Time Standards). Therefore, an error on
Contractor’s part in one phase of its operation (e.g. ambulance dispatch, system deployment plan,
ambulance maintenance, etc.) shall not be the basis for an exception to Contractor's performance
in another phase of its operation (e.g. clinical performance or response time performance).
Appropriate Response Time performance is the result of a coordinated effort of Contractor's
total operation and therefore, is solely Contractor's responsibility. Response Times shall be
measured in minutes and integer seconds, and shall be “time stamped” by the medical dispatch
center as to when the call is transferred to the Contractor and integrated with the time stamping
of the Contractor’s computer aided dispatch system. The County and the LEMSA will work with
the Contractor to assure that the Contractor’s dispatch clocks can be synchronized to the medical
communications center dispatch CADs.
a) Description of Call Classification
These Specifications outline four (4) priorities with which Contractor must comply by
meeting specified Response Times. The call classification as Emergency or Non-Emergency
and as Priority 1 through 3 is accomplished by presumptive prioritization in accordance
with the then current Emergency Medical Dispatching protocols as approved by the LEMSA.
The fourth priority includes ALS non-emergency interfacility transfers originating within the
EOA.
b) Response Time Performance Requirements
The two areas -- designated as high call density (A) and low call density (B) -- will be used
for Response Time monitoring, reporting, and compliance purposes. Contractor's Response
Time on requests for emergency medical service originating from within the service area
shall meet the following performance standards:
(1)
Priority 1 responses are defined by the dispatch protocols used by the County medical
dispatch centers as approved by the EMS Medical Director.
Potentially Life Threatening Emergency Response (Priority 1)
Contractor shall place an Emergency Ambulance on the scene of each life-threatening
emergency assignment as presumptively designated by the County’s designated medical
dispatch center as Priority 1 within the specified Response Time for that ERZ and call
Page 35
density level on not less than 90 percent of all Priority 1 response requests as
determined under “Response Time Measurement Methodology.”
The applicable Response Time performance requirements are specified in Tables 5 & 6.
For every presumptively defined life-threatening emergency call exceeding the
Response Time Standard defined herein, Contractor shall document in writing the cause
of the extended Response Time and Contractor’s efforts to eliminate recurrence.
(2)
Priority 2 responses are defined by the dispatch protocols used by the County medical
dispatch centers as approved by the EMS Medical Director.
Non-Life Threatening Emergency Response (Priority 2)
Contractor shall place an Emergency Ambulance on the scene of each non-life
threatening emergency assignment as presumptively designated by the County’s
designated medical dispatch center as Priority 2 within the specified Response Time for
that ERZ and call density level on not less than 90 percent of all Priority 2 response
requests as determined under “Response Time Measurement Methodology.”
The applicable Response Time performance requirements are specified in Tables 5 & 6.
(3)
Priority 3 responses are defined by the dispatch protocols used by the County medical
dispatch centers as approved by the EMS Medical Director.
Non Emergency Response (Priority 3)
Contractor shall place an emergency Ambulance on the scene of each non-emergency
assignment as presumptively designated by the County’s designated medical dispatch
center as Priority 3 within the specified Response Time for that ERZ and call density
level on not less than 90 percent of all Priority 3 response requests as determined under
“Response Time Measurement Methodology.”
The applicable Response Time performance requirements are specified in Tables 5 & 6.
(4)
Priority 4 requests for ambulance service are defined as non-emergency transports at
the ALS level of service.
Interfacility ALS Non-emergency Transports (Priority 4)
Contractor shall place an ALS ambulance on the scene of at least 90 percent of all
Priority 4 scheduled ambulance requests within fifteen minutes zero seconds (15:00) of
the scheduled time. This standard shall apply to all requests for service where the
scheduled time for patient pickup is greater than three hours from the time the call is
received in the Contractor’s Dispatch Center.
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If the service receives an emergency request for an ALS interfacility transport, the
applicable Response Time requirement will be the same as that for Priority 2 level
requests.
If a request for non-emergency transportation is received without a three-hour notice
the Response Time requirement will be arrival of the ambulance at the patient location
within 60 minutes of the time of the request.
c) Summary of Response Time Requirements
Tables 5 & 6 summarize the Response Time compliance requirements – also referred to as
the Response Time Standards - for ambulances in the specified ERZ, density level, and
priority.
Table 5. Response Time Compliance Requirements for Plan A
All Contra Costa County Emergency Response Zones
Priority
Level
ERZ Compliance High Call Density
Urban/Suburban
Low Call Density
Rural
Priority 1 A 90% N/A
Priority 1 B, C, D 90% 20:00
Priority 1 D
(Bethel Island)
90% 16:45 N/A
Priority 2 A, B, C, D 90%
Priority 2 D
(Bethel Island)
90% 20:00 N/A
Priority 3 A, B, C, D 90%
Priority 4 A, B, C, D 90% +/- 15 minutes (scheduled)
or minutes
N/A
Table 6. Response Time Compliance Requirements for Plan B
All Contra Costa County Emergency Response Zones
Priority
Level ERZ Compliance High Call Density
Urban/Suburban
Low Call Density
Rural
Priority 1 A, B, C 90%
Priority 2 A, B, C 90%
Priority 3 A, B, C 90%
Priority 4 A, B, C 90% +/- 15 minutes (scheduled)
or N/A
4. Modifications During the Term of Agreement
The County is planning improvements to medical dispatch during the term of the Agreement. It is
expected that more specific prioritization of calls will be implemented (i.e. MPDS). At that time
response time requirements will be modified.
Page 37
The LEMSA also recognizes that continuing research is being completed related to the continuum of
care for medical events, including the relevance of time intervals. The LEMSA will work with the
Contractor to modify response time requirements based on benefits derived by the system’s patients.
Also, call density changes will occur which may expand areas that are categorized as Low Call Density
necessitating changes to assign these areas the High Call Density desigation.
In summary, it is expected that changes to the Response Time Requirements, ERZs, and Call Density
designations will be evaluated and implemented during the term of the Agreement.
5. Response Time Measurement Methodology
Contractor's Response Times shall be calculated on a monthly basis to determine compliance
with the standards set forth in Tables 5 & 6 above. At the end of each calendar month, a date
within the last 15 days of the month will be randomly selected. This date will represent the end
date of the 30-day compliance measurement period.
The Response Time measurement methodology employed can significantly influence operational
requirements for the EMS system. The following are applicable:
a) Call Receipt
The Contractors’ Response Time clock begins at “Call Receipt” which is defined as when the
communications center that directly dispatches the ambulances receives adequate
information to identify the location of the call and the priority level.
b) At Scene
“At Scene” time means the moment the first Emergency Ambulance arrives and stops at the
exact location where the ambulance shall be parked while the crew exits to approach the
Patient and notifies Dispatch that it is fully stopped. Only the arrival of a transport capable
ambulance shall constitute “At Scene.” This does not include a supervisory or other non-
transport capable unit. In situations where the Ambulance has responded to a location other
than the scene (e.g. staging areas for hazardous materials/violent crime incidents, non-
secured scenes, gated communities or complexes, or wilderness locations), arrival at scene
shall be the time the Ambulance arrives at the designated staging location or nearest public
road access point to the patient’s location.
c) Response Time
The Response Time is defined as the interval, in exact minutes and seconds, between the Call
Receipt time and arrival At Scene time, or the time it is cancelled by a public safety agency.
d) Failure to Report At Scene Time
In instances when ambulance crews fail to report “At Scene,” the time of the next
communication between dispatch and the ambulance crew shall be used as the At-Scene
time. However, Contractor may document the actual arrival time through other means (e.g.
First Responder, AVL, communications tapes/logs, etc.) so long as an auditable report of any
edits is produced.
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e) Calculating Upgrades, Downgrades, Reassignments and Canceled Responses
From time to time special circumstances may cause changes in call priority classification.
Response Time calculations for determination of compliance with Agreement standards and
penalties for non-compliance will be as follows:
(1)
If an assignment is upgraded prior to the arrival on scene of the Emergency Ambulance
(e.g. from Priority 2 to Priority 1), Contractor’s compliance and penalties will be
calculated based on the shorter of:
Upgrades
a) Time elapsed from dispatch to time of upgrade plus the higher priority
Response Time Standard; or
b) The lower priority Response Time Standard
For example, a call is initially dispatched as a Priority 3 (non-emergency) and it is
upgraded to a Priority 2 (non-life threatening emergency). The applicable response
time requirement will be shorter of the Priority 3 Response Time or the sum of the
elapsed time from Call Receipt to the time of the upgrade plus the Priority 2 Response
Time.
(2)
If a call is downgraded prior to arrival on scene of the Emergency Ambulance (e.g. from
Priority 1 to Priority 2), Contractor’s compliance and penalties will be determined by:
Downgrades
a) If the time of the downgrade occurs after the Emergency Ambulance has
exceeded the higher priority Response Time Standard, the more stringent
higher priority standard will apply; or
b) If the time of the downgrade occurs before the Emergency Ambulance has
exceeded the higher priority Response Time Standard, the less stringent lower
priority will apply. In all such cases, documentation must be presented for
validation of the reason why the priority status was downgraded. If the
downgrade was justified, in the sole discretion of the LEMSA, the longer
standard will apply.
(3)
If an Emergency Ambulance is reassigned en route or turned around prior to arrival on
the scene (e.g. to respond to a higher priority request), compliance and penalties will be
calculated based on the Response Time Standard applicable to the assigned priority of
the initial response. The Response Time clock will not stop until the arrival of an
Emergency Ambulance on the scene from which the Ambulance was diverted.
Reassignment en route
(4)
If an assignment is cancelled prior to arrival on the scene by the emergency ambulance,
Contractor’s compliance and penalties will be calculated based on the elapsed time from
Call Receipt to the time the call was canceled.
Canceled Calls
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f) Response Times outside EOA are Excluded
Contractor shall not be held accountable for Emergency Response Time compliance for any
assignment originating outside the EOA. Responses to requests for service outside the EOA
will not be counted in the total number of calls used to determine compliance.
g) Each Incident a Separate Response
Each incident will be counted as a single response regardless of the number of units that are
utilized. The Response Time of the first arriving Emergency Ambulance will be used to
compute the Response Time for that incident.
h) Response Time Compliance for Individual Emergency Response Zones
Response time requirements for the Emergency Response Zones shall be reported and
utilized for compliance purposes. Specifically, all responses in each ERZ for each priority
level are calculated. These calculations will be used for determination of any penalties.
i) Equity in Response Times throughout the County
The LEMSA recognizes that equity in Response Times is largely based upon call and
population densities within the service area. In developing Response Time Standards, the
LEMSA has established two (2) call density designations, low and high-density.
The LEMSA may evaluate the call density and zone structure to address changes occurring
within each zone. Should the call density of any significant contiguous area within the low
call density zones become equal to or greater than the call density to the adjacent high call
density zone, then that area will be considered for reclassification for Response Time
compliance. Response time compliance changes pursuant to this section will be modified by
readjusting the then current map defining the density designations.
The LEMSA reserves the right to look at any area of the EOA to identify if there are pockets of
poor Response Time performance and refer such findings to the Contractor for mitigation.
6. Response Time Exceptions and Exception Requests
Contractor shall maintain mechanisms for backup capacity, or reserve production capacity to
increase production should a temporary system overload persist. However, it is understood that
from time to time unusual factors beyond Contractor’s reasonable control affect the achievement of
specified Response Time Standards. In the monthly calculation of Contractor's performance to
determine compliance with the Response Time Standards, every request for Emergency Ambulance
Services shall be included except as follows:
a) Multi-casualty Disaster
The Response Time requirements may be suspended at the sole discretion of the LEMSA
during a declared multi-casualty incident, medical advisory or disaster in Contra Costa
County or during a declared disaster in a neighboring jurisdiction to which ambulance
assistance is being provided as requested by the LEMSA.
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b) Good Cause
The Contract Administrator may allow exceptions to the Response Time Standards for good
cause as determined at his or her sole discretion. At a minimum, the asserted justification for
exception must have been a substantial factor in producing a particular excess Response
Time, and Contractor must have demonstrated a good faith effort to respond to the call(s).
Good cause for an exception may include, but is not limited to: incorrect or inaccurate
dispatch information received from the PSAP or calling party; disrupted voice or data radio
transmission (not due to Contractor equipment or infrastructure); material change in
dispatched location; unavoidable telephone communications failure; inability to locate
address due to non-existent address; inability to locate patient due to patient departing the
scene; delays caused by traffic secondary to the incident; unavoidable delays caused by
extreme inclement weather (e.g., fog); when units are providing County authorized mutual
aid; and remote calls or off-road locations.
Remote calls are defined when the patients’ locations are greater than ten (10) road miles
from the nearest boundary of the high-density area.
Extended delays at hospitals for transferring patients to receiving facility personnel may be
considered as potential good cause exceptions at the sole discretion of the LEMSA.
Equipment failure, ambulance failure, lost ambulance crews, or other causes deemed to be
within the Contractor’s control or awareness shall not be grounds to grant an exception to
compliance with the Response Time Standard.
Contractor is expected to mitigate all and any delays associated with potential or actual work
actions without interrupting EMS System Service delivery.
c) Exception Request Procedure
It is the Contractor’s responsibility to apply to the LEMSA for an exception to a required
Response Time.
If Contractor feels that any response or group of responses should be excluded from the
calculation of Response Time compliance due to unusual factors beyond Contractor's
reasonable control, the Contractor must provide detailed documentation for each actual
response in question to the LEMSA and request that the LEMSA exclude these runs from
calculations and late penalties. Any such request must be submitted via the method specified
by the LEMSA and received by the Contract Administrator within 10 calendar days of the
completion of the response. A request for an exception received after the 10 days will not be
considered. The Contract Administrator or designees will review each exception request and
make a decision for approval or denial.
At the sole discretion of the LEMSA, calls with extended Chute Times (the time interval from
Dispatch to ambulance En Route) of more than two (2) minutes may be excluded from
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consideration as Exceptions. All decisions by the Contract Administrator shall be considered
final.
7. Response-time Performance Reporting Procedures and Penalty Provisions
a) Response Time Performance Reporting Requirements
(1)
The Contractor shall document all times necessary to determine total ambulance
Response Time including, but not limited to, time call received by the dispatch center,
time location verified, time ambulance crew assigned, time en route to scene, arrival at
scene time, total on-scene time, time en route to hospital, total time to transport to
hospital, arrival at hospital time, and time of transfer of patient care to hospital
personnel. Other times may be required to document specific activities such as arrival at
patient side, times of defibrillation, administration of treatments and medications and
other instances deemed important for clinical care monitoring and research activities.
All times shall be recorded on the Patient Care Report Form (PCR) and in Contractor’s
computer aided dispatch system. The Contractor will provide an interface with the
computer aided dispatch database and Electronic Patient Care Report Form (EPCR)
database for the LEMSA to extract and corroborate Response Time performance.
Contractor may not make changes to times entered into the CAD after the event. Only
LEMSA personnel may make changes to times within the computer. The contractor may
request such changes from the LEMSA when errors or omissions are discovered. The
LEMSA has sole discretion whether changes to times are acceptable.
Documentation of Incident Time Intervals
(2)
Within 10 business days following the end of each month, the Contractor’s dispatch
center shall document and report to the LEMSA and the County, in a manner required by
the LEMSA, information as specified in Section IV.D.
Response Time Performance Report
a) Contractor shall use Response Time data in an on-going manner to evaluate
Contractor's performance and compliance with Response Time Standards in an
effort to continually improve its Response Time performance levels.
b) Contractor shall identify the causes of failures of performance, and shall
document efforts to eliminate these problems on an on-going basis.
c) Contractor shall provide an explanation for every call exceeding the required
Response Time interval and describe steps taken to reduce extended responses
in the future.
b) Penalty Provisions
Isolated instances of individual deviations of Response Time compliance shall be treated as
instances of minor, non-compliance under the Agreement. However, severe or chronic
deviations of Response Time compliance may constitute a default of the Agreement as
defined below.
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(1)
Contractor shall pay LEMSA a $250 penalty each time an emergency ambulance is
dispatched and the ambulance crew fails to report and document on-scene time. The
Contractor, in order to rectify the failure to report an on-scene time and to avoid the
penalty may demonstrate to the satisfaction of the Contract Administrator an accurate
on-scene time.
Penalty for Failure to Report On-scene Time
Where an on-scene time for a particular emergency call is not documented or
demonstrated to be accurate, the Response Time for that call shall be deemed to have
exceeded the required Response Time for purposes of determining Response Time
compliance.
(2)
Contractor shall pay LEMSA a penalty each month that the Contractor fails to comply
with the Response Time requirements based on the percentage of compliance for all
responses in the categories represented in Table 7 below.
Penalty for Failure to Comply with Response Time Requirements
Failure of the Contractor to achieve at least 88% Response Time compliance in each of
the ERZ for Emergency Ambulance requests will require that the Contractor submit and
implement a deployment plan that includes additional staffed ambulance hours aimed to
achieve 90% compliance with Response Times.
Table 7. County Response Time Penalties
Emergency Ambulance Requests - Priority 1 Responses for each
Compliance %
of the ERZ
Penalty
% < 90% $15,000
% $25,000
% $50,000
Emergency Ambulance Requests - Priority 2 Responses for each
Compliance %
of the ERZ
Penalty
$5,000
$10,000
$15,000
Emergency Ambulance Requests - Priority 3 Responses for each
Compliance %
of the ERZ
Penalty
$2,500
$5,000
$7,500
Non-Emergency ALS Interfacility Transports - Priority 4 Responses for entire EOA
Compliance % Penalty
$4,000
$6,000
$7,500
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(3)
Penalties are based on measurement of response time performance for all responses
within the EOA and each ERZ and grouped by priority level. The different density areas
within each ERZ will be grouped for compliance measurement. Priority 4 responses
(non-emergency ALS) will be reported for compliance measurement for the entire EOA
and not included with the priority levels in each ERZ.
Repetitive Non-Compliance
The Contractor is required to report performance for each priority level in each ERZ and
in the designated ambulance zones. Repetitive non-compliance in any given subset is
defined as three consecutive months or five instances on non-compliance in any twelve-
month period. If the Contractor is repetitively non-compliant in any subset measure, the
Contractor shall submit a plan of corrective action to LEMSA within 30 days of being
notified of repetitive non-compliance by LEMSA. Failure to correct repetitive non-
compliance may be considered a material breach of the Agreement.
Any subset of measurement of calls that does not exceed 100 responses in a single
month shall be added to the next month’s responses and accumulated until the
minimum of 100 responses is documented at which point compliance determinations
will be made.
(4)
An “Outlier” Response Time is defined as a Response Time that is excessive for the
category, such that it represents a potential threat to health and safety (Outlier). A
penalty shall be imposed for any call for which the actual Response Time equals or
exceeds the applicable “Outlier Response Time” set forth in Table 8. Penalties shall be
based on ERZ and the Priority level assigned to the call.
Penalties for Outlier Responses
The outlier penalty is in addition to a penalty assessed for failure to meet the Response
Time compliance requirements.
Table . Outlier Response Time Penalties
Priority
Level
Outlier Response Times Penalty per
Outlier High Call Density Low Call Density
Priority 1 >18:59 >29:59 $1,500
Priority 2 >22:59 >44:59 $1,000
Priority 3 >29:59 >59:59 $750
Priority 4 >29:59 late for scheduled
>89:59 for non-scheduled $500
(5)
The LEMSA may impose financial penalties for minor or major breaches of the
Agreement. For example, the Agreement will include penalties relating to the failure to
Additional Penalty Provisions
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provide reports and information to the LEMSA by specified due dates, failing to leave
PCRs documenting patient care at receiving institutions, failure to respond to a request,
and responding and transporting in a BLS unit when the call requires an ALS response
and transport. LEMSA may impose a fine of up to $500 per incident for any minor breach
of the Agreement not specifically addressed in the following Table 9. The following
specific penalties shall be included in the Agreement:
Table 9. Breach Events and Penalties
Breach Event Criteria Penalty
Failure to provide
timely operational
reports
Operational and Response Time reports are
due on a specific date after end of month
$50 per report per day received after
specified due date
Failure to leave
completed PCR at
receiving facility
100 percent of the LEMSA approved Interim
Patient Care Report (an abbreviated patient
care report) will be left at the receiving
facility prior to departure of the ambulance
crew. 100 percent of the completed PCRs
will be provided to receiving facility within
24 hours
$50 for every instance when the
Interim Patient Care Report at a
minimum, is not left at the receiving
facility prior to crew departure. A
penalty of $100 for every completed
PCR not provided to the facility within
24 hours of patient delivery.
Response and
transport by a BLS unit
when the Priority level
calls for the patient to
be transported by an
ALS unit
All 9-1-1/emergency calls shall be
responded to by an ALS ambulance and the
patient transported in the ALS unit as
defined by the LEMSA
$1,000 for every incident in which a
BLS ambulance responds and
transports a patient that requires ALS
care according LEMSA policies.
Failure to provide
timely quality
improvement data and
reports
Quality improvement and clinical data and
reports are due on specific dates
$50 per report or data submission per
day received after specified due date
Failure to provide
timely unusual
occurrence reports and
investigation updates
Unusual occurrence reports and updates on
investigations of those events are due within
a specific time from date of the occurrence
as defined in LEMSA policies and procedures
$100 per report per day received after
the specified time frame from the date
of the occurrence
Failure to respond to
an emergency request
for an Emergency
Ambulance
The contractor shall respond to all official
Emergency Ambulance Service requests
within the EOA. Failure to respond is defined
by the Contractor not sending an ambulance
en route to an emergency request.
The LEMSA shall impose a minimum
fine of $10,000 for each failure to
respond to an official Emergency
Ambulance request by the Contractor.
Failure to respond will be defined as
any call originating within the EOA for
which the Contractor fails to dispatch
and no ambulance responds. Prior to
imposition of this penalty, LEMSA will
conduct an investigation of the incident
Improper certification Staffing an ambulance with improperly
certified personnel
$250 per call responded to by
improperly certified employee
Failure to comply with
Against Medical Advice
(AMA) protocol
Field personnel fails to comply with
defined LEMSA policy and procedure for
AMA
$500 per AMA documentation and
protocol failure.
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(6)
Contractor may appeal to the LEMSA in writing within 10 business days of receipt of
notification of the imposition of any penalty or regarding LEMSA's penalty calculations.
The Contract Administrator will review all such appeals and make the decision to
eliminate, modify, or maintain the appealed penalty.
Penalty Disputes
8. Fleet Requirement
The Contractor is to maintain the number of ALS equipped and fully operating ambulances that
represent at least 120% of the peak staffing level. For example, if the Contractor’s peak number of
ambulances is twenty-seven (27), then the Contractor is to maintain a fleet of at least 33 ambulances
(27 x 120% = 32.4 rounded to 33). If a fraction is derived when multiplying the peak number of units
by 120%, the number will be rounded up to the next whole integer. (i.e. 32.4 would be rounded to
33).
9. Coverage and Dedicated Ambulances, Use of Stations/Posts
These specifications are for a performance based approach rather than a level of effort undertaking
involving defined locations. The LEMSA neither accepts nor rejects Proposer’s level of effort
estimates; rather the LEMSA accepts the Proposer’s commitment to employ whatever level of effort
is necessary to achieve the Response Time and other performance results required by the terms of
the Agreement as outlined in these specifications.
Contractor shall deploy ambulance resources in a manner consistent with this goal.
E. Personnel
1. Treatment of Incumbent Work Force
A number of dedicated highly trained personnel are currently working in the Contra Costa County
EMS system. In the event the Contractor turns out to be other than the incumbent provider, every
effort must be made to ensure a smooth transition and to encourage current EMS personnel to
remain with the system. To that end, in the event of a change in providers, all current qualified
ambulance employees working within Contra Costa County (other than owners and executive
management) are to be considered for preferential hiring by any new Contractor. A new Contractor is
expected to offer qualified non-supervisory employees (EMTs and paramedics) employment in
substantially similar positions. Supervisory and mid-management personnel should also be
considered by the Contractor for employment in order to retain continuity within the system and a
career path for the committed workforce. A new Contractor will consider current employee
scheduling and make reasonable efforts to transition its new employees to its organization as
smoothly as possible. While a plan for the transition of EMTs and paramedics is an element of this
RFP, Proposers are encouraged to exceed the minimum requirements and provide the strongest plan
possible for retention of the incumbent workforce, and additional points will be awarded for plans
which exceed the minimum requirements.
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Employment stability within the EMS system is an important concern of incumbent employees,
Contra Costa County, and the LEMSA. Incumbent personnel hired will retain "seniority status" earned
while working full-time in the Contra Costa County EMS system.
Contractor will provide full time employees with a wage and benefit program comparable to the
employees’ current program. If an incumbent provider is successful, it agrees to maintain, at a
minimum, current salary and benefit levels for personnel and consistent with offerings included in its
proposal.
The LEMSA expects that to attract and retain outstanding personnel, Contractor must utilize
reasonable compensation and scheduling methods. Contractor's economic efficiencies are not to be
derived from the use of sub-standard compensation. The system in no way intends to restrict the
ingenuity of Contractor and its employees from working out new and creative compensation (salary
and benefits) programs. The system’s goal is simply to ensure that Contractor initially and
throughout the term of the Agreement provides a financial benefit to encourage employee retention
and recruitment for the system.
Proposer shall describe how it intends to maintain continuity of service in the system by employing
current personnel and efforts to retain personnel through the term of the Agreement. If the Proposer
is the current provider, it shall describe how it intends to retain personnel through the term of the
new Agreement.
2. Character, Competence and Professionalism of Personnel
The parties understand that Ambulance services are often rendered in the context of stressful
situations. The LEMSA expects and requires professional and courteous conduct and appearance at
all times from Contractor's Ambulance personnel, medical communications personnel, middle
managers, and top executives. Contractor shall address and correct any occasional departure from
this standard of conduct.
All persons employed by Contractor in the performance of its work shall be competent and holders of
appropriate licenses and permits in their respective professions and shall undergo a criminal record
check in accordance with the State of California requirements. Contractor must independently judge
the employability and potential liability associated with employing any individual with a past history
of serious offenses.
3. Internal Health and Safety Programs
The Contractor shall implement multiple programs to enhance the safety and health of the work
force. These shall include driver-training, safety and risk management training. The County requires
Contractor to have in place, prior to assumption of EMS duties, an aggressive and effective health,
safety and loss mitigation program.
The Contractor shall provide adequate Personal Protective Equipment (PPE) and other equipment to
employees working in hazardous environments such as routine care, rescue operations, motor
vehicle accidents, etc. At a minimum, personal protective gear shall comply with CALOSHA and EMSA
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#216 and shall include appropriate head, respiratory and flesh protection for employees. Policies and
procedures should clearly describe the routine use of PPE on all patient encounters.
4. Evolving OSHA & Other Regulatory Requirements
It is anticipated, during the term of the Agreement that certain regulatory requirements for
occupational safety and health including, but not limited to, infection prevention and control, blood-
borne and respiratory pathogens and hazardous materials, may be increased. It is the LEMSA’s
expectation that Contractor will adopt procedures that meet or perform better than all requirements
for dealing with these matters.
Contractor shall make available at no cost to its employees all currently recommended
immunizations and health screening to its high-risk personnel.
5. Discrimination Not Allowed
During the performance of the Agreement, Contractor agrees that it will comply with all applicable
provisions of federal, state, and local laws and regulations prohibiting discrimination. Without
limiting this, Contractor warrants that it will fully comply with Title VI and VII of the Civil Rights Act
of 1964, as amended, the Americans with Disabilities Act (ADA) and all other regulations
promulgated there under. Contractor will not discriminate against any employee or applicant for
employment because of race, religion, color, disability, national origin, sex, sexual orientation, or age.
Contractor will take affirmative action to ensure that employment is offered and that employees are
treated during employment without regard to their race, religion, color, disability, national origin, sex,
sexual orientation, or age. Such action shall include, but is not limited to, the following: employment-
upgrade, demotion, transfer; recruitment or recruitment advertising; lay-off or termination; rates of
pay or other forms of compensation; and selection, including apprenticeship.
F. Management
1. Data and Reporting Requirements
The long-term success of any EMS system is predicated upon its ability to both measure and manage
its affairs. Therefore, the LEMSA will require Contractor to provide detailed operational, clinical, and
administrative data in a manner that facilitates its retrospective analysis.
a) Dispatch Computer
The dispatch computer utilized by Contractor shall include security features preventing
unauthorized access or retrospective adjustment and full audit trail documentation. The
LEMSA will be provided access to all data maintained by the Computer Aided Dispatch (CAD)
system as necessary to analyze demand and determine deployment procedures. The
Contractor agrees to allow the LEMSA, at Contractor’s expense, to install an interface with
the CAD to collect and monitor computer-aided dispatch information and patient care
reports and provide access to the LEMSA to voice recording systems.
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The Contractor in conjunction with the LEMSA shall establish procedures to automate the
monthly reporting requirements and to develop situational status reports that provide alerts
when system status falls outside expected parameters.
The interface made available to the LEMSA shall provide real-time monitoring of the
Contractor’s CAD screens and at a minimum provide the location and status of active
ambulance calls, pending calls, location and status of ambulances and crews.
b) Essential Patient Care Record and Assignment Data
Contractor shall utilize an electronic patient care record system (PCR) that is HL7
compatible, NEMSIS 3 and CEMSIS compliant, meets the requirements of the state EMSA and
is approved by the LEMSA for patient documentation on all EMS system responses including
patient contacts, canceled calls, interfacility, and non-transports. The PCR shall be accurately
completed to include all information required by and established in Title 22, Division 9,
Chapter 4, Article 8, Section 100171 and information shall be distributed according to
established County EMS Policies and Procedures. The Contractor shall leave interim and final
copies of the PCR (electronic or printed) at the receiving hospital upon delivery of each
patient in accordance with LEMSA policy.
The Contractor shall develop and implement a PCR monitoring process to identify when the
Interim and Final PCRs are provided to the receiving facilities. The results of the PCR
delivery performance will be reported to the LEMSA monthly.
The Contractor will support Health Information Exchange (HIE) with hospital medical
record information systems and create a process for hospitals to view PCRs as soon as they
are available.
Within 24 hours, Contractor shall provide access for the Contract Administrator and
receiving hospitals to final patient care records in computer readable format and suitable for
statistical analysis for all priorities. Records shall contain all information documented on the
PCR for all EMS system responses including patient contacts, cancelled calls, interfacility, and
non-transports.
c) Records
Contractor shall complete, maintain, and provide to the LEMSA, the ability to view online via
a secure portal as requested, adequate records and documentation to demonstrate its
performance compliance and aid LEMSA in improving, modifying, and monitoring the EMS
system.
d) Monthly Reports Required
Contractor shall provide, within 10 business days after the first of each calendar month,
computer database data in an electronic format and reports pertaining to its performance
during the preceding month as it relates to the clinical, operational, and financial
performance stipulated herein. Contractor shall document and report to Contract
Administrator in writing in a form required by the Contract Administrator. Response time
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compliance and customer complaints/resolutions shall be reported monthly. Reports other
than Response Time compliance and customer complaints/resolutions may be required less
frequently than monthly. At the end of each calendar year, no later than November 30 of the
proceeding year, LEMSA shall provide a list of required reports and their frequency and due
dates to the Contractor.
Reports in a format approved by the LEMSA shall include, at a minimum:
(1)
Continuing education compliance reports;
Clinical
Summary of clinical/service inquiries and resolutions;
Summary of interrupted calls due to vehicle/equipment failures; and
Data analysis and details of calls supporting clinical and medical oversight of
Trauma, STEMI, Stroke, and Cardiac Arrest and other system of care populations.
Data analysis and details of calls that result in no-transport (Against Medical Advice)
(2)
Calls and transports, by priority for each Emergency Response Zone and density
area;
Operational
A list of each call, sorted by Emergency Response Zone, where there was a failure to
properly record all times necessary to determine the Response Time;
Documentation of all patients meeting trauma, STEMI, stroke, or cardiac arrest
criteria including on-scene time and transport to hospital time;
Documentation and data analysis of hospital off-load delays, including time unit
arrived at facility and time patient care was transferred to receiving facility staff and
duration of off-load delays;
A list of mutual aid responses to and from system; and
EMS transports to and from medical aircraft
(3)
A list of each emergency call dispatched for which Contractor did not meet the
Response Time standard for each Emergency Response Zone and an explanation of
why the response was late;
Response Time Compliance
Canceled calls; and
Exception reports and resolution.
(4)
Within 10 business days following the last day of each month, Contractor shall ensure
that ambulance Response Time records are available to LEMSA in a computer readable
format approved by the Contract Administrator and suitable for statistical analysis for
all ambulance responses originating from requests within the County. The records shall,
at a minimum, include the following individual data elements:
Response Time Statistical Data
unit identifier
location of call – street address
location of call – city, town or unincorporated County
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location of call - longitude
location of call - latitude
location of call – Emergency Response Zone
density area (low or high)
nature of call (EMD Code)
response code to scene
time call received
time call dispatched
time unit en route
time unit upgraded or downgraded
time unit on-scene
response code at arrival on scene (for upgrade or downgrade)
time unit en route to hospital
time unit at hospital
time patient handoff to ED staff occurred
time unit clear and available for next call
outcome (dry run, transport)
receiving hospital
transport code to hospital
system of care call type (i.e. cardiac arrest, trauma, STEMI, stroke)
number of patients transported
(5)
Contractor shall provide LEMSA annually with a list of paramedics, EMTs and
dispatchers currently employed by Contractor and shall update that list monthly, as
necessary.
Personnel Reports
Contractor shall immediately notify LEMSA when paramedic personnel are no longer
employed as a paramedic.
Contractor shall report any termination or suspension for disciplinary cause, resignation
or retirement in lieu of investigation and/or disciplinary action or removal from related
duties due to disciplinary actions as required by Title 22, Division 9, Chapter 6, section
100208.1.
The personnel list shall include, at a minimum, the name, address, telephone number,
California paramedic license and expiration date or EMT certification and expiration
date, ACLS expiration date, CPR expiration date, and California Driver's License number
of each person on the list.
(6)
Monthly list of meetings with constituents and stakeholders (i.e. community
engagement)
Community/Governmental Affairs Report
Number of conducted community education events including location and hours
and number of participants,
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Number of individuals taught CPR
Number of CPR anytime kits and AEDs provided
Public Relations (PR) activities, first responder recognition,
Government relations contact report.
(7)
Contractor shall provide capability for LEMSA, at the Contractor’s expense, to access all
PCRs and provide a mechanism to create customized reports for LEMSA monitoring and
review. The electronic access shall also include real-time monitoring of CAD systems.
Electronic Access
(8)
Contractor shall provide LEMSA with such other reports and records as may be
reasonably required by the Contract Administrator.
Other Reports
G. EMS System and Community
1. Participation in EMS System Development
The LEMSA anticipates further development of its EMS system and regional efforts to enhance
disaster and mutual-aid response. LEMSA requires that its Contractor actively participate in EMS
activities, committee meetings, and work groups. Contractor agrees to participate and assist in the
development of system changes.
2. Accreditation
Within 24 months following commencement of the term of the Agreement, the Contractor will attain
accreditation as an ALS Ambulance Service through the Commission on Accreditation of Ambulance
Services (CAAS) or comparable organization as approved by the LEMSA. The Contractor shall
maintain its accreditation throughout the term of the Agreement. The LEMSA may levy a penalty of
$200 for each day that the Contractor is not accredited after the first 24 months whether due to
failure to obtain accreditation or a lapse thereof.
3. Multi-casualty/Disaster Response
Contractor shall cooperate with the LEMSA in rendering emergency assistance during a declared or
an undeclared disaster or in multi-victim response as identified in the LEMSA plans. Contractor must
have detailed written plans and procedures to mitigate impacts to and ensure continuous internal
operations during all potential emergencies, disasters or work actions (i.e. power failure, information
systems failure, earthquake).
Contractor must have an emergency electrical power system available to provide power to its critical
command, control, computer and communications systems in the event the normal electrical supply
is interrupted. This system must be tested periodically per NFPA 110.
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In the event the County declares a disaster within the County, the Contractor will assign a Field or
Dispatch Manager/Supervisor to deploy to the designated emergency operations center (when
activated) as a liaison upon request.
In the event the County declares a disaster within the County, or in the event the County directs
Contractor to respond to a disaster in a neighboring jurisdiction, normal operations may be
suspended at the discretion of the LEMSA and Contractor shall respond in accordance with the
disaster plan. Contractor shall use best efforts to maintain primary Emergency services and may
suspend non-emergency services upon notification on concurrence with the LEMSA.
At a multi-victim scene, Contractor's personnel shall perform in accordance with LEMSA multi-
casualty incident response plan and within Incident Command System (ICS).
Contractor shall not release emergency ambulance assets to another jurisdiction without approval of
the LEMSA.
During a disaster declared by the County, the LEMSA will determine, on a case-by-case basis, if the
Contractor may be temporarily exempt from response-time criteria. When Contractor is notified that
multi-casualty or disaster assistance is no longer required, Contractor shall return all of its resources
to primary area of responsibility and shall resume all operations as required under the Agreement.
a) Internal Disaster Response Notification
Contractor shall develop a plan for immediate recall of personnel during multi-casualty or
widespread disaster. This plan shall include the capability of Contractor to alert off-duty
personnel.
b) Disaster Response Vehicle/Equipment
Contractor shall maintain a county-controlled, state provided Disaster Medical Support Unit
(DMSU). In the absence of a DMSU, the Contractor shall provide one vehicle as a disaster response
vehicle. This vehicle shall not be an ambulance used in routine, day-to-day operations, but shall be
kept in good working order and available for emergency response to the scene. This vehicle may
be used to carry personnel and equipment to a disaster site. The following equipment shall be
stored in this disaster vehicle: backboards and straps; cervical collars; head immobilization sets
and foam wedges; PPE; splints for legs and arms; oxygen equipment; extra dressing and bandages;
advanced life support equipment, especially IV therapy equipment; County approved disaster
tags; and checklists for medical Incident Command personnel
c) Incident Notification
Contractor shall have a mechanism in place to communicate current field information to
appropriate LEMSA or County Health Services staff during multi-casualties, disaster
response, hazardous materials incidents, and other unusual occurrences.
d) Ambulance Strike Team
Contractor shall be able to deploy an ALS ambulance strike team consistent with State
Ambulance Strike Team Guidelines.
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Contractor shall have staff members trained and certified as Ambulance Strike Team Leaders.
e) Interagency Training for Exercises/Drills
Contractor shall participate in LEMSA sanctioned exercises and disaster drills and other
interagency training.
4. Mutual-aid and Stand-by Services
a) Mutual Aid Requirements
Contractor shall respond in a mutual aid capacity to other service areas outside of the EOA if
so directed by Contract Administrator or in accordance with mutual aid agreements.
Specifically, Contractor shall maintain documentation of the number and nature of mutual
aid responses it makes and nature of mutual aid responses made by other agencies to calls
originating within the EOA.
b) Stand-by Service
Contractor shall provide, at no charge to the LEMSA or requesting agency, stand-by services
at the scene of an emergency incident within the EOA when directed by a County designated
public safety dispatch center upon request of a public safety agency. A unit placed on stand-
by shall be dedicated to the incident. Stand-by periods exceeding eight (8) hours shall be
approved by Contract Administrator.
5. Permitted Subcontracting
The Contractor may contract with providers for ALS interfacility transports/transfers originating
within the EOA. Contractor may also subcontract for management, administrative services, dispatch,
and billing and collection activities. Such agreements must be approved by the LEMSA. The sub-
contracting ambulance entities must meet the LEMSA’s minimum requirements for ALS ambulance
services. The Contractor remains responsible and accountable to meet Response Time and reporting
requirements and the Contractor is liable to pay any penalties for non-performance by the
subcontractor.
Contractor may subcontract medical dispatch center services to another agency within or outside of
the County. Regardless, the Contractor will retain accountability and responsibility for the
performance of the Dispatch Center. Such agreement must be approved by the LEMSA.
6. Communities May Contract Directly for Level of Effort
This RFP and the Agreement are focused on Contractor performance. There are no provisions for a
level of effort or requiring ambulances to be placed in specific areas of Contra Costa County.
The Contractor may contract directly with cities, communities, or other jurisdictions to have an
ambulance or other services provided within their community. Such arrangements will support EMS
System coordination and are subject to the approval of the LEMSA and shall not be at the County’s
expense. Regardless of such arrangements, there is no change in the exclusive agreement between
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the Contractor and the LEMSA and the Contractor must continue to comply with the performance
standards of the agreement.
7. Supply Exchange and Restock
The Contractor will restock disposable medical supplies on a one-for-one basis based on utilization
on calls by first response agencies. Contractor will work with first responder agencies to create a
process of supply exchange and rotation that is cost effective. Contractor has no obligation to restock
disposable medical supplies of items not in the Contractor’s inventory. This agreement does not limit
the Contractor from changing supply vendors.
8. Handling Service Inquiries and Complaints
Contractor shall create consumer friendly processes to receive customer service complaints and lost
item and other inquires. Contractor shall log all inquiries and service complaints and will ensure that
non-clinical issues are followed through to resolution. Contractor shall provide prompt response and
follow-up to such inquiries and complaints. Contractor’s management team will analyze inquiry
reports to identify and address any trends. Such responses shall be subject to the limitations imposed
by patient confidentiality restrictions.
Contractor shall submit to the LEMSA each month a list of all complaints received and their
appropriate disposition/resolution. Contractor shall submit copies of any inquiries and resolutions of
a clinical nature to the EMS Medical Director or LEMSA within twenty-four (24) hours.
H. Administrative Provisions
1. Contractor Payments for Procurement Costs, County Compliance Monitoring, Contract
Management, and Regulatory Activities (Plan B only)
For Plan B of this Service Plan, the Contractor will reimburse the LEMSA for a portion of its
expenses related to conducting this procurement, monitoring and managing the Agreement,
provision of medical direction and conducting periodic procurements. An annual amount will be
assessed based on the LEMSA’s costs for the previous fiscal year. The fees will be limited to a
maximum of seven hundred and fifty thousand dollars ($750,000) per year.
2. No System Subsidy
Under Plan B, the Contractor will operate the EMS system without any subsidy from the LEMSA
or the County. RFP specifications are designed to provide accountability without undue
operational or financial burden for providers.
Since many of the cost savings recommendations included in the EMS Modernization Report
were not included in the Plan A requirements and provisions, this RFP allows for a request by
the Contractor to identify potential subsidies that may be required to comply with all of the Plan
A provisions. It is the desire of the County to operate a subsidy-free system, but it is recognized
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that fiscal trends of revenue collection and costs along with healthcare system changes may
require additional financial support to maintain the current performance levels.
Each Proposer must complete the subsidy request form included in Appendix 11. The Subsidy
Request Form shall be submitted separately with the “Financial Documents.”
3. Contractor Revenue Recovery
The primary means of Contractor compensation is through fee-for-service reimbursement of patient
charges.
a) Patient Charges
Contractor shall receive income from patient charges. Contractor shall comply with fee
schedules and rates stipulated in this RFP (Stipulated Rates) and as subsequently approved
by the LEMSA. The current rates are included in Appendix 7 and the Stipulated Rates are
specified in Appendix 10.
b) Fee Adjustments
The Contract Administrator will approve annual increases to patient charges based on
changes in the Consumer Price Index for Medical Services. The annual rate increases will be
the greater of three (3) percent or the increase of the CPI for any given year. All changes in
the transport fees must be approved by LEMSA.
In the event changed circumstances substantially impact the Contractor’s costs of providing
services or there are substantial reductions in revenue caused by factors that are beyond the
control of Contractor, the Contractor may request increases or decreases in charges to
patients to mitigate the financial impact of such changed circumstances. No adjustments to
patient fees will be allowed during the first twelve (12) months of the commencement of the
Agreement. If Contractor believes an adjustment is warranted, the Contractor may apply to
the Contract Administrator for a rate adjustment to be effective on or after the first
anniversary of the Agreement. Applications must be submitted at least sixty (60) days prior
to the requested effective date. Requests for changes to patient charges shall only be allowed
on an annual basis corresponding to the anniversary of the Agreement. The Contract
Administrator shall review the application and forward his or her recommendation to the
Health Services Director, who shall have the authority to approve or disapprove the request.
Approval of rate changes is required before they can become effective.
4. Federal Healthcare Program Compliance Provisions
Contractor shall comply with all applicable Federal laws, rules and regulations for operation of its
enterprise, ambulance services, and those associated with employees. This includes compliance with
all laws and regulations relating to the provision of services to be reimbursed by Medicare, Medicaid,
and other government funded programs.
a) Medicare and Medicaid Compliance Program Requirements
Contractor shall implement a comprehensive Compliance Program for all activities,
particularly those related to documentation, claims processing, billing and collection
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processes. Contractor’s Compliance Program shall substantially comply with the current
guidelines and recommendations outlined in the Office of Inspector General (OIG)
Compliance Program Guidance for Ambulance Suppliers as published in the Federal Register
on March 24, 2003 (03 FR 14255).
Contractor will engage a qualified entity to conduct a claims review on an annual basis as
described in the OIG Compliance Guidance. A minimum of 50 randomly selected Medicare
claims will be reviewed for compliance with CMS rules and regulations, appropriate
documentation, medical necessity, and level of service. The Contractor will submit the report
to the LEMSA within 120 days of the end of each contract year.
b) HIPAA, CAL HIPAA and HITECH Compliance Program Requirements
Contractor is required to implement a comprehensive plan and develop the appropriate
policies and procedures to comply with the provisions of the Health Insurance Portability
and Accountability Act of 1996 and the current rules and regulations enacted by the US
Department of Health and Human Services. The three major components of HIPAA, CAL
HIPAA and HITECH include:
1. Standards for Privacy and Individually Identifiable Health Information
2. Health Insurance Reform: Security Standards
3. Health Insurance Reform: Standards for Electronic Transaction Sets and Code
Standards
Contractor is responsible for all aspects of complying with these rules and particularly those
enacted to protect the confidentiality of patient information. Any violations of the HIPAA,
CAL HIPAA and HITECH rules and regulations will be reported immediately to the LEMSA
along with Contractor’s actions to mitigate the effect of such violations.
5. State Compliance Provisions
Contractor shall comply with all applicable state and local laws, rules and regulations for businesses,
ambulance services, and those associated with employees. Contractor shall also comply with county
and LEMSA policies, procedures, and protocols.
6. Billing/Collection Services
Contractor shall operate a billing and accounts receivable system that is well documented, easy to
audit, and which minimizes the effort required of patients to recover from third party sources for
which they may be eligible. The billing system shall:
1. electronically generate and submit Medicare and MediCal claims;
2. itemize all procedures and supplies employed on patient bills; and
3. be capable of responding to patient and third party payer inquiries regarding
submission of insurance claims, dates and types of payments made, itemized
charges, and other inquiries
The Contractor shall provide for prompt response to any queries or appeals from patients. The
Proposer shall describe its methods for receiving, monitoring, and responding to patient issues and
complaints.
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It is expected that the Contractor’s billing and collection services are conducted in a compassionate
manner and that the Contractor recognizes that many patients may not have the financial resources
to pay for their ambulance transports. The Proposer shall describe its policies for identifying patients
that qualify for a financial hardship consideration for discounting or writing off their accounts.
Billing Waivers for Impoverished, Conserved & Vulnerable: Contractor shall establish a consumer
friendly procedure that allows for responsible party to make payment arrangements. The billing
manager will review the form and assess an appropriate and acceptable monthly arrangement.
Contractor shall establish a process to reduce the costs of ambulance services to patients who have
demonstrated inability to pay through completing a “Financial Statement” form. All information
relating to financial hardship requests shall be kept confidential. The billing manager will review the
form and assess an appropriate and acceptable monthly arrangement.
Billing Appeals Process: Contractor will create a consumer friendly appeals process in cooperation
with Contra Costa Health Insurance Counseling and Advocacy Program (HICAP) that allows the
consumer sufficient time for denied claims to go through governmental and private insurers appeals
timeframes before being sent to collections. In the case of Medicare billing the first level of Medicare
appeals is 120 days. Contractor will, on a monthly basis, document the number of billing waivers,
appeals in process and average time to process appeals.
Contractor shall not attempt to collect its fees at the time of service.
Contractor shall conduct all billing and collection functions for the EMS system in a professional and
courteous manner.
7. Market Rights
The LEMSA shall not enter into agreements with any other provider for ground response to requests
for Emergency Ambulance Service or ALS interfacility transports originating within the EOA during
the term of this Agreement. Furthermore, the LEMSA will make reasonable efforts to ensure the
Contractor’s exclusivity of ALS interfacility transports originating within the EOA.
The LEMSA reserves the right to enter into separate transport agreements with air ambulance
providers. Notwithstanding any other provision of this Contract, the LEMSA may provide for air
transport of patients when such transportation is deemed to be medically in the best interest of the
patient(s). However, no such agreement shall provide for air transport of non-critical patients or of
critical patients when a ground ambulance is on-scene and transport time by ground ambulance to
the most appropriate emergency medical facility equipped, staffed, and prepared to administer care
appropriate to the needs of the patient is the same as or less than the estimated air transport time.
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8. Accounting Procedures
a) Invoicing and Payment for Services
The LEMSA shall render its invoice for any fines or penalties to the Contractor within 30
business days of the LEMSA’s receipt of the Contractor’s monthly performance reports and
after approval of the penalties determined by the LEMSA. The Contractor shall pay the
LEMSA on or before the 30th day after receipt of the invoice. Any disputes of the invoiced
amounts should be resolved in this thirty-day period. If they have not been resolved to
LEMSA or Contractor’s satisfaction, the invoice shall be paid in full and subsequent invoices
will be adjusted to reflect the resolution of disputed amounts.
b) Financial Reporting
Contractor will report trends in monthly net revenue, total expenses, number of deployed
unit hours, cost per unit hour, number of transports, collection rate, average patient charge,
net revenue/transport, cost/trip, and payer mix on a monthly basis.
c) Audits and Inspections
Contractor shall maintain separate financial records for services provided pursuant to the
Agreement in accordance with generally accepted accounting principles.
With reasonable notification and during normal business hours, LEMSA shall have the right
to review any and all business records including financial records of Contractor pertaining to
the Agreement. All records shall be made available to LEMSA at the Contractor’s Contra
Costa County office or other mutually agreeable location. LEMSA may audit, copy, make
transcripts, or otherwise reproduce such records including, but not limited to, contracts,
payroll, inventory, personnel and other records, daily logs and employment agreements.
On an annual basis, the Contractor shall provide the LEMSA with audited financial
statements by certified public accountants or governmental entity for Contractor's
ambulance operations in Contra Costa County and/or separate business records of financial
accounting of any other businesses that share overhead with the Contractor's ambulance
service operation.
Contractor may be required by the LEMSA to provide the LEMSA with periodic report(s) in
the format specified by the Contract Administrator to demonstrate billing compliance with
relevant rules and regulations and adherence with approved and specified rates.
9. County Permit
The LEMSA oversees ambulance services within the County. Pursuant to County Ordinance 83-25
and LEMSA policies, an ambulance company must obtain the appropriate ambulance service permits.
Contra Costa County ambulance permit information and applications are available
at http://cchealth.org/ems/ambulance-providers.php#simpleContained3 and a copy of the current
county ordinance can be found on the county’s website.
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10. Insurance Provisions
Contractor shall obtain and maintain in full force and effect throughout the term of this Agreement,
and thereafter as to matters occurring during the term of this Agreement, the required insurance
coverage as listed in Appendix 12. If the Proposer is self-insured, the Proposer shall document it’s
capability to provide similar coverage or assurance of coverage consistent with the insurance
requirements. The Proposer shall also include a “reserve for losses” in the development of its
financial budgets submitted with the Financial Documents.
11. Hold Harmless / Defense / Indemnification / Taxes / Contributions
a) Hold Harmelss
In General,
Contractor has the contracted duty (hereinafter "the duty") to indemnify, defend
and hold harmless, the LEMSA, the County, its Board of Supervisors, officers, employees,
agents and assigns from and against any and all claims, demands, liability, judgments,
awards, interest, attorney’s fees, costs, experts’ fees and expenses of whatsoever kind or
nature, at any time arising out of or in any way connected with the performance of this
Agreement, whether in tort, contract or otherwise. This duty shall include, but not be limited
to, claims for bodily injury, property damage, personal injury, and contractual damages or
otherwise alleged to be caused to any person or entity including, but not limited to
employees, agents and officers of Contractor.
Contractor’s liability for indemnity under this Agreement shall apply, regardless of fault, to
any acts or omissions, willful misconduct or negligent conduct of any kind, on the part of the
Contractor, its agents, subcontractors and employees. The duty shall extend to any allegation
or claim of liability except in circumstances found by a jury or judge to be the sole and legal
result of the willful misconduct of the LEMSA or the County. This duty shall arise at the first
claim or allegation of liability against the LEMSA or the County. Contractor will on request,
and at its expense, defend any action suit or proceeding arising hereunder. This clause for
indemnification shall be interpreted to the broadest extent permitted by law.”
b) Employee Character and Fitness.
Contractor accepts responsibility for determining and approving the character and fitness of
its employees (including volunteers, agents, or representatives) to provide the services
required of Contractor under this Agreement, including completion of a satisfactory
criminal/background check and periodic rechecks to the extent permitted by law.
Notwithstanding anything to the contrary in this Paragraph, Contractor shall hold County,
the LEMSA and their officers, agents and employees harmless from any liability for injuries
or damages resulting from a breach of this provision or Contractor’s actions in this regard.
12. Performance Security Bond
Contractor shall furnish performance security in the amount of two million dollars ($2,000,000) in
one of the following forms:
a) A faithful performance bond issued by a bonding company, appropriately licensed and
acceptable to the LEMSA; or
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b) An irrevocable letter of credit issued pursuant to this provision in a form acceptable to
the LEMSA and from a bank or other financial institution acceptable to the LEMSA, or
c) If the Proposer is a governmental entity, the County will waive the performance bond
requirement.
13. Term of Agreement
The initial term of the Agreement ultimately executed by Contractor shall be for a period of five (5)
years commencing at 12:01 a.m. on January 1, 2016 and terminating at midnight, December 31, 2020.
14. Earned Extension to Agreement
If, at the sole judgment and discretion of the LEMSA, the Contractor is deemed to be substantially in
compliance with the specifications defined in this RFP and the resulting Agreement, the Health
Services Director may, after seeking a recommendation from the Board of Supervisors, grant an
extension of the Agreement for up to five (5) additional years. The LEMSA shall make the offer of
extension by formal written notice to the Contractor at least eighteen (18) months prior to the
scheduled end of the term of the Agreement.
While it is the intent of the LEMSA to have completed a competitive procurement for selecting the
Contractor by the end of the term of the Agreement or extension thereof, the LEMSA recognizes that
healthcare and EMS changes may require a re-design of the EMS System. In the event that
circumstances beyond the control of the LEMSA or the County require substantial changes to the
system design that cannot be completed and implemented prior to the end of the term of the
Agreement, the LEMSA will contact the Emergency Medical Services Authority to request that this
agreement be extended for a period sufficient to cover the re-design of the EMS system. Contractor
will then be offered the opportunity to extend this Agreement for the approved period. These
extensions, if granted will be exercised for only as long as necessary to complete system changes and
only upon approval of the Board of Supervisors.
If the Contractor does not desire to continue providing services to the LEMSA as stipulated in the
Agreement after the end of the Term or extensions thereof the Contractor must give notice of its
intent not to extend the Agreement at least seventeen (17) months prior to the scheduled end of the
term of the Agreement.
15. Continuous Service Delivery
Contractor expressly agrees that, in the event of a default by Contractor under the Agreement,
Contractor will work with the LEMSA to ensure continuous and uninterrupted delivery of services,
regardless of the nature or causes underlying such breach. Contractor shall be obligated to use every
effort to assist the LEMSA to ensure uninterrupted and continuous service delivery in the event of a
default, even if Contractor disagrees with the determination of default.
16. Annual Performance Evaluation
The LEMSA may evaluate the performance of the ambulance Contractor on an annual basis. An
evaluation report will be provided to the Contra Costa County Board of Supervisors.
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The following information will normally be included in the performance evaluation:
a) Response Time performance standards assessed with reference to the minimum
requirements in the Contract;
b) Clinical performance standards assessed with reference to the minimum requirements
in the Contract;
c) Initiation of innovative programs to improve system performance;
d) Workforce stability, including documented efforts to minimize employee turnover;
e) Compliance of pricing and revenue recovery efforts with rules and regulations and the
Agreement; and
f) Compliance with information reporting requirements
g) Financial stability and sustainability
17. Default and Provisions for Termination of the Agreement
The LEMSA shall have the right to terminate or cancel the Agreement or to pursue any appropriate
legal remedy in the event Contractor materially breaches the Agreement and fails to correct such
default within seven (7) days following the service on it of a written notice by the LEMSA specifying
the default or defaults complained of and the date of intended termination of rights absent cure.
a) Definitions of Breach
Conditions and circumstances that shall constitute a material breach by Contractor shall
include, but not be limited to, the following:
1. Failure of Contractor to operate the ambulance service system in a manner which
enables the LEMSA or Contractor to remain in substantial compliance with the
requirements of the applicable federal, state, and county laws, rules, and regulations.
Minor infractions of such requirements shall not constitute a material breach, but
such willful and repeated infractions shall constitute a material breach;
2. Willful falsification of data supplied to the LEMSA by Contractor during the course of
operations, including by way of example but not by way of exclusion, dispatch data,
patient report data, Response Time data, financial data, or falsification of any other
data required under the Agreement, or a willful refusal to provide such data within a
reasonable time when demanded by the LEMSA;
3. Chronic and persistent failure by Contractor to maintain equipment in accordance
with good maintenance practices;
4. Deliberate, excessive, and unauthorized scaling down of operations to the detriment
of performance by Contractor during a "lame duck" period as described in Section
H.23;
5. Deliberately increasing the cost of providing services, failing to maintain positive
labor relations, or undertaking any activity designed to make it more difficult for a
transition to a new Contractor or for a new Contractor’s operation in the event of a
default or failure of incumbent to prevail during a subsequent bid cycle;
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6. Willful attempts by Contractor to intimidate or otherwise punish employees who
desire to sign contingent employment contracts with competing Proposers during a
subsequent bid cycle;
7. Willful attempts by Contractor to intimidate or punish employees who participate in
legally protected concerted activities, or who form or join any professional
associations;
8. Chronic and persistent failure of Contractor's employees to conduct themselves in a
professional and courteous manner, or to present a professional appearance;
9. Failure of Contractor to comply with approved rate setting, billing, and collection
procedures;
10. Failure of Contractor to meet Response Time requirements for three consecutive
measurement periods in a single category and after receiving notice of non-
compliance from Contract Administrator;
11. Failure of Contractor to comply with the vehicle lease provisions;
12. Failure of Contractor to cooperate and assist County in the investigation or
correction of any “Minor Breach” conditions;
13. Failure to comply with required payment of fines or penalties within sixty (60) days
written notice of the imposition of such fine or penalty;
14. Failure to maintain in force throughout the terms of the Agreement, including any
extensions thereof, the insurance coverage required herein;
15. Failure to maintain in force throughout the term of the Agreement, including any
extensions thereof, the performance security requirements as specified herein;
16. Failure to timely prepare and submit the required annual audit; and
17. Any other willful acts or omissions of Contractor that endanger the public health
and safety.
18. Termination
a) Written Notice
The Agreement may be canceled immediately by written mutual consent.
b) Failure to Perform
The LEMSA, upon written notice to Contractor, may immediately terminate the Agreement
should Contractor materially breach any of its obligations under the Agreement. In the event
of such termination, the LEMSA may proceed with the work in any reasonable manner it
chooses. The cost to the LEMSA of completing Contractor's performance shall be partially
supported by securing the funds of the Performance Security Bond, without prejudice to
LEMSA's rights otherwise to recover its damages or to seek any other remedy.
19. Emergency Takeover
In the event LEMSA determines that a material breach, actual or threatened, has or will occur or that
a labor dispute has prevented performance, and if the nature of the breach is, in the Contract
Administrator's opinion, such that public health and safety are endangered, and after Contractor has
been given notice and reasonable opportunity to correct deficiency, the matter shall be presented to
the Health Services Director.
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If the Health Services Director concurs that a material breach has occurred or may occur and that
public health and safety would be endangered by allowing the Contractor to continue its operations,
the Contractor shall cooperate fully with the LEMSA to effect an immediate takeover by the LEMSA of
Contractor's ambulances and crew stations. Such takeover shall be effected within not more than 72
hours after Health Services Director’s decision and approval by the Board of Supervisors to execute
the emergency takeover.
In the event of an emergency takeover, the Contractor shall deliver to the LEMSA ambulances and
associated equipment used in performance of the Contract, including supervisors' vehicles. Each
ambulance shall be equipped, at a minimum, with the equipment and supplies necessary for the
operation of ALS ambulances in accordance with LEMSA ALS Policies and Procedures.
Contractor shall deliver ambulances, dispatch and communications systems, facilities and crew
stations to the LEMSA in mitigation of any damages to LEMSA resulting from the Contractor's breach.
However, during the LEMSA's takeover of the ambulances and equipment, LEMSA and Contractor
shall be considered Lessee and Lessor, respectively. Monthly rent payable to the Contractor shall be
equal to the aggregate monthly amount of the Contractor's debt service on facilities, vehicles and
equipment as documented by the Contractor at Contract Administrator's request, and verified by the
County Auditor (provided that the cost of contractor debt service does not exceed the fair market
value of the rent for the facilities, vehicles and equipment). The County Auditor shall cause the
disbursement of these payments directly to the Contractor's obligee. In the event an ambulance is
unencumbered, or a crew station is not being rented, LEMSA shall pay the Contractor fair market
rental based upon an independent valuation.
Nothing herein shall preclude the LEMSA from seeking to recover from the Contractor such rental
and debt service payments as elements of damage from a breach of the Agreement. However, the
Contractor shall not be precluded from disputing the Health Services Director's findings or the nature
and amount of the LEMSA's damages, if any, through litigation. Failure on the part of the Contractor
to cooperate fully with the LEMSA to effect a safe/smooth takeover of operations shall itself
constitute a breach of the Contract, even if it is later determined that the original declaration of
breach by the Director was made in error.
The LEMSA shall have the right to authorize the use of vehicles and equipment by another entity.
Should the LEMSA require a substitute contractor to obtain insurance on equipment, or should the
LEMSA choose to obtain insurance on vehicles/equipment, the Contractor shall be "Named
Additional Insured" on the policy, along with the appropriate endorsements and cancellation notice.
The LEMSA agrees to return the Contractor's vehicles and equipment to the Contractor in good
working order, normal wear and tear excepted, at the end of takeover period. For any of the
Contractor's equipment not so returned, the LEMSA shall pay the Contractor fair market value of
vehicle and equipment at time of takeover, less normal wear and tear or shall pay the Contractor
reasonable costs of repair, or shall repair and return vehicles and equipment.
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The LEMSA may unilaterally terminate a takeover period at any time and return facilities and
equipment to the Contractor. The takeover period shall last no longer than the LEMSA judges
necessary to stabilize the EMS system and to protect the public health and safety by whatever means
the LEMSA chooses.
All of the Contractor's vehicles and related equipment necessary for provision of ALS services
pursuant to this Contract are hereby leased to the LEMSA during an emergency takeover period.
Contractor shall maintain and provide to the LEMSA a listing of all vehicles used in the performance
of this Contract, including reserve vehicles, their license numbers and name and address of lien
holder, if any. Changes in lien holder, as well as the transfer, sale, or purchase of vehicles used to
provide ambulance services hereunder shall be reported to the LEMSA within 30 days of said change,
sale, transfer, or purchase. Contractor shall inform and provide a copy of takeover provisions
contained herein to lien holder(s) within five (5) days of emergency takeover.
20. Transition Planning
a) Competitive Bid Required
Contractor acknowledges that the LEMSA intends to conduct a competitive procurement
process for the provision of Emergency Ambulance Service within LEMSA’s Exclusive
Operating Area prior to the termination of this Contract. Contractor acknowledges and
agrees that the LEMSA may select a different ambulance service provider to provide
exclusive Emergency Ambulance Services following said competitive procurement process,
and to reasonable extension of its obligations hereunder if such extensions are necessary to
complete such processes including, but not limited to, any reasonable decisions to cancel and
restart such processes.
b) Future Bid Cycles
Contractor acknowledges and agrees that supervisory personnel, EMT's and paramedics,
working in the EMS system have a reasonable expectation of long-term employment in the
system, even though Contractors may change. Accordingly, Contractor shall not penalize or
bring personal hardship to bear upon any of its employees who apply for work on a
contingent basis with competing Proposers and shall allow without penalty its employees to
sign contingent employment agreements with competing Proposers at employees' discretion.
Contractor may prohibit its employees from assisting competing Proposers in preparing
Proposals by revealing Contractor's trade secrets or other information about Contractor's
business practices or field operations.
21. LEMSA's Remedies
If conditions or circumstances constituting a Default as set forth in Section H.17 exist, the LEMSA
shall have all rights and remedies available at law or in equity under the Agreement, specifically
including the right to terminate the Agreement and/or the right to pursue Contractor for damages
and the right of emergency take-over as set forth in Section IV.H.18. All LEMSA's remedies shall be
non-cumulative and shall be in addition to any other remedy available to LEMSA.
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22. Provisions for Curing Material Breach and Emergency Take Over
In the event the LEMSA determines that there has been a material breach by Contractor of the
standards and performances as defined in this specification, which breach represents an immediate
threat to public health and safety, such determination shall constitute a material breach and/or
default of the Agreement. In the event of a material breach, LEMSA shall give Contractor written
notice, return receipt requested, setting forth with reasonable specificity the nature of the material
breach.
Contractor shall have the right to cure such material breach within seven (7) calendar days of receipt
of such notice and which notice should include the reason why such material breach endangers the
public's health and safety unless an immediate and grave threat to public health and safety requires
shorter notice or no notice. In cases where notice is given, within 24 hours of receipt of such notice,
Contractor shall deliver to the LEMSA, in writing, a plan of action to cure such material breach. The
LEMSA, acting through the Health Services Director or designee, may permit Contractor to
implement such a plan of action if the plan is acceptable to the LEMSA, and may set such deadlines
for the completion of such actions as the LEMSA deems appropriate, in its sole and absolute
discretion. If Contractor fails to cure such material breach within the period allowed for cure (with
such failure to be determined in the sole and absolute discretion of the LEMSA) or Contractor fails to
timely deliver the cure plan to the LEMSA, the LEMSA may execute an emergency take-over of
Contractor's operations. Contractor shall cooperate completely and immediately with the LEMSA to
affect a prompt and orderly transfer of all responsibilities to the LEMSA.
Contractor shall not be prohibited from disputing any such finding of default through appropriate
channels, provided, however that such dispute shall not have the effect of delaying, in any way, the
immediate takeover of operations by the LEMSA. These provisions shall be specifically stipulated and
agreed to by both parties as being reasonable and necessary for the protection of public health and
safety, and any legal dispute concerning the finding that a Default has occurred, shall be initiated, and
shall take place only after the emergency take-over has been completed.
Contractor's cooperation with and full support of such emergency take-over shall not be construed as
acceptance by Contractor of the findings and default, and shall not in any way jeopardize Contractor's
right of recovery based upon a later finding in an appropriate forum that the declaration of Default
was made in error. However, failure on the part of Contractor to cooperate fully with the LEMSA to
affect a smooth and safe take-over of operations, shall itself constitute a breach of the Agreement,
even if it was later determined that the original declaration of default by the LEMSA was made in
error.
For any default by Contractor which does not endanger public health and safety, or for any default by
the LEMSA, which cannot otherwise be resolved, early termination provisions which may be agreed
to by the parties will supersede these specifications.
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23. "Lame-duck" Provisions
Should the Agreement not be renewed, extended or if notice of early termination is given by
Contractor, Contractor agrees to continue to provide all services required in and under the
Agreement until the LEMSA or a new entity assumes service responsibilities, even if reasonable
extension of the Contractor’s Agreement with the LEMSA is necessary. Under these circumstances
Contractor will, for a period of several months, serve as a lame duck Contractor. To ensure continued
performance fully consistent with the requirements herein through any such period, the following
provisions shall apply:
a) Contractor shall continue all operations and support services at the same level of effort
and performance as were in effect prior to the award of the subsequent Agreement to a
competing organization including, but not limited to, compliance with provisions hereof
related to qualifications of key personnel;
b) Contractor shall make no changes in methods of operation or employee compensation
that could reasonably be considered to be aimed at cutting Contractor service and
operating costs to maximize or effect a gain during the final stages of the Agreement or
placing an undue burden on the subsequent Contractor;
c) LEMSA recognizes that if another organization should be selected to provide service,
Contractor may reasonably begin to prepare for transition of service to the new entity.
The LEMSA shall not unreasonably withhold its approval of Contractor's request to
begin an orderly transition process, including reasonable plans to relocate staff, scale
down certain inventory items, etc., as long as such transition activity does not impair
Contractor's performance during this period; and
d) Should LEMSA select another organization as a service provider in the future, Contractor
personnel shall have reasonable opportunities to discuss issues related to employment
with such organizations without adverse consequence
24. General Provisions
a) Assignment
Contractor shall not assign any portion of the Agreement for services to be rendered without
written consent first obtained from the LEMSA and any assignment made contrary to the
provisions of this section may be deemed a default of the Agreement and, at the option of the
LEMSA, shall not convey any rights to the assignee.
b) Permits and Licenses
Contractor shall be responsible for and shall hold any and all required federal, state, or local
permits or licenses required to perform its obligations under the Agreement. In addition,
Contractor shall make all necessary payments for licenses and permits for the services and
for issuance of state permits for all ambulance vehicles used. It shall be entirely the
responsibility of Contractor to schedule and coordinate all such applications and application
renewals as necessary to ensure that Contractor is in complete compliance with federal,
state, and local requirements for permits and licenses as necessary to provide the services
pursuant to this Agreement. Contractor shall be responsible for ensuring that its employee’s
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state and local certifications as necessary to provide the services, if applicable, are valid and
current at all times.
c) Compliance with Laws and Regulations
All services furnished by Contractor under the Agreement shall be rendered in full
compliance with all applicable federal, state, and local laws, ordinances, rules, and
regulations. It shall be Contractor’s sole responsibility to determine which, and be fully
familiar with, all laws, rules, and regulations that apply to the services under the Agreement
and to maintain compliance with those applicable standards at all times.
d) Private Work
Contractor shall not be prevented from conducting private work that does not interfere with
the requirements of Agreement.
e) Retention of Records
Contractor shall retain all documents pertaining to Agreement for seven (7) years from the
end of the fiscal year following the date of service; for any further period that is required by
law; and until all Federal/State audits are complete and exceptions resolved for this
Agreement's funding period. Upon request, and except as otherwise restricted by law,
Contractor shall make these records available to authorized representatives of the LEMSA,
the County, the State of California, and the United States Government. Any and all records
received and manufactured by the County under this Agreement shall be deemed County
Records, for all purposes, including disclosure pursuant to the California Public Records Act,
Government Code 6250, et seq.
f) Product Endorsement/Advertising
Contractor shall not use the name of Contra Costa County for the endorsement of any
commercial products or services without the expressed written permission of the Contract
Administrator.
g) Observation and Inspections
LEMSA representatives may, at any time, and without notification, directly observe
Contractor's operations of the Dispatch Center, maintenance facility, or any ambulance post
location. A LEMSA representative may ride as "third person" on any of Contractor's
Ambulance units at any time, provided, that in exercising this right to inspection and
observation, LEMSA representatives shall conduct themselves in a professional and
courteous manner, shall not interfere with Contractor employee's duties and shall at all
times be respectful of Contractor's employer/employee relationships.
At any time during normal business hours and as often as may be reasonably deemed
necessary by the LEMSA, LEMSA representatives may observe Contractor's office operations,
and Contractor shall make available to County for its examination any and all business
records, including incident reports, and patient records pertaining to the Agreement. The
LEMSA may audit, copy, make transcripts, or otherwise reproduce such records for LEMSA
to fulfill its oversight role.
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h) Omnibus Provision
Contractor understands and agrees that for seven years following the conclusion of the
Agreement it may be required to make available upon written request to the Secretary of the
US Department of Health and Human Services, or any other fully authorized representatives,
the specifications and subsequent Agreements, and any such books, documents and records
that are necessary to certify the nature and extent of the reasonable costs of services.
i) Relationship of the Parties
Nothing in the Agreement shall be construed to create a relationship of employer and
employee or principal and agent, partnership, joint venture or any other relationship other
than that of independent parties contracting with each other solely for the purpose of
carrying out the provisions of the Agreement. Contractor is an independent contractor and is
not an employee of County or LEMSA. Contractor is responsible for all insurance (worker’s
compensation, unemployment, etc.) and all payroll related tax. Nothing in the Agreement
shall create any right or remedies in any third party. The Agreement is entered solely for the
benefit of the County, LEMSA, and Contractor.
j) Rights and Remedies Not Waived
Contractor will be required to covenant that the provision of services to be performed by
Contractor under the Agreement shall be completed without compensation from LEMSA or
County unless County agrees to a specified subsidy amount proposed under Plan A. The
acceptance of work under the Agreement shall not be held to prevent LEMSA’s maintenance
of an action for failure to perform work in accordance with the Agreement.
k) Consent to Jurisdiction
Contractor shall consent to the exclusive jurisdiction of the courts of the State of California
or a federal court in California in any and all actions and proceedings between the parties
hereto arising under or growing out of the Agreement. Venue shall lie in Contra Costa County,
California.
l) End-term Provisions
Contractor shall have 90 days after termination of the Agreement in which to supply the
required audited financial statements and other such documentation necessary to facilitate
the close out of the Agreement at the end of the term.
m) Notice of litigation
Contractor shall agree to notify the LEMSA within 24 hours of any litigation or significant
potential for litigation of which Contractor is aware.
n) Cost of Enforcement
If legal proceedings are initiated by any party to this Agreement, whether for an alleged
breach of the terms or judicial interpretation thereof, the prevailing party to such action
shall, in addition to all other lawful remedies, be entitled to recover reasonable attorney’s
fees, consultant and expert fees, and other such costs, to the extent permitted by the court.
o) General Contract Provisions
In addition to the specific contract provisions listed in this document, the written Agreement
will include general conditions required by the LEMSA in contracts such as those listed
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herein. A Sample of General Contract Provisions and a Business Associates Agreement is
included in Appendix 13. These provisions will become part of the final agreement with the
successful Proposer. Any exceptions to the requirements, terms and conditions as stated
herein, and in the Sample Provisions must be identified separately in the Proposer’s
response.
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SECTION V. COMPETITIVE CRITERIA
This section sets forth the performance criteria to be competitively assessed and scored by the
Review Panel (the Competitive Criteria).
For each Competitive Criterion, the narrative below defines a base level of performance to which
every Proposer must agree (the Minimum Requirements). This agreement must be unqualified and
expressly stated in the Proposal. If a Proposer fails to agree to any Minimum Requirement related to
any Competitive Criterion, the LEMSA may, in its discretion, declare the Proposal unresponsive and
disqualified. The Proposer must agree to the Minimum Requirements regardless of whether the
Proposer goes on to propose levels of performance that are higher than contained in the Minimum
Requirements for a given Competitive Criterion. For Proposers offering to meet, but not exceed, the
Minimum Requirements for a given Competitive Criterion, the Proposal must set forth the
information requested below regarding the manner in which the Proposer will meet the performance
level specified in the Minimum Requirements.
For each Competitive Criterion, Proposers are encouraged to propose levels of performance higher
than the Minimum Requirements. The narrative describes the policy and operational goals for each
Competitive Criterion, which the LEMSA is seeking to maximize through competition. It also provides
guidelines and examples to illustrate how the policy and operational goals might be promoted.
However, the specific concepts and activities comprising these examples are neither specifically
required nor exclusive. The Competitive Criteria provide an opportunity for a Proposer to
differentiate its proposed service from that of other Proposers and to demonstrate the organizational
capabilities and experience which it would bring to bear if it becomes the Contractor.
Because every Proposer is required to commit to the Minimum Requirements, no points shall be
awarded in connection with a Competitive Criterion unless a higher level of performance is proposed.
Points available for each Competitive Criterion for which a higher level of performance is proposed
shall be scored as set forth in Section II.G.
A goal of this RFP is to increase the levels of communication, cooperation, collaboration, and in some
cases functional integration among the different entities comprising the EMS and healthcare delivery
systems for the benefit of the patient. This goal is furthered by various provisions in the Core
Requirements and in the Minimum Requirements. In addition, certain of the Competitive Criteria
invite Proposers to propose higher levels of collaboration.
A. Clinical
1. Competitive Criterion: Quality Improvement
a) Minimum Requirements—Demonstrable Progressive Clinical Quality Improvement
LEMSA requires that the Contractor develop and implement a comprehensive quality
management program that incorporates assuring compliance with the Agreement, minimum
performance standards, and rules and regulations. The program shall also include structural
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process and outcome indicators as part of a progressive clinical quality improvement
process that is integrated with the EMS system’s quality management program. The clinical
indicators measured by all system participants will be developed through collaborative
efforts of the first responder agencies, the Contractor, and the LEMSA and based on current
EMS science and call demand. The LEMSA ultimately will approve and implement the quality
monitoring and improvement plan to be used in the County by all EMS system participants.
Proposers should review the LEMSA’s quality management program requirements at
http://cchealth.org/ems/quality.php.
The LEMSA supports a coordinated system of emergency services that are patient-centered,
add value to the community served and improve patient outcome. Proposers must commit to
a clear, concise, and implementable set of processes and practices designed to measure,
trend and sustain tangible improvements for the patients and other customers served by the
EMS system, the Proposer’s employees who serve Contra Costa County, and the other
agencies involved in the Contra Costa County EMS system.
The current level of the scientific research and the large number of variables outside the
EMS system’s control of patient outcomes limits the ability to define realistic and achievable
outcome measures. In addition, accessing reliable outcome data may be limited. For these
reasons, the Contractor will be expected to participate in the collection of both outcome and
process measures to promote enhanced clinical outcomes. It is anticipated that these
measures will be utilized and further developed throughout the term of the Agreement.
Fundamental to a progressive clinical quality program is the proactive identification and
management of potential risks to patient safety to prevent adverse occurrences rather than
simply reacting when they occur. Contractor is to ensure that an ongoing, proactive program
for identifying risks to patient safety and reducing medical/health care errors is defined and
implemented.
Contractor will seek to reduce the risk of sentinel events and medical/health care system
error-related occurrences by conducting its own proactive risk assessment activities
(Failure Mode Effect Analysis-FMEA) annually on at least one identified, high-risk process
and by using available information about sentinel events known to occur in EMS
organizations that provide similar care and services. This effort is undertaken so that
processes, functions and services can be designed and redesigned to prevent such
occurrences in the organization.
Contractor will conduct and document one FMEA annually on at least one identified, high-
risk process. Contractor will redesign the identified process to minimize the risk of that
failure mode or to protect patients from its effects, teach and implement the redesigned
process, identify and implement measures of effectiveness and implement a strategy for
maintaining the effectiveness of the redesigned process over time.
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In addition to generally committing to these Minimum Requirements, Proposers shall
illustrate their ability to achieve them by describing their overall approach to
comprehensive quality management.
b) Higher Levels of Commitment—Quality Management
In the majority of American EMS systems, “quality management” is limited to a retrospective
evaluation of patient care reports. A growing number of EMS systems, however, are
expanding the scope of their quality management efforts to include clinical performance
indicators paired with an education system designed to effect clinical improvements. The
LEMSA is committed to such a comprehensive model of quality management that, while
patient centered, encompasses all vital functions within the system. This Competitive
Criterion encourages Proposers to join in this commitment.
Examples of ways in which a Proposer may demonstrate a higher level of commitment in
this area may include, but are not limited to, those described below. These are examples only
and these examples are not listed to inhibit Proposers’ innovative offerings.
A Proposal might incorporate the 2013-2014 Baldridge National Quality Program: Health
Care Criteria for Performance Excellence. A copy of this program can be downloaded at
www.nist.gov/baldrige/. The core areas addressed by this process provide a solid
framework for a comprehensive and progressive quality management program. These areas
include:
Leadership;
Strategic Planning;
Focus on Patients, Other Customers and Markets;
Measurement, Analysis, and Knowledge Management;
Workforce Engagement;
Process Management; and
Results.
The Proposer’s quality management capability could be supported by providing a list of Key
Performance Indicators (KPI) for each of the key result areas utilized in Proposer’s
operations and proposed for Contra Costa County. Include a specific data definition and data
source for each KPI.
CMS has adopted the “Triple Aim” concept to improve quality of care and the patient
experience while controlling costs. This program forms the basis for the CMS value based
purchasing arrangements for healthcare providers. The Proposer may describe how it
intends to incorporate the “Triple Aim” premises in its quality management activities. More
about the “Triple Aim” can be reviewed at the Institute for Healthcare Improvement website
(http://www.ihi.org) and at CMS websites.
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2. Competitive Criterion: Clinical and Operational Benchmarking
It is important for an organization to monitor and measure performance in all aspects of its
operations. The definition of what activities are to be measured and monitored is an essential
component.
a) Minimum Requirements— Clinical and Operational Benchmarking
Benchmarking of Key Performance Indicators (KPIs), including KPIs focused on clinical care
is required. These include structure, process and outcome measurements. KPIs will evolve as
part of ongoing EMS system performance improvement as approved by the EMS Medical
Director and the LEMSA. KPIs will include State required core metrics in addition to local
core performance indicators. The Contractor shall provide, on a monthly basis, information
necessary to benchmark KPIs. KPIs focusing on clinical activities to be measured will include,
at a minimum:
1. Response time performance by zone, priority, and County-wide;
2. Presumptive impressions at dispatch compared to field intervention;
3. Scene time and total pre-hospital time for time dependent clinical conditions like
Acute Coronary Syndrome (ACS), stroke, and major trauma;
4. Cardiac arrest survival in accordance with Utstein protocols;
5. Fractal measurement of time to first defibrillation;
6. Compliance with protocols, procedures, timelines, and destinations for ST-Elevation
Myocardial Infarction (STEMI) patients;
7. Compliance with protocols, procedures, and timelines for patients with pulmonary
edema and congestive heart failure;
8. Compliance with protocols, procedures, and timelines for patients with asthma or
seizures;
9. Compliance with protocols, procedures, and timelines for patients with cardiac
arrest;
10. Compliance with protocols, procedures, timelines, and destinations for systems of
care patients (e.g. Trauma, STEMI, Stroke, Cardiac Arrest);
11. Compliance with protocols, procedures, and timelines for assessment of pain relief;
12. Analysis of high risk, low frequency clinical performance issues and strategies to
support competent care.
13. Successful airway management rate by entire system, provider type and individual,
including EtCO2 detection;
14. Successful IV application rate by entire system, provider type and individual;
15. Complaint management;
16. Paramedic skill retention;
17. Use of mutual aid; and
18. Safety.
Contractor will be required to produce a periodic report that describes overall compliance
with protocols and provides an analysis of which protocols have the most compliance
challenges.
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Proposers should describe their current and proposed benchmarking, KPI monitoring, and
its method for regularly assessing compliance with EMS Medical Protocols.
b) Higher Levels of Commitment—Clinical and Operational Benchmarking
Measuring and monitoring KPIs on a regular and consistent basis promotes an
organization’s improvement and development. EMS organizations that are committed to
improvement not only measure and monitor, but use the results to effect change. Proposers
can demonstrate a higher level of commitment to measurement, monitoring, benchmarking,
and improvement by documenting performance indicators that they measure and describing
the use of the results.
Non-clinical performance indicators are relevant for operational, financial, or organizational
advancement. Incorporating such focus areas demonstrates a higher level of commitment to
performance and improvement.
Examples of ways in which a Proposer may demonstrate a higher level of commitment in
this area may include but are not limited to those described below. These are examples only
and these examples are not listed to inhibit Proposers’ innovative offerings.
The Contractor’s system for benchmarking might include non-clinical KPIs such as:
employee injuries;
vehicle collisions (>$250 damage) per 100,000 fleet miles;
critical vehicle/equipment breakdowns (interfering with a response or transport)
per 100,000 fleet miles;
consumer satisfaction;
employee turnover; and
employee satisfaction.
Other KPI benchmarking might include comparing clinical data published by the National
Association of EMS Physicians or other national organizations with other similarly designed
clinically sophisticated systems. The organization’s approach to learning and performance
improvement using industry and non-industry benchmarking can also demonstrate higher
levels of capability and commitment.
Participation in, or publishing the results of, peer reviewed research is another strong
process measure of a system’s ongoing commitment to clinical sophistication. The Proposer
might demonstrate a higher level of commitment by describing past participation in and
proposed out-of-hospital research projects. For illustration, such projects might include but
are not limited to research involving:
Impacts of Public Access Defibrillation (PAD);
Reduction of “at scene” time;
Reduction of “at patient” status to first shock or ALS intervention;
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Other research projects as approved by the EMS Medical Director.
3. Competitive Criterion: Dedicated Clinical Oversight Personnel
It is LEMSA’s goal that all organizations participating in the Contra Costa County EMS system have
adequate and competent oversight and management of the clinical services and quality improvement
activities.
a) Minimum Requirements—Clinical Leadership Personnel
A senior manager shall be responsible for oversight and management of the key
performance indicators and ongoing organization-wide quality management programs.
The Contractor shall provide a physician (may be part-time) and a full-time Registered
Nurse or Paramedic with specialized training and experience in quality improvement to
implement and oversee Contractor’s on-going Quality Management program. These
individuals shall be responsible for the medical quality assurance evaluation of all services
provided pursuant to this Agreement. At a minimum, the Contractor shall provide and
maintain two full-time Clinical and Educational Services positions, in addition to the
individual identified to oversee the Contractor’s on-going quality managment program. In
addition, the Contractor shall provide at least one full-time Analyst to evaluate Patient Care
Reports and eighty (80) compensated hours per month for designated field personnel to
participate in clinical quality improvement activities.
The LEMSA’s minimum requirement for EMS quality improvement, education and training is
the IHI Open School Basic Certificate. Information can be found
at http://www.ihi.org/education/IHIOpenSchool/Courses/Pages/OSInTheCurriculum.aspx.
Within eighteen months, the full-time staff dedicated to quality management and education
will have completed an IHI Open School Basic Certificate.
Proposers are required to document their commitment to have the senior members of their
Contra Costa County operating unit actively participate in the leadership and oversight of the
EMS quality management system. This commitment includes, but is not limited to, active
participation of Proposer’s senior leadership in meetings related to EMS and public health
and safety coordinated by the LEMSA and actively participating in projects designed to
improve the quality of EMS in the County of Contra Costa.
The Proposer shall describe its commitment of leadership to clinical quality and describe the
individual to oversee its clinical quality program including a job description and reporting
relationships.
b) Higher Levels of Commitment—Clinical Leadership Personnel
An organization’s commitment is demonstrated by the caliber, qualifications, and expertise
dedicated to an endeavor.
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Examples of ways in which a Proposer may demonstrate a higher level of commitment in
this area may include, but are not limited to those described below. These are examples only
and these examples are not listed to inhibit Proposers’ innovative offerings.
1. Implementing specific programs and activities to fully engage the workforce in
quality management, such as peer review activities, medical audits, etc.;
2. The quality management competencies that members of the leadership team will
possess including their ability to analyze performance data and conduct
improvement projects;
3. Methods used to communicate openly with the workforce and to assess the
effectiveness of this communication;
4. Activities used by the organization to communicate performance data to the
members of the workforce involved in the process whose performance is being
monitored;
5. Strategies used by the organization’s leadership team to promote legal and ethical
behavior for themselves and the entire organization;
6. The organization’s process for handling breaches of ethical behavior;
7. Activities of the organization’s leadership to promote a culture focused on patient
and employee safety;
8. Procedures used by the organization to handle situations that have or may have had
an adverse impact on patients or the public;
9. Commitment to patient safety; and
10. Transparency and public reporting of clinical performance and benchmarks.
4. Competitive Criterion: Medical Direction
Ambulance services employ Medical Directors to lead the clinical care services. The involvement,
commitment, and expertise expected from the Medical Director should directly contribute to the
Contractors clinical service levels, quality of care and quality management and improvement
a) Minimum Requirements—Medical Direction
Proposer shall engage a physician as its Medical Director to oversee the Contractor’s clinical
activities. The Proposer shall identify its Medical Director and provide a curriculum vita
outlining his or her experience and qualifications. Proposer shall also provide a job
description or contract, which specifies expectations as to role, responsibilities and time
commitment of the Medical Director. These roles are separate and distinct from that of the
LEMSA Medical Director and have no statutory authority within the EMS system for medical
oversight.
b) Higher Levels of Commitment— Medical Direction
Examples of ways in which a Proposer may demonstrate a higher level of commitment in
this area may include, but are not limited to those described below. These are examples only
and these examples are not listed to inhibit Proposers’ innovative offerings.
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1. Demonstrate higher levels of Medical Direction commitment by emphasizing the
individual’s qualifications such as Board Certification in Emergency Medicine,
completion of the NAEMSP Medical Director’s Course, etc.
2. Committing the Medical Director to active involvement with the Contractor and its
employees, training, research, field observation, and pledges to work with the
LEMSA Medical Director.
3. Committing to support its Medical Director in liaising with other members of the
Contra Costa County medical community to identify and support the system’s
standard of care and to identify and resolve issues that may arise.
5. Competitive Criteria: Focus on Patients and Other Customers
Clinical quality is not measured solely by the patient’s physical outcome. It is important to monitor
and analyze the entire interaction of the patient and customers within the EMS system.
a) Minimum Requirements—Focus on Patients and Other Customers
At a minimum, the Contractor shall have a comprehensive mechanism for handling patient
and customer complaints or issues. The Proposer shall describe the organization’s
mechanism for managing complaints. Include methods for receiving, investigating, resolving,
and tracking complaints. Include the method for analyzing complaint patterns along with
examples of improvement activities that have resulted from this analysis.
Contractor shall establish and publish a user-friendly Customer Access Hotline giving
internal and external customers and system participants the ability to contact a designated
liaison of the Contractor’s leadership team to discuss recommendations or suggestions for
service improvements. The number may either be answered by a designated manager or
provide an opportunity for the caller to leave a voicemail message. The hotline number will
be published in the local telephone directory and on the Contractor website and publicized
at local healthcare facilities, fire stations, and public safety agencies. Members of the
Contractor’s leadership team are to be automatically notified of any incoming calls. A
management designee must return the call to the customer within 30 minutes, 90% of the
time. Incidents that require feedback are to be attended to by the end of the next business
day.
b) Higher Levels of Commitment—Focus on Patients and Other Customers
Examples of ways in which a Proposer may demonstrate a higher level of commitment in
this area may include, but are not limited to those described below. These are examples only
and these examples are not listed to inhibit Proposers’ innovative offerings.
1. Identify how the organization determines the desires, needs, and expectations of
patients and other customers. Include a list of key customer groups other than
patients.
2. Discuss the mechanisms the organization uses to incorporate the “voice of the
customer” in planning processes.
3. Other aspects of healthcare have documented inequalities in diagnosis and
treatment based on age, ethnicity, and gender. Describe the organization’s system
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for assuring and monitoring equitable EMS care to traditionally underserved
patients such as children, the elderly, homeless, substance abusers and mental
health patients as well as to all patients based on neighborhood, age, gender, and
ethnicity.
4. Describe and provide detailed examples of the methods the organization uses to
assess and monitor the effectiveness at meeting the needs and desires of patients
and other customers. If possible, provide examples of what you have learned by
using these monitoring methods and the action you have taken to improve the
service to patients and other customers.
5. Most EMS systems engage in infection control practices designed to protect
providers from acquiring infections. Fewer EMS systems engage in hygiene
practices that are designed to protect patients from contamination. Describe the
mechanism for providing infection control for employees, system partners in
healthcare and patients.
6. Competitive Criterion: Continuing Education Program Requirements
a) Minimum Requirements— Continuing Education
Contractor shall provide in-house or sub-contracted in-service training programs designed
to meet state and LEMSA licensure/certification requirements at no cost to employees. All
in-service and continuing education programs must comply with state regulations. The EMS
Medical Director may mandate specific continuing education programs and content
requirements, and the LEMSA may review and audit any continuing education programs
offered by the Contractor.
b) Higher Levels of Commitment—Continuing Education
Examples of ways in which a Proposer may demonstrate a higher level of commitment in
this area may include, but are not limited to those described below. These are examples
only and these examples are not listed to inhibit Proposers’ innovative offerings.
1. Targeting educational content to address local system needs;
2. Expanded content of training program offerings;
3. Introduction of innovative educational/training methods; and
4. Measuring competency with specified skill sets.
B. Operations
1. Competitive Criterion: Dispatch and Communications
Ambulance Response Times are impacted by the efficiency and reliability of the dispatch system
referring calls to the sometimes-complex communication chain connecting a local resident or visitor
who has just dialed 9-1-1 to the ambulance crew, which is asked to respond to the incident address.
This communication chain varies between different jurisdictions within Contra Costa County.
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This RFP is intended to promote a higher level of collaboration between the Contractor and County
PSAPS, designated dispatch centers and public safety agencies to improve the efficiency and
reliability of communications between those entities. The goal in this Competitive Criterion is to
improve efficiency and promote a seamless dispatch process by minimizing the transfer of calls or
information from the calls.
a) Minimum Requirements—Dispatch and Communications
It is anticipated that during the term of the Agreement the County will make significant
changes in the medical dispatch process. The EMS Modernization Project calls for a single
medical dispatch center with full implementation of prioritization of ambulance requests. At
a minimum, the Proposer shall commit to this improvement in the medical call-taking and
dispatch processes and agree to work with the LEMSA and County to effect such changes.
The Proposer shall agree to negotiate with the LEMSA and the County in good faith to
achieve these goals.
The Contractor shall provide a dispatch center and maintain all equipment and software
(fixed, mobile, linkages) necessary to receive requests for emergency ambulance services
from County designated dispatch centers.
Staffing levels shall be such that electronic or telephonic notifications from the County
designated public safety dispatch centers are answered or responded to within fifteen (15)
seconds, 95% of the time, and that ambulances are dispatched to respond to Emergency
Requests within thirty (30) seconds, 90% of the time, from the receipt of information
establishing a location and priority for the response.
The Contractor and its Dispatch Center staff shall maintain a professional relationship and
level of interaction with other public safety dispatch centers and medical facilities, both
within and outside of the County.
The Contractor is required to provide CAD-to-CAD interfaces with the designated medical
dispatch centers within the County to expedite the transmission of call information in order
for the Contractor to dispatch its units, based on the “Automated EMS Message Transmission
Network Specification” available on the EMS website
at http://cchealth.org/ems/pdf/mtnspec v1.5.pdf.
The Contractor shall provide access for LEMSA staff members to access the Contractor’s CAD
to audit and create reports for system performance monitoring.
Contractor shall be responsible for all mobile radio equipment and cellular phones for use in
the field including obtaining radio channels and all necessary FCC licenses and other permits
as may be required for the operation of said system. This will enable Contractor to
effectively receive communications from the Contractor’s Dispatch Center and shall be
capable of receiving and replying to such requests for emergency ambulance services by
voice or data linkage.
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1. Contractor's communications system shall be capable of receiving and transmitting
all communications necessary to provide emergency ambulance services pursuant
to this Agreement including communicating with hospitals and other public safety
agencies as required in a declared disaster situation. Radio equipment used for
ambulance-to-hospital communications shall be configured so that personnel
actually providing patient care are able to directly communicate with base or
receiving hospital staff about the patient. The Contractor’s ambulance crews shall be
capable of transmitting 12-lead ECGs to receiving facilities.
2. Contractor shall equip all ambulances and supervisory vehicles used in performance
of services in Contra Costa County with radio equipment for communications with
Contractor’s Dispatch Center, East Bay Regional Communications System (EBRCSA),
and suitable for operation on the (CALCORD) California On-Scene Emergency
Coordination Radio System. Radios operated on EBRCS shall be P25 Phase 2
compliant (additional information regarding EBRCSA is available at
http://www.ebrcsa.org).
3. Contractor shall operate the two-way radios in conformance with all applicable
rules and regulations of the Federal Communication Commission (FCC), and in
conformance with all applicable LEMSA rules and operating procedures.
4. Contractor shall ensure access to cellular telephones for use on ambulances and
supervisory units.
5. Contractor shall equip all ambulances with Automatic Vehicle Location (AVL)
devices. Contractor shall make available to LEMSA designated dispatch centers the
real-time AVL information for on-duty ambulances and supervisory units within the
County.
Proposers shall fully describe how they intend to comply with the minimum requirements
listed above and include a description of the equipment and technology to be used.
b) Higher Levels of Commitment— Dispatch and Communications
Examples of ways in which a Proposer may demonstrate a higher level of commitment in
this area may include, but are not limited to those described below. These are examples only
and these examples are not listed to inhibit Proposers’ innovative offerings.
1. Contractor may identify a means and commit to implementation of combined call-
taking and dispatch of ambulances meeting the goals identified in the EMS
Modernization Project Report in all or part of the EOA.
2. Contractor may collaborate with existing PSAPs and dispatch centers to locate or
consolidate PSAP/Dispatch operations.
3. Other Strategies to Reduce Response Times: Proposers may propose other
reasonably achievable strategies to be undertaken at the Contractor’s expense,
which would be likely to materially reduce ambulance Response Times across all or
any significant part of the EMS system.
4. Proposer may commit a defined annual amount to contribute to the consolidation of
the medical dispatch centers. This amount may be stipulated for the Contractor to
provide call-taking and dispatch with the transfer of callers from County PSAPs or it
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may be an amount contributed to another agency providing call-taking, dispatch,
and deployment of ambulances. The contribution can include funding, assignment of
personnel, or the provision of other services.
2. Competitive Criterion: Vehicles
Contractor shall acquire and maintain all ambulances and support vehicles necessary to perform its
services under the Agreement. All costs of maintenance including parts, supplies, spare parts and
costs of extended maintenance agreements shall be the responsibility of the Contractor.
a) Minimum Requirements—Vehicles
At a minimum, the Contractor shall meet the requirements listed below.
1. All ambulances shall meet the standards of Title XIII, California Code of Regulations.
2. Ambulance vehicles used in providing contract services shall bear the markings of
the County logo and "Contra Costa County Emergency Medical Services" in at least
four (4) inch letters on both sides. Such vehicles shall display the "9-1-1" emergency
telephone number and state the level of service, "Paramedic Unit,” on both sides.
3. Ambulance vehicles shall be marked to identify the company name, but shall not
display any telephone number other than 9-1-1 or any other advertisement.
4. Overall design, color, and lettering are subject to the approval of the Contract
Administrator.
5. Proposer shall describe the ambulance and supervisory vehicles to be utilized for
the services covered under the Agreement.
6. Ambulance replacement shall occur on a regular schedule and the Proposer shall
identify its policy for the maximum number of years and mileage that an ambulance
will be retained in the EMS System.
7. Each ambulance shall be equipped with GPS route navigation capabilities.
b) Higher Levels of Commitment—Vehicles
Examples of ways in which a Proposer may demonstrate a higher level of commitment in
this area may include, but are not limited to those described below. These are examples only
and these examples are not listed to inhibit Proposers’ innovative offerings.
1. Documenting the type, age, mileage, and configuration of the ambulance fleet and
supervisory vehicles; and
2. Installing equipment and selecting vehicles that provide innovations for safety,
specialized transport capabilities, reduced environmental impact, etc.
3. Competitive Criterion: Equipment
Acquisition and maintenance of all equipment including parts, supplies, spare parts, and costs of
extended maintenance agreements shall be the responsibility of the Contractor.
a) Minimum Requirements—Equipment
Contractor shall have sole responsibility for furnishing all equipment necessary to provide
required service. All on-board equipment, medical supplies and personal communications
equipment will meet or exceed the minimum requirements of LEMSA’s Ambulance
Equipment and Supply List. A listing of the required on-board equipment, medical
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equipment, and supplies can be found on LEMSA’s website. Contractor shall also comply
with the specific pediatric equipment requirements as specified in EMSA #188, Pediatric
Equipment for ambulance and First Responders.
Contractor agrees that equipment and supply requirements may be changed with the
approval of the Contract Administrator due to changes in technology.
LEMSA may inspect Contractor's ambulances at any time, without prior notice. If any
ambulance fails to meet the minimum in-service requirements contained in the Ambulance
Equipment and Supply list as determined by the LEMSA, the LEMSA may:
1. Immediately remove the ambulance from service until the deficiency is corrected if
the missing item is deemed a critical omission;
2. Subject the Contractor to a $500.00 penalty; and
3. The foregoing shall not preclude dispatch of the nearest available ambulance even
though not fully equipped, in response to a life threatening emergency so long as
another appropriately equipped ambulance of at least equal level of service is also
dispatched to the scene. The LEMSA may adopt protocols governing provisional
dispatch of ambulances not in compliance with minimum in-service requirements
and Contractor shall comply with these protocols.
b) Higher Levels of Commitment—Equipment
Examples of ways in which a Proposer may demonstrate a higher level of commitment in
this area may include but are not limited to those described below. These are examples only
and these examples are not listed to inhibit Proposers’ innovative offerings.
1. Providing equipment or technologies above those required by the minimum
equipment list. These additional items may include advances in clinical care
capabilities, opportunities for increasing safety for crewmembers and patients,
and items to increase ease of work, improve efficiency or make efforts more
effective.
2. Providing “smart” technologies that are blue tooth or otherwise compatible with
data systems and electronic patient care records to improve patient care delivery,
oversight and enhance performance improvement.
4. Competitive Criterion: Vehicle and Equipment Maintenance
a) Minimum Requirements—Vehicle and Equipment Maintenance
Contractor shall be responsible for all maintenance of ambulances, support vehicles, and on-
board equipment used in the performance of its work. LEMSA expects that all Ambulances
and equipment used in the performance of the Agreement will be maintained in an excellent
manner. Any Ambulance, support vehicle, and/or piece of equipment with any deficiency
that compromises, or may reasonably compromise its function, must be immediately
removed from service.
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The appearance of ambulances and equipment impacts customers' perceptions of the
services provided. Therefore, the LEMSA requires the Ambulances and equipment that have
defects, even significant visible but only cosmetic damage, be removed from service for
repair without undue delay.
Contractor must ensure an ambulance maintenance program that is designed and conducted
to achieve the highest standard of reliability appropriate to a modern high performance
ambulance service by utilizing appropriately trained personnel, knowledgeable in the
maintenance and repair of ambulances, developing and implementing standardized
maintenance practices, and incorporating an automated or manual maintenance program
record keeping system.
Contractor must ensure all point of care equipment on the ambulance meets CLIA standards
and submit a description of the program used to assure compliance.
All costs of maintenance and repairs, including parts, supplies, spare parts and inventories of
supplies, labor, subcontracted services, and costs of extended warranties, shall be at the
Contractor’s expense.
b) Higher Levels of Commitment—Vehicle and Equipment Maintenance
Examples of ways in which a Proposer may demonstrate a higher level of commitment in
this area may include, but are not limited to those described below. These are examples only
and these examples are not listed to inhibit Proposers’ innovative offerings.
1. Proposer offers to exceed the maintenance standard as outlined in the Standards—
Accreditation of Ambulance services published by the Commission on Accreditation
of Ambulance services; and/or
2. The Proposer describes how it will exceed minimum requirements for the testing,
monitoring, maintaining, and retaining documentation for all bio-medical
equipment such as complying with the then current and applicable Joint
Commission on the Accreditation of Healthcare Organizations (JCAHO) or equivalent
standard.
5. Competitive Criterion: Deployment Planning
The Contractor will be expected to work continuously to refine and improve its coverage and
deployment plans throughout the term of the Agreement. All plan modifications will be at
Contractor’s sole discretion and expense.
a) Minimum Requirements—Deployment Planning
Contractor shall agree to deploy its ambulances in such a manner to achieve the Response
Time requirements. The Contractor shall also commit to modify and adjust its deployment
strategies in the event that Response Time performance is not complying with the standards
or if it is identified that there are areas of the County, which are chronically experiencing
delayed responses.
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The Proposer shall describe its methods and initial deployment plans to be used in Contra
Costa County. A description of the methodology used by the organization to monitor and
modify its plans will also be documented. At a minimum, the Contractor shall identify the
average number of unit-hours deployed each week, the number of units on-duty by hour-of-
day and day of week, and the posting locations for ambulances.
b) Higher Levels of Commitment—Deployment Planning
Examples of ways in which a Proposer may demonstrate a higher level of commitment in
this area may include, but are not limited to those described below. These are examples only
and these examples are not listed to inhibit Proposers’ innovative offerings.
1. The Proposer describing sophisticated processes it has developed or will use to
achieve exemplary Response Time performance; and/or
2. The identification and use of technologies or managerial processes to enhance
Response Time performance.
3. The Proposer will describe processes to provide real time situational awareness to
other EMS System stakeholders to facilitate patient care delivery e.g. alerts or visual
displays.
C. Personnel
The LEMSA recognizes that those employed in the Contra Costa County EMS system ultimately
determine the effectiveness and quality of the service. Proposers are encouraged to focus on
employees especially as it pertains to safety, workload, advancement opportunities, and
compensation.
1. Competitive Criterion: Field Supervision
The LEMSA recognizes the Contractor’s need to ensure adequate supervision of its personnel and the
delegation of authority to address day-to-day operational needs. The LEMSA also desires that these
personnel and operational supervisory responsibilities do not displace the Contractor’s provision of
direct clinical supervision of the Contractor’s caregivers.
a) Minimum Requirements—Field Supervision
Contractor shall provide 24-hours a day on-duty field supervisory coverage in each
geographic area of the EOA (West, Central and East) within Contra Costa County. An on-duty
employee or officer must be authorized and capable to act on behalf of the Contractor in all
operational matters.
The Proposers shall also specifically describe how its Supervisors are able to monitor,
evaluate, and improve the clinical care provided by the Contractor’s personnel and to ensure
that on-duty employees are operating in a professional and competent manner.
All field supervisory level staff will have successfully completed ICS 100, 200, 300 & 400,
NIMS 700 & 800.
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b) Higher Levels of Commitment—Field Supervision
Examples of ways in which a Proposer may demonstrate a higher level of commitment in
this area may include, but are not limited to those described below. These are examples only
and these examples are not listed to inhibit Proposers’ innovative offerings.
1. The provision of a dedicated supervisor(s) and vehicle(s) for Contra Costa County
coverage;
2. Demonstrate that all areas of the EOA have adequate dedicated supervision that is
committed to supervision and support of field personnel and the community and
that their administrative tasks are limited in order to allow this high level of
interaction.
3. Specialized training for supervisors (i.e. Strike team leadership, patient safety and
leadership);
4. Exemplary qualification requirements; and
5. Other defined activities to support and supervise field personnel.
2. Competitive Criterion: Work Schedules
This is a performance-based Agreement and Contractor is encouraged to be creative in delivering
services. Contractor is expected to support employees by employing reasonable work schedules and
conditions.
a) Minimum Requirements—Work Schedules
The LEMSA emphasizes that the Contractor is responsible for conducting the employment
matters with its employees, including managing personnel and resources fairly and
effectively in a manner that ensures compliance with the Agreement ultimately executed by
Contractor. The LEMSA will not otherwise involve itself in Contractor’s
management/employee relationships.
Specifically, patient care must not be hampered by impaired motor skills of personnel
working extended shifts, part-time jobs, voluntary overtime, or mandatory overtime without
adequate rest. To mitigate fatigue and safety concerns, Contractor’s paramedics and EMTs
working on an Emergency Ambulance or as a field supervisor should work reasonable
schedules to ensure that potential fatigue and the resulting safety issues are reduced.
Proposer shall describe its policies and procedures used to monitor employee fatigue and
impairment.
b) Higher Levels of Commitment—Work Schedules
Examples of ways in which a Proposer may demonstrate a higher level of commitment in
this area may include, but are not limited to those described below. These are examples only
and these examples are not listed to inhibit Proposers’ innovative offerings.
The delineation of monitoring mechanisms, procedures, and policies designed to ensure
that employees are not overworked or expected to work for extended time periods that
may cause fatigue and impair the employee’s ability to perform safely and appropriately.
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3. Competitive Criterion: Internal Risk Management/Loss Control Program
Education and aggressive prevention of conditions in which accidents occur are the best mechanism
to avoid injuries to Contractor staff and Patients.
a) Minimum Requirements—Risk Management
The LEMSA requires Contractor to implement an aggressive health, safety, and loss
mitigation program including, at a minimum:
1. Pre-screening of potential employees (including drug testing);
2. Initial and on-going driver training;
3. Lifting technique training;
4. Review current information related to medical device FDA reportable events, recall,
equipment failure, accidents; and
5. Review employee health/infection control related information such as needle sticks,
employee injuries, immunizations, exposures and other safety/risk management
issues.
6. Ensure DEA compliant medication control processes.
Planning for safety and risk mitigation processes will include, at a minimum:
1. Gathering data on ALL incidents that occur among the Contractor’s workforce;
2. Devise policies prescribing safe practices and providing intervention in unsafe or
unhealthy work-related behaviors;
3. Gather safety information as required by law;
4. Implement training and corrective action on safety related incidents, as required by
law; and
5. Provide safe equipment and vehicles.
Proposer shall describe its risk management program.
b) Higher Levels of Commitment—Risk Management
Examples of ways in which a Proposer may demonstrate a higher level of commitment in
this area may include, but are not limited to those described below. These are examples only
and these examples are not listed to inhibit Proposers’ innovative offerings.
Implementation of a comprehensive safety and risk management plan that involves
employees, analyzes processes, monitors safety activities, and incorporates all processes
into policies, procedures and training programs designed to enhance safety for the
workforce and patients.
4. Competitive Criterion: Workforce Engagement
An experienced, highly skilled, well rested, and satisfied workforce is essential to the provision of
high quality EMS services. Proposers are encouraged to meet with current system employees
and their labor representatives prior to submitting proposals.
a) Minimum Requirements—Workforce Engagement
At a minimum, the Proposer shall describe and document the following:
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1. Describe the organization’s method for providing system and individual
performance feedback to employees.
2. Describe the organization’s mechanism for involving front line employees in quality
and performance improvement projects.
3. Describe the credentialing requirements for the employees including but not limited
to EMT’s, paramedics, supervisors, dispatchers, and mechanics.
4. Describe the methods to assess, maintain, and develop new skills for employees in
the workforce.
5. Describe the organization’s practices to ensure diversity in the workforce. Address
the organization’s level of diversity alignment with the communities that you serve.
6. Describe the organization’s practices and policies designed to promote workforce
harmony and prevent discrimination based on age, national origin, gender, race,
sexual orientation, religion, and physical ability.
7. Impaired providers present a significant safety risk for patients, partners, and
others in the community. Proposers should describe their commitment to ensuring
that providers are free from the influence of alcohol and intoxicating drugs.
8. Describe the organization’s processes to ensure harmonious relationships with
other EMS System stakeholders.
b) Higher Levels of Commitment— Workforce Engagement
Examples of ways in which a Proposer may demonstrate a higher level of commitment in
this area may include, but are not limited to the following. These are examples only and
these examples are not listed to inhibit Proposers’ innovative offerings.
1. The organization’s process for assessing the engagement and satisfaction level of
employees. Include description of an ongoing process that produces qualitative and
quantitative KPIs for employee satisfaction.
2. The method used by the organization for two-way communication between front
line employees and the leadership team.
3. The organization’s mechanism for encouraging, gathering, providing feedback on
and acting on employee improvement suggestions.
4. The development of a career ladder and professional development process for
members of the workforce. Include a description of the succession plan for key
positions.
5. The method for recognition of workforce patient care excellence and contributions.
D. Management
1. Competitive Criterion: Key Personnel
a) Minimum Requirements—Key Personnel
Proposers shall identify the individuals who will fill the key leadership positions for Contra
Costa County. Provide resumes for the individuals. If the positions have not been filled for
Contra Costa County, provide the job descriptions that will be used for the positions that
include minimum qualifications and scope of responsibilities.
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Identify out-of-county leadership personnel who will be actively involved in the Contra Costa
County operations, if applicable. Include their resumes, qualifications, and scope of
responsibilities.
b) Higher Levels of Commitment—Key Personnel
Examples of ways in which a Proposer may demonstrate a higher level of commitment in
this area may include, but are not limited to those described below. These are examples only
and these examples are not listed to inhibit Proposers’ innovative offerings.
1. Provision of on-going training for key managers and development programs for EMS
managers and supervisors offered to those personnel at no cost. While there is no
specific program regarding the exact content of the development program,
managers should receive training similar to the content provided in the American
Ambulance Association's Ambulance Service Manager Certificate Program.
2. Stability of the Contractor’s leadership team directly correlates with the
continuation of the performance of the EMS system. The Proposer may describe
how it will ensure continuity and reduce managerial turnover in the system.
3. Assignment of key personnel to participate in countywide initiatives e.g. Health
Information Exchange, Quality Improvement and Community Outreach.
E. EMS System and Community
1. Competitive Criterion: Supporting Improvement in the First Response System
The EMS system in Contra Costa County is collaboration among numerous related and unrelated
agencies, which are dependent on one another to assure positive outcomes for the individuals
being served. The LEMSA’s goals regarding this collaborative system include: 1) provide a
seamless handoff of patients by first responders to the emergency ambulance service; and 2)
achieve the prevailing industry standard with respect to the provision of training to first
responders.
The emergency ambulance service can play a role as a partner within the pre-hospital EMS
system that is concerned with the provision of emergency medical services to people who are
seriously injured or ill. As a result, the ambulance service provider has, in many communities,
emerged as the organization charged with facilitating ongoing and enhanced EMS training within
the EMS system. This is a cost of doing business recognized by ambulance providers across the
country and serves a practical source of such training in most communities. It is also the logical
source for such training, because the ambulance provider is the entity with a direct role in the
most EMS responses in the County.
The LEMSA and the County desire to increase collaboration between the first responders and the
ambulance service. This increased collaboration may take many forms including formal
agreements or combined work and training activities. The Proposers are not expected to
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negotiate formal agreements with other EMS participants prior to the award of the Agreement. If
a Proposer proposes to commit to a collaborative arrangement as described in this section, it is
only necessary to state that commitment and describe the terms on which the Proposer is willing
to collaborate in the Proposal.
a) Minimum Requirements—First Response System
Proposer must commit to:
1. Exercise its best, good faith efforts to maintain positive working relationships with
all first response agencies across the EOA;
2. Make continuing EMS education services available without cost to all first
responders across the EOA at the level prevailing in the industry;
3. Restock at the Contractor’s cost basic life support supplies utilized on a one-for-one
basis, based on utilization on calls by first response agencies;
4. Provide internship opportunities for EMT or paramedic students, giving preference
to students from training programs located in Contra Costa County; and
5. Contractor shall designate from among its employees a single individual as its
contact person/liaison for the First Response agencies.
Proposers shall describe in detail how they intend to address the Minimum Requirements
listed above.
b) Higher Level of Commitment—First Response System
Examples of ways in which a Proposer may demonstrate a higher level of commitment in
this area may include, but are not limited to those described below. These are examples only
and these examples are not listed to inhibit Proposers’ innovative offerings.
Proposers may propose strategies to strengthen the collaborative interface between the
Contractor and first responders and to improve the quality and efficiency of the EMS
response system through support for first responders and other agencies integral to the
provision of emergency services. Examples of possible strategies include:
1. Shared medical direction with the provider
2. Group purchasing arrangements that may allow First Responder agencies to acquire
medical equipment and non-exchanged supplies at a lower cost
3. Collaborative training programs
4. Collaborative strategies to address call surges, including possible coordination of
responses during MCI and other disaster events.
5. Coordination between or collaborative continuous quality improvement
programming
6. EMS Week Recognition and Awards Program Sponsorship
7. Coordination of public education initiatives and programming
8. Coordination of injury and illness prevention programs
9. Collaborative public information services
10. If fire districts within the EOA impose a first responder fee, the Contractor may
negotiate with the districts to provide billing and collection services for these fees.
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11. In the Contractor’s response for Plan B, the contractor may provide additional
support to the ALS and BLS first responders. This support may include financial
and/or provision of services to the first responders.
12. Proposers may propose other reasonable achievable strategies to be undertaken at
the Contractor’s expense, which would be likely to materially expand or enhance the
capacity of first responder agencies to provide services more effectively or
economically.
It is recognized that some of the suggestions for a “higher level of commitment” in
connection with this Competitive Criterion “Supporting Improvement in the First
Response System” may be relevant to a Proposer’s response to other Competitive
Criteria or to certain Core Requirements. As noted above, information provided in
response to other requirements or criteria cannot be taken into account when rating
the Proposer’s response to this Competitive Criterion. If Proposers desire that
previously provided information or offerings be considered under this criterion, the
specific commitments should be repeated in the response to this criterion.
Proposers desiring to offer a higher level of commitment in response to this
Competitive Criterion should set forth here a comprehensive description of the
collaborative working relationship they intend to offer to local first responder
agencies, including a description of each of the specific components and
commitments, which the Proposer is offering.
2. Competitive Criterion: Health Status Improvement and Community Education
The LEMSA desires that its Contractor take significant steps to improve injury and illness prevention
and system access through community education programs provided to the school system and
community groups. It is the LEMSA’s expectation that Contractor will plan such programs working
collaboratively with other public safety and EMS related groups such as the American Heart
Association, American Stroke Association, the American Red Cross, and area healthcare organizations.
a) Minimum Requirements—Community Education
Contractor will allocate one hundred thousand dollars ($100,000) under Plan A and three
hundred thousand dollars ($300,000) under Plan B annually for community education and
improvement activities. The Proposer shall describe how these funds will be used for the
benefit of the Community.
Contractor shall annually plan and implement definitive community education programs,
which shall include: identification of and presentations to key community groups which
influence the public perception of the EMS system’s performance, supporting HeartSafe
Communities initiatives, Public Access Defibrillation programs, conducting citizen and
school based CPR training events, participation in EMS week and other educational activities
involving illness and injury prevention, system awareness/access, and appropriate
utilization of the EMS system.
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Proposers shall describe their planned community education program for both Plans A and
B.
b) Higher Level of Commitment—Health Status Improvement and Community Education
Examples of ways in which a Proposer may demonstrate a higher level of commitment in
this area may include, but are not limited to those described below. These are examples only
and these examples are not listed to inhibit Proposers’ innovative offerings.
According to the UCSF Center for Health Professions, on a national level, the ethnic
compositions of the EMT and paramedic workforce does not fully reflect the U.S. population.
This is of some concern because EMTs are frequently involved in situations where cultural
understanding is vital, particularly in urban areas. Accordingly, Contractor may collaborate
with the LEMSA and public health officials to develop and facilitate EMT training programs,
internships and related opportunities for Contra Costa County residents from racial/ethnic
and income groups that are underrepresented among health and emergency medical
professionals.
Proposer may offer to undertake projects that shall demonstrably improve the health status
in the community. Health status improvement programs targeted to “at-risk populations”
may include, but are not limited to: seat belt use, child passenger safety program, bike
helmet and safety program, participation in NTHSA Safe Communities Program, Every 15
minutes, 9-1-1 awareness, gun safety, hunting safety, Back to Sleep Program, Safely
Surrendered Baby Program, drowning prevention, earthquake and disaster preparedness,
concussion prevention programs, equestrian accident prevention, senior safety program,
and home hazard inspection program.
The impact of health status improvement projects should be statistically demonstrable. For
example, this includes selecting indicators that can be used to measure the process and
outcomes of an intervention strategy for health improvement, collecting and analyzing data
on those indicators, and making the results available to the community to inform
assessments of the effectiveness of an intervention and the contributions of participating
entities.
Steps in the health improvement projects may include:
Analyzing the community’s health issues
Inventorying resources
Developing a health improvement strategy
Establishing accountability for activities
Monitoring process and outcomes
Developing partnerships with Public Health, Law and Human Services
Contractor may seek external grant funding for health status improvement projects.
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F. Integration with Healthcare Providers
1. Competitive Criterion: Collaboration with Healthcare Providers
The evolving role of EMS and dramatic changes in the healthcare delivery systems provide a
challenge and opportunity in Contra Costa County.
The successful bidder will collaborate with hospitals, healthcare systems, mental health providers,
County Health Services, and others involved in community health.
It is anticipated that the Contractor will enter into agreements with various healthcare agencies for
provision of ambulance transportation and other services during the term of the Agreement. The
Contractor will include the County as party on all such agreements so in the event of a Contractor
change the agreements will be remain in force within the EOA and/or County.
a) Minimum Requirements— Collaboration with Healthcare Providers
The Proposer will describe its commitment to furthering collaboration with other healthcare
providers within the EOA and County. The Proposer will also describe its commitment to
working with the LEMSA and healthcare providers to implement a standardized electronic
health record to be shared among the caregivers.
b) Higher Level of Commitment—Collaboration with Healthcare Providers
Proposer may demonstrate a higher level commitment considering the items described
below. These are examples only and these examples are not listed to inhibit Proposers’
innovative offerings.
1. Commiting to a more significant role in establishing the out-of-hospital electronic
healthcare record including first responder and ambulance patient care data and its
immediate dessimination to the receiving facility. This may include the commitment
of specific software, equipment, and/or funding.
2. Provide Letters of Interest (LOI) with existing healthcare providers indicating a
desire to establish services to healthcare systems beyond those covered under this
RFP.
3. Identify activities that the Contractor will undertake to create the opportunity for
expanded mobile health care services to support community health and integrated
healthcare within the County and the State.
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SECTION VI. FINANCIAL CRITERIA
A. Financial Strength and Stability
The Proposer must provide documentation of its financial strength and stability as a going concern.
The Proposer must satisfy the LEMSA that it can financially support the services covered in this RFP
and be able to afford losses that may arise from inaccurate estimates of revenue, expenses, fines, and
resource requirements necessary to comply with the performance standards identified in this RFP.
Specifically, the LEMSA desires an understanding of the Proposer’s financial stability, Liquidity
(solvency), financial leverage (debt), asset efficiency (management or turnover), profitability,
revenue recovery performance and other financial indicators.
The documents requested in this Section are to be included in separately sealed containers and will
be evaluated by an independent entity engaged to evaluate the financial components. They will not
be examined by the Review Panel.
The information requested in this Section will allow for the determination of the Proposers’ current
financial situation and allow an assessment of the Proposers’ projected revenue and expenses in
order to establish reasonableness.
B. Financial Situation Documents
1. Financial Statements
Provide year-end financial statements for the last three years and the most recent year-to-date
financial statements. These should support the organization’s financial ability to perform the services
included in this RFP and the Proposal.
2. Audited Statements
Provide independently audited financial statements for the most recent fiscal year.
3. Financial Commitments
Provide a list of commitments, and potential commitments, which may impact assets, lines of credit,
guarantor letters or otherwise affect the responder’s ability to perform the Contract. Identify current
lines of credit and available funds remaining. Document any potential events, litigation, contract
failures, judgments, or other actions that may significantly impact the Proposer’s financial situation.
4. Working Capital
The Proposer shall describe its working capital sources and quantify the amount it expects to need
for startup and improvements to the Contra Costa County EMS system. The information shall include
the estimated amount of start-up capital required to finance administration and ambulance
operations for the first six (6) months of the Agreement. Include the source of this capital and if any
part of it will be borrowed, include verification from a financial institution that your organization is
approved or pre-qualified to borrow sufficient funds. Provide any assurances for such funding from
Page 94
parent or related organization in the form of a letter guaranteeing the amount of funding that may be
necessary for start-up and on-going losses if projections are inadequate.
5. Performance Security
The Proposer shall document its method and ability to provide the required performance security.
6. Financial Interests
The Proposer shall disclose and describe any financial interests in related businesses.
C. Financial Projections
The Proposer is required to complete a pro forma budget for the first three (3) years of operation
under the Agreement.
1. Revenue projections
All Proposers shall use the same assumptions regarding call volume, payer mix, and charges in the
preparation of the revenue projections for the first three years. The Proposers will be expected to use
their experience or consultants to derive the service mix, cash flow projections, CPI increases, and
per transport collection by payers.
The most recently available payer mix is available in Section I.H.4 of this RFP. The fixed charges are
included in Appendix 10 and the methodology for determining the annual charge increases is
described in Section IV.H.3.b. The total call and transport volume is provided in the separate
electronic CAD files.
The Proposer shall complete the Basis for Revenue Projections included in Appendix 14
2. Revenue Flow Projections
The revenue generated from ambulance transports is not received the date that the transport occurs.
All Proposers shall complete the Revenue Flow Projections included in Appendix 15. This is to be
completed solely based on transports occuring after start-up. An incumbent provider should not
include revenue derived from transports prior to the contract start date.
3. Expense Projections
The Proposers’ expenses are going to vary between Plans A and B. Therefore three-year expense
projections will need to be provided for in each Plan. In addition to the expense budget line items, the
Proposers shall document their assumptions used to develop the pro formas. The required
documentation of assumptions and expense budget templates are included in Appendix 16.
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4. One-Time Start Up and Capital Items
The one-time expenses for start-up shall be documented on the template provided in Appendix 17.
Some of these expenses may not be required on an incumbent provider, but the incumbent should
complete the value of existing assets in the template.
5. Pro Forma Summary
The comparison of revenue and expenditures shall be summarized in the template provided in
Appendix 18. This shall be completed for each plan and for each of the first three years of operation.
D. Pricing
The Proposer is required to complete and sign the Price Sheet Form for ALS interfacility transports.
The Price Sheet Form is included in Appendix 19.
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Appendix 1
MANDATORY TABLE OF
CONTENTS
Appendix 1 Mandatory Table of Contents Page 1
Appendix 1
Mandatory Table of Contents
FACE SHEET (FORM IN APPENDIX 9-EXHIBIT A)
SECTION I. EXECUTIVE SUMMARY
SECTION II.
A. Insurance Certificates (Requirements in Appendix 12)
SUBMISSION OF REQUIRED FORMS
B. Debarment and Suspension Certification (Form in Appendix 9-Exhibit B)
C. References (Form in Appendix 9-Exhibit C)
D. Investigative Authorization-Individual (Form in Appendix 9-Exhibit D)
E. Investigative Authorization-Entity (Form in Appendix 9-Exhibit E)
SECTION III. QUALIFICATION REQUIREMENTS
A. Organizational Disclosures
1. Organizational ownership and legal structure
2. Continuity of business
Supporting documentation required.
3. Licenses and permits
Supporting documentation required.
4. Government investigations
Supporting documentation required.
5. Litigation
Supporting documentation required (May be in electronic format).
Supporting documentation required. (May be in electronic format)
Appendix 1 Mandatory Table of Contents Page 2
B. EXPERIENCE AS SOLE PROVIDER
1.Demonstrate Capability in Lieu of Experience
2.Comparable experience
Supporting documentation required for applicable qualifications in this section.
3. Government contracts
Supporting documentation required.
4. Contract Compliance
Supporting documentation required.
C. Demonstrated Response Time Performance
Supporting documentation required.
D. Demonstrated High Level Clinical Care
Supporting documentation required.
Supporting documentation required.
Appendix 1 Mandatory Table of Contents Page 3
SECTION IV. CORE REQUIREMENTS
A. Two Service Plans are to be Addressed
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.A.
_________ Proposer takes exception to provisions contained in Section IV.A. as delineated
below. Proposer recognizes that taking exception with any provision of the Core Requirements
may result in finding that the Proposal is unresponsive and result in disqualification.
Exceptions:
B. Contractor’s Functional Responsibilities
1. Basic Services
2. Services Description
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.B. (1.-2.)
_________ Proposer takes exception to provisions contained in Section IV.B. (1.-2.) as
delineated below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
Appendix 1 Mandatory Table of Contents Page 4
C. Clinical
1. Clinical Overview
2. Medical Oversight
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.C. (1.-2.)
_________ Proposer takes exception to provisions contained in Section IV.C. (1.-2.) as
delineated below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
3. Minimum Clinical Levels and Staffing Requirements
Supporting narrative and/or documentation required.
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.C.3.
_________ Proposer takes exception to provisions contained in Section IV.C.3 as delineated
below. Proposer recognizes that taking exception with any provision of the Core Requirements
may result in finding that the Proposal is unresponsive and result in disqualification.
Exceptions:
Appendix 1 Mandatory Table of Contents Page 5
D. Operations
1. Operations Overview
a) Emergency Response Zones
Attestation for Plan A
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.D.1.a.
_________ Proposer takes exception to provisions contained in Section IV.D.1.a. as delineated
below. Proposer recognizes that taking exception with any provision of the Core Requirements
may result in finding that the Proposal is unresponsive and result in disqualification.
Exceptions:
Attestation for Plan B
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.D.1.a.
_________ Proposer takes exception to provisions contained in Section IV.D.1.a. as delineated
below. Proposer recognizes that taking exception with any provision of the Core Requirements
may result in finding that the Proposal is unresponsive and result in disqualification.
Exceptions:
b) All Emergency and Non-emergency ALS Ambulance Calls
c) Primary Response to Isolated Peripheral Areas of the EOA
d) Substantial Penalty Provisions for Failure to Respond
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.D.1. (b.-d.)
_________ Proposer takes exception to provisions contained in Section IV.D.1. (b.-d.) as
delineated below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
Appendix 1 Mandatory Table of Contents Page 6
2. Transport Requirement and Limitations
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.D.2. (a.-b.)
_________ Proposer takes exception to provisions contained in Section IV.D.2. (a-b.) as
delineated below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
3. Response time Performance Requirements
a) Description of Call Classification
b) Response Time Performance Requirements
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.D.3. (a.-b.)
_________ Proposer takes exception to provisions contained in Section IV.D3. (a-b.) as
delineated below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
c) Summary of Response Time Requirements
Attestation for Plan A
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.D.3.c.
_________ Proposer takes exception to provisions contained in Section IV.D.3.c. as delineated
below. Proposer recognizes that taking exception with any provision of the Core Requirements
may result in finding that the Proposal is unresponsive and result in disqualification.
Exceptions:
Appendix 1 Mandatory Table of Contents Page 7
Attestation for Plan B
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.D.3.c.
_________ Proposer takes exception to provisions contained in Section IV.D.3.c. as delineated
below. Proposer recognizes that taking exception with any provision of the Core Requirements
may result in finding that the Proposal is unresponsive and result in disqualification.
Exceptions:
4. Modifications During the Term of Agreement
5. Response Time Measurement Methodology
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.D.4 and IV.D.5. (a.-i.)
_________ Proposer takes exception to provisions contained in Section IV.D.4 and IV.D.5. (a.-i.)
as delineated below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
6. Response Time Exceptions and Exception Requests
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.D.6. (a.-c.)
_________ Proposer takes exception to provisions contained in Section IV.D.6. (a.-c.) as
delineated below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
Appendix 1 Mandatory Table of Contents Page 8
7. Response Time Performance Reporting Procedures and Penalty Provisions
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.D.7. (a.-b.)
_________ Proposer takes exception to provisions contained in Section IV.D.7. (a.-b.) as
delineated below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
8. Fleet Requirement
9. Coverage and Dedicated Ambulances, Use of Stations/Posts
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.D. (8.-9.)
_________ Proposer takes exception to provisions contained in Section IV. D. (8.-9.) as
delineated below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
E. Personnel
1. Treatment of Incumbent Work Force
Supporting narrative and/or documentation required.
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.E.1.
_________ Proposer takes exception to provisions contained in Section IV. E.1. as delineated
below. Proposer recognizes that taking exception with any provision of the Core Requirements
may result in finding that the Proposal is unresponsive and result in disqualification.
Exceptions:
Appendix 1 Mandatory Table of Contents Page 9
2. Character, Competence and Professionalism of Personnel
3. Internal Health and Safety Programs
4. Evolving OSHA & Other Regulatory Requirements
5. Discrimination Not Allowed
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.E.(2.-5.)
_________ Proposer takes exception to provisions contained in Section IV. E.(2.-5.). as
delineated below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
F. Management
1. Data and Reporting Requirements
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.F.1. (a.-d.)
_________ Proposer takes exception to provisions contained in Section IV. F.1. (a.-d.). as
delineated below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
Appendix 1 Mandatory Table of Contents Page 10
G. EMS System and Community
1. Participation in EMS System Development
2. Accreditation
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.G. (1.-2.)
_________ Proposer takes exception to provisions contained in Section IV.G. (1.-2.). as
delineated below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
3. Multi-casualty/Disaster Response
4. Mutual Aid and Stand-by Services
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.G. (3.-4.)
_________ Proposer takes exception to provisions contained in Section IV.G. (3.-4.). as
delineated below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
5. Permitted Subcontracting
6. Communities May Contract Directly for Level of Effort
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.G. (5.-6.)
_________ Proposer takes exception to provisions contained in Section IV.G. (5.-6.). as
delineated below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
Appendix 1 Mandatory Table of Contents Page 11
7. Supply Exchange and Restock
8. Handling Service Inquiries and Complaints
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.G. (7.-8.)
_________ Proposer takes exception to provisions contained in Section IV.G. (7.-8.). as
delineated below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
H. Administrative Provisions
1. Contractor Payments for Procurement Costs, County Compliance Monitoring, Contract
Management, and Regulatory Activities (Plan B only)
Attestation for Plan B
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.H.1.
_________ Proposer takes exception to provisions contained in Section IV.H.1.. as delineated
below. Proposer recognizes that taking exception with any provision of the Core Requirements
may result in finding that the Proposal is unresponsive and result in disqualification.
Exceptions:
2. No Subsidy System
Attestation for Plan B
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.H.2.
_________ Proposer takes exception to provisions contained in Section IV.H.2.. as delineated
below. Proposer recognizes that taking exception with any provision of the Core Requirements
may result in finding that the Proposal is unresponsive and result in disqualification.
Exceptions:
Appendix 1 Mandatory Table of Contents Page 12
Supporting narrative and/or documentation required.
Attestation for Plan A
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.H.2.
_________ Proposer takes exception to provisions contained in Section IV.H.2.. as delineated
below. Proposer recognizes that taking exception with any provision of the Core Requirements
may result in finding that the Proposal is unresponsive and result in disqualification.
Exceptions:
3. Contractor Revenue Recovery
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.H. 3. (a.-b.)
_________ Proposer takes exception to provisions contained in Section IV.H. 3. (a.-b.) as
delineated below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
Appendix 1 Mandatory Table of Contents Page 13
4. Federal Healthcare Program Compliance Provisions
5. State Compliance Provisions
6. Billing/Collection Services
7. Market Rights
8. Accounting Procedures
99.County Permit..
10. Insurance Provisions
Insurance documentation required
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.H. (4.-10.)
_________ Proposer takes exception to provisions contained in Section IV.G. (4.-10.). as
delineated below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
Appendix 1 Mandatory Table of Contents Page 14
11. Hold Harmless / Defense / Indemnification / Taxes / Contributions
12. Performance Security Bond
13. Term of Agreement
14. Earned Extension to Agreement
15. Continuous Service Delivery
16. Annual Performance Evaluation
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.H. (10.-16.)
_________ Proposer takes exception to provisions contained in Section IV.H. (10.-16.). as
delineated below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
17. Default and Provisions for Termination of the Agreement
18. Termination
19. Emergency Takeover
20. Transition Planning
21. LEMSA's Remedies
22. Provisions for Curing Material Breach and Emergency Take Over
23. "Lame duck" Provisions
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.H. (17.-23.)
_________ Proposer takes exception to provisions contained in Section IV.H. (17.-23.). as
delineated below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
Appendix 1 Mandatory Table of Contents Page 15
24. General Provisions
Exceptions to General Provisions of Contract Requires Documentation
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section IV.H.24 (a.-o.)
_________ Proposer takes exception to provisions contained in Section IV.H.24. (a.-o.) as
delineated below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
SECTION V. COMPETITIVE CRITERIA
A. Clinical
1. Competitive Criterion: Quality Improvement
a) Minimum Requirements—Demonstrable Progressive Clinical Quality Improvement
Supporting narrative and/or documentation required.
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section V.A.1.a.
_________ Proposer takes exception to provisions contained in Section V.A.1.a. as delineated
below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
b) Higher Levels of Commitment—Quality Management
Supporting narrative and/or documentation required.
Appendix 1 Mandatory Table of Contents Page 16
2. Competitive Criterion: Clinical and Operational Benchmarking
a) Minimum Requirements—Clinical and Operational Benchmarking
Supporting narrative and/or documentation required.
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section V.A.2.a.
_________ Proposer takes exception to provisions contained in Section V.A.2.a. as delineated
below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
b) Higher Levels of Commitment—Clinical and Operational Benchmarking
3. Competitive Criterion: Dedicated Clinical Oversight Personnel
Supporting narrative and/or documentation required.
a) Minimum Requirements—Clinical Leadership Personnel
Supporting narrative and/or documentation required.
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section V.A.3.a.
_________ Proposer takes exception to provisions contained in Section V.A.3.a. as delineated
below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
b) Higher Levels of Commitment—Clinical Leadership Personnel
Supporting narrative and/or documentation required.
Appendix 1 Mandatory Table of Contents Page 17
4. Competitive Criterion: Medical Direction
a) Minimum Requirements—Medical Direction
Supporting narrative and/or documentation required.
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section V.A.4.a.
_________ Proposer takes exception to provisions contained in Section V.A.4.a. as delineated
below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
b) Higher Levels of Commitment—Medical Direction
5. Competitive Criteria: Focus on Patients and Other Customers
Supporting narrative and/or documentation required.
a) Minimum Requirements— Focus on Patients and Other Customers
Supporting narrative and/or documentation required.
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section V.A.5.a.
_________ Proposer takes exception to provisions contained in Section V.A.5.a. as delineated
below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
b) Higher Levels of Commitment— Focus on Patients and Other Customers
Supporting narrative and/or documentation required.
Appendix 1 Mandatory Table of Contents Page 18
6. Competitive Criterion: Continuing Education Program Requirements
a) Minimum Requirements—Continuing Education
Supporting narrative and/or documentation required.
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section V.A.6.a.
_________ Proposer takes exception to provisions contained in Section V.A.6.a. as delineated
below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
b) Higher Levels of Commitment— Continuing Education
Supporting narrative and/or documentation required.
B. Operations
1. Competitive Criterion: Dispatch and Communications
a) Minimum Requirements— Dispatch and Communications
Supporting narrative and/or documentation required.
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section V.B.1.a.
_________ Proposer takes exception to provisions contained in Section V.B.1.a. as delineated
below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
b) Higher Levels of Commitment— Dispatch and Communications
Supporting narrative and/or documentation required.
Appendix 1 Mandatory Table of Contents Page 19
2. Competitive Criterion: Vehicles
a) Minimum Requirements—Vehicles
Supporting narrative and/or documentation required.
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section V.B.2.a.
_________ Proposer takes exception to provisions contained in Section V.B.2.a. as delineated
below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
b) Higher Levels of Commitment— Vehicles
3. Competitive Criterion: Equipment
Supporting narrative and/or documentation required.
a) Minimum Requirements—Equipment
Supporting narrative and/or documentation required.
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section V.B.3.a.
_________ Proposer takes exception to provisions contained in Section V.B.3.a. as delineated
below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
b) Higher Levels of Commitment— Equipment
Supporting narrative and/or documentation required.
Appendix 1 Mandatory Table of Contents Page 20
4. Competitive Criterion: Vehicle and Equipment Maintenance
a) Minimum Requirements— Vehicle and Equipment Maintenance
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section V.B.4.a.
_________ Proposer takes exception to provisions contained in Section V.B.4.a. as delineated
below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
b) Higher Levels of Commitment— Vehicle and Equipment Maintenance
5. Competitive Criterion: Deployment Planning
Supporting narrative and/or documentation required.
a) Minimum Requirements— Deployment Planning
Supporting narrative and/or documentation required.
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section V.B.5.a.
_________ Proposer takes exception to provisions contained in Section V.B.5.a. as delineated
below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
b) Higher Levels of Commitment— Deployment Planning
Supporting narrative and/or documentation required.
Appendix 1 Mandatory Table of Contents Page 21
C. Personnel
1. Competitive Criterion: Field Supervision
a) Minimum Requirements— Field Supervision
Supporting narrative and/or documentation required.
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section V.C.1.a.
_________ Proposer takes exception to provisions contained in Section V.C.1.a. as delineated
below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
b) Higher Levels of Commitment— Field Supervision
2. Competitive Criterion: Work Schedules
Supporting narrative and/or documentation required.
a) Minimum Requirements— Work Schedules
Supporting narrative and/or documentation required.
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section V.C.2.a.
_________ Proposer takes exception to provisions contained in Section V.C.2.a. as delineated
below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
b) Higher Levels of Commitment— Work Schedules
Supporting narrative and/or documentation required.
Appendix 1 Mandatory Table of Contents Page 22
3. Competitive Criterion: Internal Risk Management/Loss Control Program
a) Minimum Requirements—Risk Management
Supporting narrative and/or documentation required.
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section V.C.3.a.
_________ Proposer takes exception to provisions contained in Section V.C.3.a. as delineated
below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
b) Higher Levels of Commitment— Risk Management
4. Competitive Criterion: Workforce Engagement
Supporting narrative and/or documentation required.
a) Minimum Requirements— Workforce Engagement
Supporting narrative and/or documentation required.
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section V.C.4.a.
_________ Proposer takes exception to provisions contained in Section V.C.4.a. as delineated
below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
b) Higher Levels of Commitment— Workforce Engagement
Supporting narrative and/or documentation required.
Appendix 1 Mandatory Table of Contents Page 23
D. Management
1. Key Personnel
a) Minimum Requirements—Key Personnel
Supporting narrative and/or documentation required.
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section V.D.1 .a.
_________ Proposer takes exception to provisions contained in Section V.D.1.a. as delineated
below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
b) Higher Levels of Commitment—Key Personnel
E. EMS System and Community
Supporting narrative and/or documentation required.
1. Supporting Improvement in the First Response System
a) Minimum Requirements—First Response System
Supporting narrative and/or documentation required.
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section V.E.1.a.
_________ Proposer takes exception to provisions contained in Section V.E.1.a. as delineated
below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
b) Higher Levels of Commitment—First Response System
Supporting narrative and/or documentation required.
Appendix 1 Mandatory Table of Contents Page 24
2. Health Status Improvement and Community Education
a) Minimum Requirements—Community Education
Supporting narrative and/or documentation required.
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section V.E.2.a.
_________ Proposer takes exception to provisions contained in Section V.E.2.a. as delineated
below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
b) Higher Levels of Commitment—Health Status Improvement and Community Education
F. Integration with Healthcare Providers
Supporting narrative and/or documentation required.
1. West Side Healthcare District Area
a) Minimum Requirements—Collaboration with Healthcare Providers
Supporting narrative and/or documentation required.
Attestation:
_________ Proposer understands and agrees to comply without qualification to provisions,
requirements, and commitments contained in Section V.F.1.a.
_________ Proposer takes exception to provisions contained in Section V.F.1.a. as delineated
below. Proposer recognizes that taking exception with any provision of the Core
Requirements may result in finding that the Proposal is unresponsive and result in
disqualification.
Exceptions:
b) Higher Levels of Commitment— Collaboration with Healthcare Providers
Supporting narrative and/or documentation required.
Appendix 1 Mandatory Table of Contents Page 25
SEPARATE SUBMISSION: FINANCIAL DOCUMENTS
A. Financial Documents
The Proposer shall submit all of the requested financial documents in a separately sealed containt
labeled “Financial Documents.” There shall be one (1) original and five (5) copies plus one (1)
electronic version on a disk or USB memory stick.
B. Financial Situation Documents
The Proposer shall submit the following documents and information supporting the following:
1. Financial Statements
2. Audited Statements
Supporting documentation required. (Separate sealed envelope labeled “Financial Documents”)
3. Financial Commitments
Supporting documentation required. (Separate sealed envelope labeled “Financial Documents”)
4. Working Capital
Supporting documentation required. (Separate sealed envelope labeled “Financial Documents”)
5. Performance Security
Supporting documentation required. (Separate sealed envelope labeled “Financial Documents”)
6. Financial Interests
Supporting documentation required. (Separate sealed envelope labeled “Financial Documents”)
Supporting documentation required. (Separate sealed envelope labeled “Financial Documents”)
C. Financial Projections
Proposers shall submit the following financial projections and assumptions consistent with the
specified templates contained in the Appendices.
1. Revenue projections
Supporting documentation required. (Separate sealed envelope labeled “Financial Documents”)
Appendix 1 Mandatory Table of Contents Page 26
2. Revenue Flow Projections
3. Expense Projections
Supporting documentation required. (Separate sealed envelope labeled “Financial Documents”)
4. One-Time Start Up and Capital Items
Supporting documentation required. (Separate sealed envelope labeled “Financial Documents”)
5. Pro Forma Summary
Supporting documentation required. (Separate sealed envelope labeled “Financial Documents”)
Supporting documentation required. (Separate sealed envelope labeled “Financial Documents”)
D. ALS Interfacility Pricing
Proposer shall complete and submit the ALS Interfacility Price Sheet in Appendix 20.
Supporting documentation required. (Separate sealed envelope labeled “Financial Documents”)
Page 97
Appendix 2
MAP OF EXCLUSIVE
OPERATING AREA
Appendix 2 Exclusive Operating Areas Page 1
Page 98
Appendix 3
EMERGENCY RESPONSE
ZONE MAPS
Page 99
Appendix 4
COUNTY AMBULANCE
ORDINANCE
Page 100
Appendix 5
CURRENT AMBULANCE
ZONES MAP
Page 101
Appendix 6
CALL DENSITY
RESPONSE AREAS IN
EOA
Page 102
Appendix 7
CURRENT AMBULANCE
RATES
Appendix 7
Contra Costa County
Current Approved Ambulance Rates
Emergency Base Rate ------------------------------------------------------------------------------- $1,957.19
Mileage Rate (per loaded mile) ------------------------------------------------------------------------ $45.00
Oxygen ----------------------------------------------------------------------------------------------------$175.00
Page 103
PROCUREMENT
TIMELINE
APPENDIX 8
PROCUREMENT TIME LINE
Date Activity
13 January 2015 Board Approval of RFP
27 February 2015 RFP Released
13 March 2015 RFP Questions/Clarifications Due
19 March 2015 Proposer’s Conference
21 May 2015 Proposals due at 4 p.m. and Public Proposal Opening
5 June 2015 Proposer presentations
10 June 2015 Notice of Intent to Award - Protest period Begins
7 July 2015 Presentation to Board; authorization to proceed
17 July 2015 Contract finalized
28-July 2015 Board approval of contract
1 January 2016 Startup of new contract
Page 104
Appendix 9
REQUIRED FORMS
EXHIBIT A
FACE SHEET
Page | 1
***THIS FORM MUST APPEAR AS THE FIRST PAGE OF THE PROPOSAL***
This is a proposal to contract with Contra Costa County to provide emergency medical and ALS interfacility
ambulance services.
Name of Proposer:
Dba:
Type Of Organization: Corporation LLC Partnership Other _______
Date Founded Or Incorporated: __/__/____
Legal Address:
Phone: (___)____-_____ ext.:_____ Fax: (___)___-_____ (Required For Notification)
Federal Tax Identification Number:
Contact person:
Title:
Phone: (___)____-_____ E-Mail:
Address For Mailings: (If different from above):
Authorized Signature: _________________________________________
Date Submitted: __/___/_____
Print Name:
Title:
EXHIBIT B
DEBARMENT AND SUSPENSION CERTIFICATION
Page | 1
The Proposer, under penalty of perjury, certifies that, except as noted below, Proposer, its
principal, and any named subcontractor:
1. Is not currently under suspension, debarment, voluntary exclusion, or determination of
ineligibility by any federal agency;
2. Has not been suspended, debarred, voluntarily excluded or determined ineligible by any
federal agency within the past three years;
3. Does not have a proposed debarment pending; and,
4. Has not been indicted, convicted, or had a civil judgment rendered against it by a court
of competent jurisdiction in any matter involving fraud or official misconduct within the
past three years.
If there are any exceptions to this certification, insert the exceptions in the following space.
Exceptions will not necessary result in denial of award, but will be considered in determining
Proposer responsibility. For any exception noted above, indicate below to whom it applies,
initiating agency, and dates of action.
Notes: Providing false information may result in criminal prosecution or administrative
sanctions. The above certification is part of the Proposal. Signing this Proposal on the
signature portion thereof shall also constitute signature of this Certification.
Proposer Name: ______________________________________________________________
Proposer Signature: ____________________________________________________________
Title: ________________________________________________
Date: ___/__/____
EXHIBIT C REFERENCES Page | 1 CURRENT REFERENCES Proposer name:______________________________________________ Company Name: Address: City, State, Zip Code: Contact Person: Telephone Number: (____) _______ - _________ Service Provided: Dates/Type of Service: ___/____/_____, Company Name: Address: City, State, Zip Code: Contact Person: Telephone Number: (____) _______ - _________ Service Provided: Dates/Type of Service: ___/____/_____,
EXHIBIT C REFERENCES Page | 2 Company Name: Address: City, State, Zip Code: Contact Person: Telephone Number: (____) _______ - _________ Service Provided: Dates/Type of Service: ___/____/_____,
EXHIBIT C REFERENCES Page | 3 FORMER REFERENCES Proposer name: ______________________________________________ Company Name: Address: City, State, Zip Code: Contact Person: Telephone Number: (____) _______ - _________ Service Provided: Dates/Type of Service: ___/____/_____, Company Name: Address: City, State, Zip Code: Contact Person: Telephone Number: (____) _______ - _________ Service Provided: Dates/Type of Service: ___/____/_____,
EXHIBIT C REFERENCES Page | 4 Company Name: Address: City, State, Zip Code: Contact Person: Telephone Number: (____) _______ - _________ Service Provided: Dates/Type of Service: ___/____/_____,
EXHIBIT D
INVESTIGATIVE AUTHORIZATION – INDIVIDUAL
Page | 1
The undersigned, being ___________ (title) for __________ (entity), which is a prospective
Contractor to provide Emergency Ambulance Services to Contra Costa County recognizes that
public health and safety requires assurance of safe, reliable and cost efficient ambulance
service. That assurance will require an inquiry into matters which are determined relevant by
the Contra Costa County EMS Agency or its agents, such as, but not limited to, the character,
reputation, competence of the entity’s owners and key employees.
The undersigned specifically acknowledges that such inquiry may involve an investigation of his
or her personal work experience, educational qualifications, moral character, financial stability
and general background, and specifically agrees that the EMS Agency, or its agents, may
undertake a personal investigation of the undersigned for the purpose stated. This
authorization shall expire six (6) months from the signature date.
AUTHORIZATION FOR SUCH PERSONAL INVESTIGATION IS HEREBY EXPRESSLY GIVEN:
______________________________________________________________________
Date: _____/____/_______
Individual Name
ACKNOWLEDGEMENT
STATE OF ______________________________________________
COUNTY OF ____________________________________________
On this _______ day of _______, 20____, before me, the undersigned, a Notary Public in and
for said County and State, personally appears ________________ to me known to be the
person described herein and who executed the foregoing Affirmation Statement, and
acknowledged that he/she executed the same as his/her free act and deed.
Witness my hand and Notarial Seal subscribed and affixed in said County and State, the day and
year above written.
Notary Public;__________________________________________________
Notary Public Seal Commission Expiration Date: ___/___/____
EXHIBIT E
INVESTIGATIVE AUTHORIZATION – ENTITY
Page | 1
The undersigned entity, a prospective Contractor to provide Emergency Ambulance Services for
Contra Costa County recognizes that public health and safety requires assurance of safe,
reliable and cost-efficient ambulance service. That assurance will require inquiry into aspects of
entity’s operations determined relevant by the Contra Costa County EMS Agency, or its agents.
The entity specifically agrees that the Contra Costa County EMS Agency or its agents may
conduct an investigation for the purpose into, but not limited to the following matters;
1. The financial stability of the entity, including its owners and officers, any information
regarding potential conflict of interests, past problems in dealing with other clients or
cities where the entity has rendered service, or any other aspect of the entity
operations or its structure, ownership or key personnel which might reasonably be
expected to influence the Contra Costa County EMS Agency’s selection decision.
2. The entity’s current business practices, including employee compensation and benefits
arrangements, pricing practices, billings and collections practices, equipment
replacement and maintenance practices, in-service training programs, means of
competing with other companies, employee discipline practices, public relations efforts,
current and potential obligations to other buyers, and genera internal personnel
relations.
3. The attitude of current and previous customers of the entity toward the entity’s services
and general business practices, including patients or families of patients served by the
entity, physicians or other health care professionals knowledgeable of the entity’s past
work, as well as other units of local government with which the entity has dealt in the
past.
4. Other business in which entity owners and/or other key personnel in the entity
currently have a business interest.
5. The accuracy and truthfulness of any information submitted by the entity in connection
with such evaluation.
EXHIBIT E
INVESTIGATIVE AUTHORIZATION – ENTITY
Page | 2
This authorization shall expire six (6) months from the date of the signature.
AUTHORIZATION FOR SUCH INVESTIGATION IS HEREBY EXPRESSLY GIVEN BY THE ENTITY:
Entity Name: _________________________________________________
Authorized Representative (Signature): ___________________________________________
Authorized Representative (Printed):___________________________________
Title: ______________________________
Date: __/___/___
ACKNOWLEDGEMENT
STATE OF ______________________________________________________
COUNTY OF ____________________________________________________
On this _________ day of _______, 20____, before me appeared __________ to me personally
known, who being by me duly sworn, did say that he/she is the _________ of ___________ and
that said instrument was signed in behalf of said entity by authority delegated to him/her, and
said affiant acknowledges said instrument to be the free act and deed of said entity. In
WITNESS WHEREOF, I have hereunto set by hand and affixed my official seal the day and year
last above written.
___________________________________________________________
Notary Public
Notary Public Seal Commission Expiration Date: ___/___/_____
Page 105
Appendix 10
STIPULATED
AMBULANCE CHARGES
Appendix 10
Contra Costa County
Stipulated Ambulance Rates for Year 1 of Contract
Emergency Base Rate ------------------------------------------------------------------------------- $2,100.00
Mileage Rate (per loaded mile) ------------------------------------------------------------------------ $50.00
Oxygen ----------------------------------------------------------------------------------------------------$175.00
Treat and Refused Transport -------------------------------------------------------------------------$450.00
Page 106
Appendix 11
SUBSIDY REQUEST
FORM
Appendix 11
Plan A
Subsidy Requirements
Proposer shall identify any subsidies required to support the level of service and performance
requirements for Plan A. An annual subsidy for each of the first five years of the term of the
Agreement shall be identified in this submission, if a subsidy is required.
Year One Subsidy: -------------------------------------------------------------------- $_________________________
Year Two Subsidy: ------------------------------------------------------------------- $_________________________
Year Three Subsidy: ----------------------------------------------------------------- $_________________________
Year Four Subsidy: ------------------------------------------------------------------- $_________________________
Year Five Subsidy: ------------------------------------------------------------------- $_________________________
FIRM: __________________________________________________________________________
SIGNATURE:___________________________________________________________________
DATE: ___/____/_____
PRINTED NAME: _____________________________________________________________
TITLE: _________________________________________________________________________
Page 107
Appendix 12
INSURANCE
REQUIRMENTS
APPENDIX 12
INSURANCE REQUIREMENTS
Page | 1
1. EVIDENCE OF INSURANCE: Certificates of insurance are required from a reputable
insurer evidencing all overages required for the term of any contract that may be
awarded pursuant to this RFP.
2. COUNTY NAMED AS ADDITIONAL INSURED: The County’s insurance requirements for
Additional Insured reads, “All insurance required above with the exception shall be
endorsed to name as additional insured.” An endorsement is an amendment to a
contract, such as an insurance policy, by which the original terms are changed. The
insurance certificate (also known as the “Accord”) carries a disclaimer, “This certificate
is issued as a matter of information only and confers no rights upon the certificate
holder. This certificate does not amend, extend or alter the coverage afforded by the
policy below.” Additional insured listed in the description box are not a proper risk
transfer. Any amendment or extension of the coverage such as an additional insured
should be provided by a separate endorsement page or copy of the policy.
3. INSURANCE PROVISIONS
3.1 CONTRACTOR shall obtain and maintain in full force and effect throughout the
term of this Agreement, and thereafter as to matters occurring during the term
of this Agreement, the following insurance coverage:
(a) Workers' Compensation insurance. If and to the extent required by law
during the term of this Agreement, CONTRACTOR shall provide
workers' compensation insurance for the performance of any of
CONTRACTOR's duties under this Agreement; including but not
limited to, coverage for workers' compensation and employer's
liability and a waiver of subrogation, and shall provide COUNTY
with certification of all such coverages upon request by COUNTY’s
Risk Manager.
(b) Liability insurance.CONTRACTOR shall obtain and maintain in full force
and effect during the term of this Agreement the following liability
insurance coverages, issued by a company with an A.M. Best rating
of A: VII or better:
1. General Liability. Commercial general liability [CGL] insurance coverage
(personal injury and property damage) of not less than FIVE
MILLION DOLLARS ($5,000,000) combined single limit per
occurrence, covering liability or claims for any personal injury,
including death, to any person and/or damage to the property of
any person arising from the acts or omissions of CONTRACTOR or
any officer, agent, or employee of CONTRACTOR under this
Agreement. If the coverage includes an aggregate limit, the
APPENDIX 12
INSURANCE REQUIREMENTS
Page | 2
aggregate limit shall be no less than twice the per occurrence
limit.
2.Professional Liability/Errors and Omissions. Professional liability [or
errors and omissions] insurance for all activities of CONTRACTOR
arising out of or in connection with this Agreement in an amount
not less than THREE MILLION DOLLARS ($3,000,000) per claim.
3.Comprehensive Automobile Liability Insurance. Comprehensive
automobile liability insurance (Bodily Injury and Property
Damage) on owned, hired, leased and non-owned vehicles used in
conjunction with CONTRACTOR's business of not less than THREE
MILLION DOLLARS ($3,000,000) combined single limit per
occurrence.
(c) Certificates. All insurance coverages referenced in 7(b), above, shall
be evidenced by one or more certificates of coverage or, with the
approval of COUNTY's Risk Manager, demonstrated by other
evidence of coverage acceptable to COUNTY's Risk Manager, which
shall be filed by CONTRACTOR with the County Fire Department
prior to commencement of performance of any of CONTRACTOR's
duties; shall reference this Agreement by its COUNTY number or
title and department; shall be kept current during the term of this
Agreement; shall provide that COUNTY be given no less than thirty
(30) days prior written notice of any non-renewal, cancellation,
other termination, or material change, except that only ten (10)
days prior written notice shall be required where the cause of non-
renewal or cancellation is non-payment of premium; and shall
provide that the inclusion of more than one insured shall not
operate to impair the rights of one insured against another insured,
the coverage afforded applying as though separate policies had
been issued to each insured, but the inclusion of more than one
insured shall not operate to increase the limits of the company's
liability. For the insurance coverages referenced in 7(b)(1) and (3),
CONTRACTOR shall also file with the evidence of coverage an
endorsement from the insurance provider naming COUNTY, its
officers, employees, agents and volunteers as additional insureds
and waiving subrogation, and the certificate or other evidence of
coverage shall provide that if the same policy applies to activities
of CONTRACTOR not covered by this Agreement then the limits in
the applicable certificate relating to the additional insured coverage
of COUNTY shall pertain only to liability for activities of
CONTRACTOR under this Agreement, and that the insurance
APPENDIX 12
INSURANCE REQUIREMENTS
Page | 3
provided is primary coverage to COUNTY with respect to any
insurance or self-insurance programs maintained by COUNTY. The
additional insured endorsements for the general liability coverage
shall use Insurance Services Office (ISO) Form No. CG 20 09 11 85
or CG 20 10 11 85, or equivalent, including (if used together) CG
2010 10 01 and CG 2037 10 01; but shall not use the following
forms: CG 20 10 10 93 or 03 94. Upon request of COUNTY’s Risk
Manager, CONTRACTOR shall provide or arrange for the insurer to
provide within thirty (30) days of the request, certified copies of
the actual insurance policies or relevant portions thereof.
(d) Deductibles/Retentions. Any deductibles or self-insured retentions
shall be declared to, and be subject to approval by, COUNTY’s Risk
Manager, which approval shall not be denied unless the COUNTY's
Risk Manager determines that the deductibles or self-insured
retentions are unreasonably large in relation to compensation
payable under this Agreement and the risks of liability associated
with the activities required of CONTRACTOR by this Agreement. At
the option of and upon request by COUNTY’s Risk Manager if the
Risk Manager determines that such deductibles or retentions are
unreasonably high, either the insurer shall reduce or eliminate such
deductibles or self-insurance retentions as respects COUNTY, its
officers, employees, agents and volunteers or CONTRACTOR shall
procure a bond guaranteeing payment of losses and related
investigations, claims administration and defense expenses.
Page 108
Appendix 13
SAMPLE STANDARD
COUNTY CONTRACT
Initials:___________ _____________
Contractor County Dept.
1.Compliance with Law. Contractor is subject to and must comply with all applicable federal, state, and local laws
and regulations with respect to its performance under this Contract, including but not limited to, licensing,
employment, and purchasing practices; and wages, hours, and conditions of employment, including
nondiscrimination.
2.Inspection. Contractor's performance, place of business, and records pertaining to this Contract are subject to
monitoring, inspection, review and audit by authorized representatives of the County, the State of California, and the
United States Government.
3.Records. Contractor must keep and make available for inspection and copying by authorized representatives of the
County, the State of California, and the United States Government, the Contractor's regular business records and such
additional records pertaining to this Contract as may be required by the County.
a.Retention of Records. Contractor must retain all documents pertaining to this Contract for five years from the
date of submission of Contractor's final payment demand or final Cost Report; for any further period that is
required by law; and until all federal/state audits are complete and exceptions resolved for this Contract's funding
period. Upon request, Contractor must make these records available to authorized representatives of the County,
the State of California, and the United States Government.
b.Access to Books and Records of Contractor, Subcontractor. Pursuant to Section 1861(v)(1) of the Social
Security Act, and any regulations promulgated thereunder, Contractor must, upon written request and until the
expiration of five years after the furnishing of services pursuant to this Contract, make available to the County,
the Secretary of Health and Human Services, or the Comptroller General, or any of their duly authorized
representatives, this Contract and books, documents, and records of Contractor necessary to certify the nature and
extent of all costs and charges hereunder.
Further, if Contractor carries out any of the duties of this Contract through a subcontract with a value or cost of
$10,000 or more over a twelve-month period, such subcontract must contain a clause to the effect that upon
written request and until the expiration of five years after the furnishing of services pursuant to such subcontract,
the subcontractor must make available to the County, the Secretary, the Comptroller General, or any of their duly
authorized representatives, the subcontract and books, documents, and records of the subcontractor necessary to
verify the nature and extent of all costs and charges thereunder.
This provision is in addition to any and all other terms regarding the maintenance or retention of records under
this Contract and is binding on the heirs, successors, assigns and representatives of Contractor.
4.Reporting Requirements. Pursuant to Government Code Section 7550, Contractor must include in all documents
and written reports completed and submitted to County in accordance with this Contract, a separate section listing the
numbers and dollar amounts of all contracts and subcontracts relating to the preparation of each such document or
written report. This section applies only if the Payment Limit of this Contract exceeds $5,000.
Initials:___________ _____________
Contractor County Dept.
5.Termination and Cancellation.
a.Written Notice. This Contract may be terminated by either party, in its sole discretion, upon thirty-day advance
written notice thereof to the other, and may be cancelled immediately by written mutual consent.
b.Failure to Perform. County, upon written notice to Contractor, may immediately terminate this Contract should
Contractor fail to perform properly any of its obligations hereunder. In the event of such termination, County
may proceed with the work in any reasonable manner it chooses. The cost to County of completing Contractor's
performance will be deducted from any sum due Contractor under this Contract, without prejudice to County's
rights to recover damages.
c.Cessation of Funding. Notwithstanding any contrary language in Paragraphs 5 and 11, in the event that federal,
state, or other non-County funding for this Contract ceases, this Contract is terminated without notice.
6.Entire Agreement. This Contract contains all the terms and conditions agreed upon by the parties. Except as
expressly provided herein, no other understanding, oral or otherwise, regarding the subject matter of this Contract will
be deemed to exist or to bind any of the parties hereto.
7.Further Specifications for Operating Procedures. Detailed specifications of operating procedures and budgets
required by this Contract, including but not limited to, monitoring, evaluating, auditing, billing, or regulatory changes,
may be clarified in a written letter signed by Contractor and the department head, or designee, of the county
department on whose behalf this Contract is made. No written clarification prepared pursuant to this Section will
operate as an amendment to, or be considered to be a part of, this Contract.
8.Modifications and Amendments.
a.General Amendments. In the event that the total Payment Limit of this Contract is less than $100,000 and this
Contract was executed by the County’s Purchasing Agent, this Contract may be modified or amended by a written
document executed by Contractor and the County’s Purchasing Agent or the Contra Costa County Board of
Supervisors, subject to any required state or federal approval. In the event that the total Payment Limit of this
Contract exceeds $100,000 or this Contract was initially approved by the Board of Supervisors, this Contract may
be modified or amended only by a written document executed by Contractor and the Contra Costa County Board
of Supervisors or, after Board approval, by its designee, subject to any required state or federal approval.
b.Minor Amendments. The Payment Provisions and the Service Plan may be amended by a written administrative
amendment executed by Contractor and the County Administrator (or designee), subject to any required state or
federal approval, provided that such administrative amendment may not increase the Payment Limit of this
Contract or reduce the services Contractor is obligated to provide pursuant to this Contract.
9.Disputes. Disagreements between County and Contractor concerning the meaning, requirements, or performance of
this Contract shall be subject to final written determination by the head of the county department for which this
Contract is made, or his designee, or in accordance with the applicable procedures (if any) required by the state or
federal government.
10.Choice of Law and Personal Jurisdiction.
Initials:___________ _____________
Contractor County Dept.
a. This Contract is made in Contra Costa County and is governed by, and must be construed in accordance with, the
laws of the State of California.
b. Any action relating to this Contract must be instituted and prosecuted in the courts of Contra Costa County, State
of California.
11.Conformance with Federal and State Regulations and Laws. Should federal or state regulations or laws touching
upon the subject of this Contract be adopted or revised during the term hereof, this Contract will be deemed amended
to assure conformance with such federal or state requirements.
12.No Waiver by County. Subject to Paragraph 9. (Disputes) of these General Conditions, inspections or approvals, or
statements by any officer, agent or employee of County indicating Contractor's performance or any part thereof
complies with the requirements of this Contract, or acceptance of the whole or any part of said performance, or
payments therefor, or any combination of these acts, do not relieve Contractor's obligation to fulfill this Contract as
prescribed; nor is the County thereby prevented from bringing any action for damages or enforcement arising from
any failure to comply with any of the terms and conditions of this Contract.
13.Subcontract and Assignment. This Contract binds the heirs, successors, assigns and representatives of Contractor.
Prior written consent of the County Administrator or his designee, subject to any required state or federal approval, is
required before the Contractor may enter into subcontracts for any work contemplated under this Contract, or before
the Contractor may assign this Contract or monies due or to become due, by operation of law or otherwise.
14.Independent Contractor Status. The parties intend that Contractor, in performing the services specified herein, is
acting as an independent contractor and that Contractor will control the work and the manner in which it is performed.
This Contract is not to be construed to create the relationship between the parties of agent, servant, employee,
partnership, joint venture, or association. Contractor is not a County employee. This Contract does not give
Contractor any right to participate in any pension plan, workers’ compensation plan, insurance, bonus, or similar
benefits County provides to its employees. In the event that County exercises its right to terminate this Contract,
Contractor expressly agrees that it will have no recourse or right of appeal under any rules, regulations, ordinances, or
laws applicable to employees.
15.Conflicts of Interest. Contractor covenants that it presently has no interest and that it will not acquire any interest,
direct or indirect, that represents a financial conflict of interest under state law or that would otherwise conflict in any
manner or degree with the performance of its services hereunder. Contractor further covenants that in the
performance of this Contract, no person having any such interests will be employed by Contractor. If requested to do
so by County, Contractor will complete a “Statement of Economic Interest” form and file it with County and will
require any other person doing work under this Contract to complete a “Statement of Economic Interest” form and file
it with County. Contractor covenants that Contractor, its employees and officials, are not now employed by County
and have not been so employed by County within twelve months immediately preceding this Contract; or, if so
employed, did not then and do not now occupy a position that would create a conflict of interest under Government
Code section 1090. In addition to any indemnity provided by Contractor in this Contract, Contractor will indemnify,
defend, and hold the County harmless from any and all claims, investigations, liabilities, or damages resulting from or
related to any and all alleged conflicts of interest. Contractor warrants that it has not provided, attempted to provide,
or offered to provide any money, gift, gratuity, thing of value, or compensation of any kind to obtain this Contract.
16.Confidentiality. To the extent allowed under the California Public Records Act, Contractor agrees to comply and to
require its officers, partners, associates, agents and employees to comply with all applicable state or federal statutes or
regulations respecting confidentiality, including but not limited to, the identity of persons served under this Contract,
Initials:___________ _____________
Contractor County Dept.
their records, or services provided them, and assures that no person will publish or disclose or permit or cause to be
published or disclosed, any list of persons receiving services, except as may be required in the administration of such
service. Contractor agrees to inform all employees, agents and partners of the above provisions, and that any person
knowingly and intentionally disclosing such information other than as authorized by law may be guilty of a
misdemeanor.
17.Nondiscriminatory Services. Contractor agrees that all goods and services under this Contract will be available to
all qualified persons regardless of age, gender, race, religion, color, national origin, ethnic background, disability, or
sexual orientation, and that none will be used, in whole or in part, for religious worship.
18.Indemnification. Contractor will defend, indemnify, save, and hold harmless County and its officers and employees
from any and all claims, demands, losses, costs, expenses, and liabilities for any damages, fines, sickness, death, or
injury to person(s) or property, including any and all administrative fines, penalties or costs imposed as a result of an
administrative or quasi-judicial proceeding, arising directly or indirectly from or connected with the services provided
hereunder that are caused, or claimed or alleged to be caused, in whole or in part, by the negligence or willful
misconduct of Contractor, its officers, employees, agents, contractors, subcontractors, or any persons under its
direction or control. If requested by County, Contractor will defend any such suits at its sole cost and expense. If
County elects to provide its own defense, Contractor will reimburse County for any expenditures, including
reasonable attorney’s fees and costs. Contractor’s obligations under this section exist regardless of concurrent
negligence or willful misconduct on the part of the County or any other person; provided, however, that Contractor is
not required to indemnify County for the proportion of liability a court determines is attributable to the sole
negligence or willful misconduct of the County, its officers and employees. This provision will survive the expiration
or termination of this Contract.
19.Insurance. During the entire term of this Contract and any extension or modification thereof, Contractor shall keep
in effect insurance policies meeting the following insurance requirements unless otherwise expressed in the Special
Conditions:
a.Commercial General Liability Insurance.For all contracts where the total payment limit of the contract is
$500,000 or less, Contractor will provide commercial general liability insurance, including coverage for business
losses and for owned and non-owned automobiles, with a minimum combined single limit coverage of $500,000
for all damages, including consequential damages, due to bodily injury, sickness or disease, or death to any person
or damage to or destruction of property, including the loss of use thereof, arising from each occurrence. Such
insurance must be endorsed to include County and its officers and employees as additional insureds as to all
services performed by Contractor under this Contract. Said policies must constitute primary insurance as to
County, the state and federal governments, and their officers, agents, and employees, so that other insurance
policies held by them or their self-insurance program(s) will not be required to contribute to any loss covered
under Contractor’s insurance policy or policies. Contractor must provide County with a copy of the endorsement
making the County an additional insured on all commercial general liability policies as required herein no later
than the effective date of this Contract. For all contracts where the total payment limit is greater than $500,000,
the aforementioned insurance coverage to be provided by Contractor must have a minimum combined single limit
coverage of $1,000,000.
b.Workers' Compensation. Contractor must provide workers' compensation insurance coverage for its employees.
c.Certificate of Insurance. The Contractor must provide County with (a) certificate(s) of insurance evidencing
liability and worker's compensation insurance as required herein no later than the effective date of this Contract.
If Contractor should renew the insurance policy(ies) or acquire either a new insurance policy(ies) or amend the
Initials:___________ _____________
Contractor County Dept.
coverage afforded through an endorsement to the policy at any time during the term of this Contract, then
Contractor must provide (a) current certificate(s) of insurance.
d.Additional Insurance Provisions.No later than five days after Contractor’s receipt of: (i) a notice of
cancellation, a notice of an intention to cancel, or a notice of a lapse in any of Contractor’s insurance coverage
required by this Contract; or (ii) a notice of a material change to Contractor’s insurance coverage required by this
Contract, Contractor will provide Department a copy of such notice of cancellation, notice of intention to cancel,
notice of lapse of coverage, or notice of material change. Contractor’s failure to provide Department the notice as
required by the preceding sentence is a default under this Contract
20.Notices. All notices provided for by this Contract must be in writing and may be delivered by deposit in the United
States mail, postage prepaid. Notices to County must be addressed to the head of the county department for which
this Contract is made. Notices to Contractor must be addressed to the Contractor's address designated herein. The
effective date of notice is the date of deposit in the mails or of other delivery, except that the effective date of notice to
County is the date of receipt by the head of the county department for which this Contract is made.
21.Primacy of General Conditions. In the event of a conflict between the General Conditions and the Special
Conditions, the General Conditions govern unless the Special Conditions or Service Plan expressly provide otherwise.
22.Nonrenewal. Contractor understands and agrees that there is no representation, implication, or understanding that the
services provided by Contractor under this Contract will be purchased by County under a new contract following
expiration or termination of this Contract, and Contractor waives all rights or claims to notice or hearing respecting
any failure to continue purchasing all or any such services from Contractor.
23.Possessory Interest. If this Contract results in Contractor having possession of, claim or right to the possession of
land or improvements, but does not vest ownership of the land or improvements in the same person, or if this Contract
results in the placement of taxable improvements on tax exempt land (Revenue & Taxation Code Section 107), such
interest or improvements may represent a possessory interest subject to property tax, and Contractor may be subject to
the payment of property taxes levied on such interest. Contractor agrees that this provision complies with the notice
requirements of Revenue & Taxation Code Section 107.6, and waives all rights to further notice or to damages under
that or any comparable statute.
24.No Third-Party Beneficiaries. Nothing in this Contract may be construed to create, and the parties do not intend to
create, any rights in third parties.
25.Copyrights, Rights in Data, and Works Made for Hire. Contractor will not publish or transfer any materials
produced or resulting from activities supported by this Contract without the express written consent of the County
Administrator. All reports, original drawings, graphics, plans, studies and other data and documents, in whatever
form or format, assembled or prepared by Contactor or Contractor’s subcontractors, consultants, and other agents in
connection with this Contract are “works made for hire” (as defined in the Copyright Act, 17 U.S.C. Section 101 et
seq., as amended) for County, and Contractor unconditionally and irrevocably transfers and assigns to Agency all
right, title, and interest, including all copyrights and other intellectual property rights, in or to the works made for hire.
Unless required by law, Contractor shall not publish, transfer, discuss, or disclose any of the above-described works
made for hire or any information gathered, discovered, or generated in any way through this Agreement, without
County’s prior express written consent. If any of the works made for hire is subject to copyright protection, County
reserves the right to copyright such works and Contractor agrees not to copyright such works. If any works made for
hire are copyrighted, County reserves a royalty-free, irrevocable license to reproduce, publish, and use the works
made for hire, in whole or in part, without restriction or limitation, and to authorize others to do so.
Initials:___________ _____________
Contractor County Dept.
26.Endorsements. In its capacity as a contractor with Contra Costa County, Contractor will not publicly endorse or
oppose the use of any particular brand name or commercial product without the prior written approval of the Board of
Supervisors. In its County-contractor capacity, Contractor will not publicly attribute qualities or lack of qualities to a
particular brand name or commercial product in the absence of a well-established and widely accepted scientific basis
for such claims or without the prior written approval of the Board of Supervisors. In its County-contractor capacity,
Contractor will not participate or appear in any commercially produced advertisements designed to promote a
particular brand name or commercial product, even if Contractor is not publicly endorsing a product, as long as the
Contractor's presence in the advertisement can reasonably be interpreted as an endorsement of the product by or on
behalf of Contra Costa County. Notwithstanding the foregoing, Contractor may express its views on products to other
contractors, the Board of Supervisors, County officers, or others who may be authorized by the Board of Supervisors
or by law to receive such views.
27.Required Audit. (A) If Contractor is funded by $500,000 or more in federal grant funds in any fiscal year from any
source, Contractor must provide to County, at Contractor's expense, an audit conforming to the requirements set forth
in the most current version of Office of Management and Budget Circular A-133. (B) If Contractor is funded by less
than $500,000 in federal grant funds in any fiscal year from any source, but such grant imposes specific audit
requirements, Contractor must provide County with an audit conforming to those requirements. (C) If Contractor is
funded by less than $500,000 in federal grant funds in any fiscal year from any source, Contractor is exempt from
federal audit requirements for that year; however, Contractor's records must be available for and an audit may be
required by, appropriate officials of the federal awarding agency, the General Accounting Office (GAO), the pass-
through entity and/or the County. If any such audit is required, Contractor must provide County with such audit.
With respect to the audits specified in (A), (B) and (C) above, Contractor is solely responsible for arranging for the
conduct of the audit, and for its cost. County may withhold the estimated cost of the audit or 10 percent of the
contract amount, whichever is greater, or the final payment, from Contractor until County receives the audit from
Contractor.
28.Authorization. Contractor, or the representative(s) signing this Contract on behalf of Contractor, represents and
warrants that it has full power and authority to enter into this Contract and to perform the obligations set forth herein.
29.No Implied Waiver. The waiver by County of any breach of any term or provision of this Contract will not be
deemed to be a waiver of such term or provision or of any subsequent breach of the same or any other term or
provision contained herein.
Initials:___________ _____________
Contractor County Dept.
Number:
HIPAA BUSINESS ASSOCIATE ATTACHMENT
__________
To the extent, and as long as required by the Health Insurance Portability and Accountability Act of 1996 and the
Health Information Technology for Economic and Clinical Health Act, this HIPAA Business Associate Attachment
(“Attachment”) supplements and is made a part of the Contract identified as Number _________ (hereinafter referred
to as “Agreement”) by and between a Covered Entity (Contra Costa County for its Health Services Department,
hereinafter referred to as “County”) and Business Associate (the Contractor identified in the Agreement, hereinafter
referred to as “Associate”).
A. County wishes to disclose certain information to Associate pursuant to the terms of the Agreement, some of
which may constitute Protected Health Information (“PHI”), defined below.
B. County and Associate intend to protect the privacy and provide for the security of PHI disclosed to Associate
pursuant to the Agreement as required by the Health Insurance Portability and Accountability Act of 1996
(“HIPAA”), the Health Information Technology for Economic and Clinical Health Act (“HITECH Act”), and
the regulations promulgated thereunder (collectively, the “HIPAA Regulations”), and other applicable laws.
C. As part of the HIPAA Regulations, the Privacy Rule and the Security Rule, defined below, require County to
enter into a contract containing specific requirements with Associate prior to the disclosure of PHI, as set forth
in, but not limited to, Title 45, Sections 164.314(a), 164.502(e), and 164.504(e) of the Code of Federal
Regulations and contained in this Attachment.
In consideration of the mutual promises below and the exchange of information pursuant to this Attachment, the
parties agree as follows:
1. DDefinitions. As used in this Attachment, the following terms have the following meanings:
a. BBreach has the meaning given to such term under the HITECH Act set forth at 42 U.S.C. Section 17921.
b. BBusiness Associate (“Associate”) means an individual or entity that provides services, arranges, performs or
assists in the performance of activities on behalf of the County and who uses or discloses PHI, pursuant to
the HIPAA Regulations including, but not limited to, 42 U.S.C. Section 17938 and 45 C.F.R. Section
160.103.
c. CCovered Entity (“County”) means Contra Costa County for its Health Services Department.
d. DData Aggregation has the meaning given to such term under the Privacy Rule, including, but not limited to,
45 C.F.R. Section 164.501, as in effect or as amended.
e. DDesignated Record Set has the meaning given to such term under the Privacy Rule, including, but not limited
to, 45 C.F.R. Section 164.501, as in effect or as amended.
f. EElectronic Media is:
(1) Electronic storage media including memory devices in computers (hard drives) and any
removable/transportable digital memory medium, such as magnetic tape or disk, optical disk, or digital
memory card; or
(2) Transmission media used to exchange information already in electronic storage media. Transmission
media include, for example, the Internet (wide-open), extranet (using internet technology to link a
business with information accessible only to collaborating parties), leased lines, dial-up lines, private
networks, and the physical movement of removable/transportable electronic storage media.
g. EElectronic Protected Health Information (ePHI) is any Protected Health Information that is stored in or
transmitted by electronic media.
h. EElectronic Health Record has the meaning given to such term under the HITECH Act, including, but not
limited to, 42 U.S.C. Section 17921.
Initials:___________ _____________
Contractor County Dept.
i. HHealth Care Operations has the meaning given to such term under the Privacy Rule, including, but not
limited to, 45 C.F.R. Section 164.501, as in effect or as amended.
j. PPrivacy Rule means the Standards for Privacy of Individually Identifiable Health Information set forth in 45
C.F.R. Parts 160 and 164, as in effect or as amended.
k. PProtected Health Information (“PHI”) means any information in any form or medium, including oral,
paper, or electronic: (i) that relates to the past, present or future physical or mental condition of an
individual; the provision of health care to an individual; or the past, present or future payment for the
provision of health care to an individual; and (ii) that identifies the individual or with respect to which there is
a reasonable basis to believe the information can be used to identify the individual, and shall have the
meaning given to such term under the Privacy Rule, including, but not limited to, 45 C.F.R. Section 164.501.
Protected Health Information includes electronic Protected Health Information (45 C.F.R. Sections
160.103, 164.501).
l. PProtected Information means PHI provided by County to Associate or created or received by Associate on
behalf of the County in connection with the Agreement.
m. RRequired by Law has the same meaning given to such term under the Privacy Rule, including, but not limited
to, 45 C.F.R. Section 164.103.
n. SSecurity Incident means the attempted or successful unauthorized access, use, disclosure, modification, or
destruction of information or interference with system operations in an information system.
o. SSecurity Rule means the standards for protecting the security of electronic Protected Health Information in
45 C.F.R. Parts 160 and 164, as in effect or as amended.
p. UUnsecured PHI shall have the meaning given to such term under the HITECH Act and any guidance issued
pursuant to said Act including, but not limited to, 42 U.S.C. Section 17932(h).
Terms used, but not defined, in this Attachment will have the same meanings as those terms are given in the
HIPAA Privacy Rule.
2. OObligations of Associate.
a. PPermitted Uses. Associate shall not use Protected Information except for the purpose of performing
Associate’s obligations under the Agreement and as permitted under the Agreement and this Attachment, or
as Required by Law. Further, Associate shall not use Protected Information in any manner that would
constitute a violation of the Privacy Rule or the HITECH Act.
b. PPermitted Disclosures. Associate shall not disclose Protected Information in any manner that would
constitute a violation of the Privacy Rule or the HITECH Act if so disclosed by County. However, Associate
may disclose Protected Information (i) in a manner permitted pursuant to the Agreement and this
Attachment, (ii) for the proper management and administration of Associate, (iii) as Required by Law, or (iv)
for Data Aggregation purposes for the Health Care Operations of County. To the extent that Associate
discloses Protected Information to a third party, Associate must obtain, prior to making any such disclosure
(i) reasonable written assurances from such third party that such Protected Information will be held
confidential as provided pursuant to this Attachment and only disclosed as Required By Law or for the
purposes for which it was disclosed to such third party, and (ii) a written agreement from such third party to
immediately notify Associate or any breaches of confidentiality of the Protected Information, to the extent it
has obtained knowledge of such breach.
c. PProhibited Uses and Disclosures. Associate shall not use or disclose Protected Information for fundraising
or marketing purposes. Associate shall not disclose Protected Information to a health plan for payment or
health care operations purposes if the patient has requested this special restriction, and has paid out-of-
pocket in full for the health care item or services to which the PHI solely relates (42 U.S.C. Section
17935(a)). Associate shall not directly or indirectly receive remuneration in exchange for Protected
Information, except with the prior written consent of County and as permitted by the HITECH Act, 42
Initials:___________ _____________
Contractor County Dept.
U.S.C. Section 17935(d)(2); however, this prohibition shall not affect payment by County to Associate for
services provided pursuant to the Agreement.
d. AAppropriate Safeguards. Associate agrees to implement administrative, physical, and technical safeguards
that reasonably and appropriately protect the confidentiality, integrity, and availability of Protected
Information that it creates, receives, maintains, or transmits on behalf of County as required by the
Agreement or this Attachment and in accordance with 42 C.F.R. Sections 164.308, 164.310, and 164.312.
Associate shall comply with the policies and procedures and documentation requirements of the Security
Rule, including, but not limited to, 45 C.F.R. Section 164.316.
e. RReporting of Improper Use or Disclosure. Associate will notify County in writing within twenty-four (24)
hours of its discovery of any security incident or any other use or disclosure of Protected Information not
permitted by the Agreement or this Attachment of which Associate or its officers, employees or agents
become aware, without unreasonable delay, and in no case later than ten (10) calendar days after discovery.
Associate will take (i) prompt corrective action to cure any deficiencies and (ii) any action pertaining to such
unauthorized disclosure required by applicable federal and state laws and regulations.
f. Associate’s Agents. Associate agrees to ensure that any agents, including subcontractors, to whom it provides
Protected Information, agree in writing to the same restrictions and conditions that apply to Associate with
respect to such Protected Information and implement the safeguards required by paragraph c, above, with
respect to ePHI. Associate agrees to implement and maintain sanctions against agents and subcontractors
who violate such restrictions and will mitigate the effects of any such violation.
g. AAccess to Protected Information. Associate agrees to make Protected Information maintained by Associate
or its agents or subcontractors in Designated Record Sets available to County for inspection and copying
within ten (10) days of request by County to enable County to fulfill its obligations under the Privacy Rule set
forth at 45 C.F.R. Section 164.524. If Associate maintains an Electronic Health Records, Associate shall
provide such information in electronic format to enable County to fulfill its obligations under the HITECH
Act, including, but not limited to, 42 U.S.C. Section 17935(e).
h. AAmendment of Protected Information. Within ten (10) days of receipt of a request from County for an
amendment of Protected Information or a record about an individual contained in a Designated Record Set,
Associate or its agents or subcontractors will make such Protected Information available to County for
amendment and incorporate any such amendment to enable County to fulfill its obligations under the
Privacy Rule set forth at 45 C.F.R. Section 164.526. If any individual requests an amendment of Protected
Information directly from Associate or its agents or subcontractors, Associate must notify County within five
(5) calendar days of the request, without unreasonable delay. County, and not Associate, will determine if
and when to deny a request for an amendment of Protected Information maintained by Associate.
i. AAvailability and Accounting of Information. Within ten (10) calendar days of notice by County of a request
for an accounting of disclosure of Protected Information, Associate and its agents or subcontractors shall
make available to County the information required to provide an accounting of disclosures to enable County
to fulfill its obligations under the Privacy Rule set forth at 45 C.F.R. Section 164.528, and the HITECH Act,
including, but not limited to, 42 U.S.C. Section 17935(c), as determined by County. As set forth in, and as
limited by, 45 C. F. R. Section 164.528, Associate need not provide an accounting to County of disclosures:
(i) to carry out treatment, payment or health care operations, as set forth in 45 C.F.R. Section 164.502; (ii) to
individuals of PHI about them as set forth in 45 C. F. R. 164.502; (iii) to persons involved in the individual’s
care or other notification purposes as set forth in 45 C. F. R. Section 164.510; (iv) for national security or
intelligence purposes as set forth in 45 C.F.R. Section 164.512(k)(2); or (v) to correctional institutions or law
enforcement officials as set forth in 45 C.F.R. Section 164.512(k)(5). Associate agrees to implement a
process that allows for an accounting to be collected and maintained by Associate and its agents or
subcontractors for at least six (6) years prior to the request, but not before the compliance date of the Privacy
Rule. However, accounting of disclosures from an Electronic Health Record for treatment, payment or
health care operations purposes are required to be collected and maintained for only three (3) years prior to
the request, and only to the extent that Associate maintains an electronic health record and is subject to this
requirement. At a minimum, such information must include: (i) the date of disclosure; (ii) the name of the
Initials:___________ _____________
Contractor County Dept.
entity or person who received Protected Information and , if known, the address of the entity or person; (iii)
a brief description of Protected Information disclosed; and (iv) a brief statement of the purpose of the
disclosure that reasonably informs the individual of the basis for the disclosure, or a copy of the individual’s
authorization, or a copy of the written request for disclosure. In the event that the request for an accounting
is delivered directly to Associate or its agents or subcontractors, Associate will send the request, in writing, to
County within five (5) calendar days of receipt. It will then be County’s responsibility to prepare and deliver
or otherwise respond to the accounting request. Associate will not disclose any Protected Information except
as set forth in Section 2.b. of this Attachment.
j. GGovernmental Access to Records. Associate agrees to make its internal practices, books, and records relating
to the use and disclosure of Protected Information available to the Secretary of the U.S. Department of
Health and Human Services (the “Secretary”) for purposes of determining Associate’s compliance with the
HIPAA Privacy Rule. Associate agrees to provide County with copies of any Protected Information that
Associate provides to the Secretary of the U.S. Department of Health and Human Services at the same time
Associate provides such Protected Information to the Secretary of the U.S. Department of Health and
Human Services.
k. MMinimum Necessary. Associate and its agents and subcontractors will only request, use, and disclose the
minimum amount of Protected Information necessary to accomplish the purpose of the request, use, or
disclosure. Associate understands and agrees that the definition of “minimum necessary” is in flux and shall
keep itself informed of guidance issued by the Secretary with respect to what constitutes “minimum
necessary.”
l. DData Ownership. Associate acknowledges that Associate has no ownership rights with respect to Protected
Information.
m. RRetention of Protected Information. Except as provided in Section 3.c. of this Attachment, Associate and its
subcontractors and agents must retain all Protected Information throughout the term of the Agreement and
must continue to maintain the information required by Section 2.h. of this Attachment for a period of six (6)
years after termination or expiration of the Agreement. However, accounting of disclosures from an
Electronic Health Record for treatment, payment or health care operations purposes are required to be
collected and maintained for only three (3) years prior to the request, and only to the extent that Associate
maintains an electronic health record and is subject to this requirement.
n. AAssociate’s Insurance. In addition to any other insurance requirements specified in the Agreement,
Associate will, at its sole cost and expense, insure its activities in connection with this Attachment. Associate
will obtain, keep in force and maintain insurance or equivalent program(s) of self-insurance with appropriate
limits, as determined by County, at its sole discretion, that will cover losses that may arise from any breach of
this Attachment, breach of security, or any unauthorized use or disclosure of Protected Information. It is
expressly understood and agreed that the insurance required herein does not in any way limit the liability of
Associate with respect to its activities in connection with this Attachment.
o. NNotification of Breach. During the term of the Agreement, Associate shall notify County within twenty-four
(24) hours of any suspected or actual breach of security, intrusion, or unauthorized use or disclosure of PHI
of which Associate becomes aware and/or any actual or suspected use or disclosure of data in violation of any
applicable federal or state laws or regulations. Associate shall take (i) prompt corrective action to cure any
such deficiencies; and (ii) any action pertaining to such unauthorized disclosure required by applicable
federal and state laws and regulations. In the event the breach was caused, directly or indirectly, by negligent
misconduct on the part of Associate, Associate’s agents or subcontractors, Associate will be solely responsible
for all damages resulting from the breach.
p. BBreach Pattern or Practice by County. Pursuant to 42 U.S.C. Section 17934(b), if the Associate knows of a
pattern of activity or practice of County that constitutes a material breach of violation of the County’s
obligations under the Agreement or Attachment, the Associate must take reasonable steps to cure the breach
or end the violation. If the steps are unsuccessful, the Associate must terminate the Agreement, if feasible, or
if termination is not feasible, report the problem to the Secretary of the U.S. Department of Health and
Initials:___________ _____________
Contractor County Dept.
entity or person who received Protected Information and , if known, the address of the entity or person; (iii)
a brief description of Protected Information disclosed; and (iv) a brief statement of the purpose of the
disclosure that reasonably informs the individual of the basis for the disclosure, or a copy of the individual’s
authorization, or a copy of the written request for disclosure. In the event that the request for an accounting
is delivered directly to Associate or its agents or subcontractors, Associate will send the request, in writing, to
County within five (5) calendar days of receipt. It will then be County’s responsibility to prepare and deliver
or otherwise respond to the accounting request. Associate will not disclose any Protected Information except
as set forth in Section 2.b. of this Attachment.
j. GGovernmental Access to Records. Associate agrees to make its internal practices, books, and records relating
to the use and disclosure of Protected Information available to the Secretary of the U.S. Department of
Health and Human Services (the “Secretary”) for purposes of determining Associate’s compliance with the
HIPAA Privacy Rule. Associate agrees to provide County with copies of any Protected Information that
Associate provides to the Secretary of the U.S. Department of Health and Human Services at the same time
Associate provides such Protected Information to the Secretary of the U.S. Department of Health and
Human Services.
k. MMinimum Necessary. Associate and its agents and subcontractors will only request, use, and disclose the
minimum amount of Protected Information necessary to accomplish the purpose of the request, use, or
disclosure. Associate understands and agrees that the definition of “minimum necessary” is in flux and shall
keep itself informed of guidance issued by the Secretary with respect to what constitutes “minimum
necessary.”
l. DData Ownership. Associate acknowledges that Associate has no ownership rights with respect to Protected
Information.
m. RRetention of Protected Information. Except as provided in Section 3.c. of this Attachment, Associate and its
subcontractors and agents must retain all Protected Information throughout the term of the Agreement and
must continue to maintain the information required by Section 2.h. of this Attachment for a period of six (6)
years after termination or expiration of the Agreement. However, accounting of disclosures from an
Electronic Health Record for treatment, payment or health care operations purposes are required to be
collected and maintained for only three (3) years prior to the request, and only to the extent that Associate
maintains an electronic health record and is subject to this requirement.
n. AAssociate’s Insurance. In addition to any other insurance requirements specified in the Agreement,
Associate will, at its sole cost and expense, insure its activities in connection with this Attachment. Associate
will obtain, keep in force and maintain insurance or equivalent program(s) of self-insurance with appropriate
limits, as determined by County, at its sole discretion, that will cover losses that may arise from any breach of
this Attachment, breach of security, or any unauthorized use or disclosure of Protected Information. It is
expressly understood and agreed that the insurance required herein does not in any way limit the liability of
Associate with respect to its activities in connection with this Attachment.
o. NNotification of Breach. During the term of the Agreement, Associate shall notify County within twenty-four
(24) hours of any suspected or actual breach of security, intrusion, or unauthorized use or disclosure of PHI
of which Associate becomes aware and/or any actual or suspected use or disclosure of data in violation of any
applicable federal or state laws or regulations. Associate shall take (i) prompt corrective action to cure any
such deficiencies; and (ii) any action pertaining to such unauthorized disclosure required by applicable
federal and state laws and regulations. In the event the breach was caused, directly or indirectly, by negligent
misconduct on the part of Associate, Associate’s agents or subcontractors, Associate will be solely responsible
for all damages resulting from the breach.
p. BBreach Pattern or Practice by County. Pursuant to 42 U.S.C. Section 17934(b), if the Associate knows of a
pattern of activity or practice of County that constitutes a material breach of violation of the County’s
obligations under the Agreement or Attachment, the Associate must take reasonable steps to cure the breach
or end the violation. If the steps are unsuccessful, the Associate must terminate the Agreement, if feasible, or
if termination is not feasible, report the problem to the Secretary of the U.S. Department of Health and
Initials:___________ _____________
Contractor County Dept.
Human Services. Associate shall provide written notice to County of any pattern of activity or practice of
County that Associate believes constitutes a material breach or violation of the County’s obligations under the
Agreement or Attachment within five (5) days of discovery and shall meet with County to discuss and attempt
to resolve the problem as one of the reasonable steps to cure the breach or end the violation.
q. CCertification and Enforcement. At any time during the term of the Agreement, and without advance notice,
County and its authorized agents or contractors may examine Associate’s facilities, systems, procedures and
records as may be necessary to determine the extent to which Associate’s security safeguards comply with
HIPAA, HITECH Act, other HIPAA Regulations, and this Attachment.
3. TTermination.
a. MMaterial Breach. A breach by Associate of any material provision of this Attachment, as determined by
County, constitutes grounds for termination of the Agreement pursuant to General Conditions Paragraph 5.
(Termination and Cancellation), Subsection b. (Failure to Perform), of the Agreement.
b. RReasonable Steps to Cure Breach. If County knows of an activity or practice of Associate that constitutes a
material breach or violation of Associate’s obligations under the provisions of this Attachment, County may,
in its sole discretion, terminate the Agreement pursuant to Section 3.a., above, or provide Associate an
opportunity to cure such breach or end such violation. If Associate’s efforts to cure such breach or end such
violation are unsuccessful, County will either (i) terminate the Agreement, if feasible or (ii) if termination of
the Agreement is not feasible, County will report Associate’s breach or violation to the Secretary of the U.S.
Department of Health and Human Services.
c. EEffect of Termination. Upon termination of the Agreement for any reason, Associate must return or
destroy, at the exclusive option of County, all Protected Information that Associate, its agents and
subcontractors, still maintain in any form, and Associate may not retain any copies of such Protected
Information. If return or destruction is not feasible, Associate may retain the Protected Information and
must continue to extend the protections of Sections 2.a., 2.b., 2.c., and 2.d. of this Attachment to such
information and limit further use of such Protected Information to those purposes that make the return or
destruction of such Protected Information infeasible. If Associate destroys the Protected Information,
Associate must verify in writing to County that such Protected Information has been destroyed.
4. DDisclaimer. County makes no warranty or representation that compliance by Associate with this Attachment,
HIPAA, HITECH Act, or the HIPAA Regulations, will be adequate or satisfactory for Associate’s own
purposes. Associate is solely responsible for all decisions made by Associate regarding the safeguarding of PHI.
5. CChanges to HIPAA and its regulations.
a. CCompliance with Law. The parties acknowledge that state and federal laws relating to electronic data security
and privacy are evolving and that changes to this Attachment may be required to ensure compliance with
such developments. The parties agree to take such action(s) as may be necessary to implement the standards
and requirements of HIPAA, HITECH Act, the HIPAA Regulations, and other applicable state and federal
laws relating to the security and/or confidentiality of PHI.
b. NNegotiations. In the event that a state or federal law, statute, or regulation materially affects the Agreement or
this Attachment, the parties agree to negotiate immediately and in good faith any necessary or appropriate
revisions to the Agreement or this Attachment. If the parties are unable to reach an agreement concerning
such revisions within the earlier of thirty (30) calendar days after the date of notice seeking negotiations or the
effective date of a change in law or regulations, or if the change is effective immediately, then County may, in
its sole discretion, immediately terminate the Agreement upon written notice to Associate.
Initials:___________ _____________
Contractor County Dept.
6. MMiscellaneous Provisions.
a. AAssistance in Litigation or Administrative Proceedings. Associate will make itself, and any subcontractors,
employees or agent assisting Associate in the performance of its obligations under the Agreement, available
to County, at no cost to County, to testify as witnesses or otherwise, in the event of litigation or administrative
proceedings against County, its officers or employees, based upon a claimed violation of HIPAA, HITECH
Act, the HIPAA Regulations, or other laws relating to security and privacy and arising out of the Agreement
or this Attachment.
b. NNo Third Party Beneficiaries. Nothing express or implied in this Attachment is intended to confer, nor shall
anything herein confer, upon any person other than County, Associate, and their respective successors or
assigns, any rights, remedies, obligations, or liabilities whatsoever.
c. IInterpretation. The provisions of this Attachment prevail over any provisions in the Agreement that may
conflict, or appear to be inconsistent with, any provision of this Attachment. This Attachment and the
Agreement will be interpreted as broadly as necessary to implement and comply with HIPAA and the
Privacy Rule. The parties agree that any ambiguity in this Attachment will be resolved in favor of a meaning
that complies, and is consistent, with HIPAA and the Privacy Rule.
d. NNotice to Secretary. Associate understands and agrees that if County knows of a pattern of activity or
practice of Associate that constitutes a material breach or violation of Associate’s obligations under this
Attachment and the breach or violation continues and termination of the Agreement is not feasible, County
will report the problem to the Secretary of the U.S. Department of Health and Human Services, as required
by HIPAA, HITECH Act, and the HIPAA regulations.
e. SSurvival. The obligations of Associate pursuant to Sections 2.l. and 3.c. of this Attachment survive the
termination or expiration of the Agreement.
Form approved by County Counsel [12/2009]
Page 109
Appendix 14
BASIS FOR REVENUE
PROJECTIONS
TEMPLATE
Appendix 14Basis for Revenue ProjectionsPage 1 of 2# TransportsTotal ChargesCash Collections # TransportsTotal ChargesCash Collections # TransportsTotal ChargesCash CollectionsALS 1-Emergency ALS 1-Emergency ALS 1-EmergencyALS 2ALS 2ALS 2BLS-Emergency BLS-Emergency BLS-EmergencyALS 1-Non-emergency ALS 1-Non-emergency ALS 1-Non-emergencyBLS Non-emergency BLS Non-emergency BLS Non-emergencyTOTAL TOTAL TOTAL# TransportsTotal ChargesCash Collections # TransportsTotal ChargesCash Collections # TransportsTotal ChargesCash CollectionsALS 1-Emergency ALS 1-Emergency ALS 1-EmergencyALS 2 ALS 2 ALS 2BLS-Emergency BLS-Emergency BLS-EmergencyALS 1-Non-emergency ALS 1-Non-emergency ALS 1-Non-emergencyBLS Non-emergency BLS Non-emergency BLS Non-emergencyTOTAL TOTAL TOTAL# TransportsTotal ChargesCash Collections # TransportsTotal ChargesCash Collections # TransportsTotal ChargesCash CollectionsALS 1-Emergency ALS 1-Emergency ALS 1-EmergencyALS 2ALS 2ALS 2BLS-Emergency BLS-Emergency BLS-EmergencyALS 1-Non-emergency ALS 1-Non-emergency ALS 1-Non-emergencyBLS Non-emergency BLS Non-emergency BLS Non-emergencyTOTAL TOTAL TOTAL# TransportsTotal ChargesCash Collections # TransportsTotal ChargesCash Collections # TransportsTotal ChargesCash CollectionsALS 1-Emergency ALS 1-Emergency ALS 1-EmergencyALS 2ALS 2ALS 2BLS-Emergency BLS-Emergency BLS-EmergencyALS 1-Non-emergency ALS 1-Non-emergency ALS 1-Non-emergencyBLS Non-emergency BLS Non-emergency BLS Non-emergencyTOTAL TOTAL TOTALInsurance (Year One) Insurance (Year Two) Insurance (Year Three)Self Pay (Year One) Self Pay (Year Two) Self Pay (Year Three)Medicare (Year One) Medicare (Year Two) Medicare (Year Three)Medi-Cal (Year One) Medi-Cal (Year Two) Medi-Cal (Year Three)
Appendix 14Basis for Revenue ProjectionsPage 2 of 2# TransportsTotal ChargesCash Collections # TransportsTotal ChargesCash Collections # TransportsTotal ChargesCash CollectionsALS 1-Emergency ALS 1-Emergency ALS 1-EmergencyALS 2 ALS 2 ALS 2BLS-Emergency BLS-Emergency BLS-EmergencyALS 1-Non-emergency ALS 1-Non-emergency ALS 1-Non-emergencyBLS Non-emergency BLS Non-emergency BLS Non-emergencyTOTAL TOTAL TOTALTotal Fee-for-Service Revenue (Year One) Total Fee-for-Service Revenue (Year Two) Total Fee-for-Service Revenue (Year Three)Other Revenue (Year One)Federal/State Reimbursement (GEMT)Other Revenue (Contracts, etc.)TOTALOther Revenue (Year Two)Federal/State Reimbursement (GEMT)Other Revenue (Contracts, etc.)Other Revenue (Year Three)Federal/State Reimbursement (GEMT)Other Revenue (Contracts, etc.)TOTAL TOTALTOTAL REVENUE (Year Three)Total Fee-for-service RevenueTotal Other RevenueTOTAL REVENUETOTAL REVENUE (Year One)Total Fee-for-service RevenueTotal Other RevenueTOTAL REVENUETOTAL REVENUE (Year Two)Total Fee-for-service RevenueTotal Other RevenueTOTAL REVENUE
Page 110
Appendix 15
REVENUE FLOW
PROJECTION TEMPLATE
Total ChargesNet Revenue Expected Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12Month 1Month 2Month 3Month 4Month 5Month 6Month 7Month 8Month 9Month 10Month 11Month 12TOTALPortion of Monthly Net Revenue Expected in Month ReceivedTotal and Net Revenue Projected by Month
Page 111
Appendix 16
EXPENSE BUDGET
TEMPLATES
Appendix 16
Expense Budgets (Plans A B)
Page 1 of 6
ANNUAL EXPENSES
Personnel
Wages
Paramedics -$
EMTs -$
QI/Training -$
Management/Supervisors -$
Other Personnel -$
Overtime Expense -$
Benefits -$
Other Personnel -$
TOTAL PERSONNEL -$
General and Administration
Professional Services -$
Medical Director Fees -$
Consulting Fees -$
Billing & Collection Fees/Expenses -$
Contract Administration Fees
Office Supplies & Equipment -$
Leased equipment -$
Occupancy leases, rents -$
Utilities and Telephone -$
Insurance -$
Performance Security Expense -$
Overhead Expenses -$
Taxes and Licenses -$
Travel Expenses -$
Office Capital Equp Depreciation -$
Misc Expenses -$
Operations
Dispatch and communication expense -$
Information technology expenses -$
Training/ QI expenses -$
Community Education Expenses -$
Vehicles
Fuel, oil, tires, disposable supplies -$
Repair and maintenance -$
Vehicle lease expense -$
Depreciation -$
Medical
Medical Equipment -$
Pharmaceuticals, oxygen -$
Medical Supplies -$
Depreciation -$
Other Expenses -$
TOTAL NON-PERSONNEL -$
TOTAL EXPENSES -$
YEAR 1 (Plan A)
Appendix 16
Expense Budgets (Plans A B)
Page 2 of 6
ANNUAL EXPENSES
Personnel
Wages
Paramedics -$
EMTs -$
QI/Training -$
Management/Supervisors -$
Other Personnel -$
Overtime Expense -$
Benefits -$
Other Personnel -$
TOTAL PERSONNEL -$
General and Administration
Professional Services -$
Medical Director Fees -$
Consulting Fees -$
Billing & Collection Fees/Expenses -$
Contract Administration Fees
Office Supplies & Equipment -$
Leased equipment -$
Occupancy leases, rents -$
Utilities and Telephone -$
Insurance -$
Performance Security Expense -$
Overhead Expenses -$
Taxes and Licenses -$
Travel Expenses -$
Office Capital Equp Depreciation -$
Misc Expenses -$
Operations
Dispatch and communication expense -$
Information technology expenses -$
Training/ QI expenses -$
Community Education Expenses -$
Vehicles
Fuel, oil, tires, disposable supplies -$
Repair and maintenance -$
Vehicle lease expense -$
Depreciation -$
Medical
Medical Equipment -$
Pharmaceuticals, oxygen -$
Medical Supplies -$
Depreciation -$
Other Expenses -$
TOTAL NON-PERSONNEL -$
TOTAL EXPENSES -$
YEAR 2 (Plan A)
Appendix 16
Expense Budgets (Plans A B)
Page 3 of 6
ANNUAL EXPENSES
Personnel
Wages
Paramedics -$
EMTs -$
QI/Training -$
Management/Supervisors -$
Other Personnel -$
Overtime Expense -$
Benefits -$
Other Personnel -$
TOTAL PERSONNEL -$
General and Administration
Professional Services -$
Medical Director Fees -$
Consulting Fees -$
Billing & Collection Fees/Expenses -$
Contract Administration Fees
Office Supplies & Equipment -$
Leased equipment -$
Occupancy leases, rents -$
Utilities and Telephone -$
Insurance -$
Performance Security Expense -$
Overhead Expenses -$
Taxes and Licenses -$
Travel Expenses -$
Office Capital Equp Depreciation -$
Misc Expenses -$
Operations
Dispatch and communication expense -$
Information technology expenses -$
Training/ QI expenses -$
Community Education Expenses -$
Vehicles
Fuel, oil, tires, disposable supplies -$
Repair and maintenance -$
Vehicle lease expense -$
Depreciation -$
Medical
Medical Equipment -$
Pharmaceuticals, oxygen -$
Medical Supplies -$
Depreciation -$
Other Expenses -$
TOTAL NON-PERSONNEL -$
TOTAL EXPENSES -$
YEAR 3 (Plan A)
Appendix 16
Expense Budgets (Plans A B)
Page 4 of 6
ANNUAL EXPENSES
Personnel
Wages
Paramedics -$
EMTs -$
QI/Training -$
Management/Supervisors -$
Other Personnel -$
Overtime Expense -$
Benefits -$
Other Personnel -$
TOTAL PERSONNEL -$
General and Administration
Professional Services -$
Medical Director Fees -$
Consulting Fees -$
Billing & Collection Fees/Expenses -$
Contract Administration Fees
Office Supplies & Equipment -$
Leased equipment -$
Occupancy leases, rents -$
Utilities and Telephone -$
Insurance -$
Performance Security Expense -$
Overhead Expenses -$
Taxes and Licenses -$
Travel Expenses -$
Office Capital Equp Depreciation -$
Misc Expenses -$
Operations
Dispatch and communication expense -$
Information technology expenses -$
Training/ QI expenses -$
Community Education Expenses -$
Vehicles
Fuel, oil, tires, disposable supplies -$
Repair and maintenance -$
Vehicle lease expense -$
Depreciation -$
Medical
Medical Equipment -$
Pharmaceuticals, oxygen -$
Medical Supplies -$
Depreciation -$
Other Expenses -$
TOTAL NON-PERSONNEL -$
TOTAL EXPENSES -$
YEAR 1 (Plan B)
Appendix 16
Expense Budgets (Plans A B)
Page 5 of 6
ANNUAL EXPENSES
Personnel
Wages
Paramedics -$
EMTs -$
QI/Training -$
Management/Supervisors -$
Other Personnel -$
Overtime Expense -$
Benefits -$
Other Personnel -$
TOTAL PERSONNEL -$
General and Administration
Professional Services -$
Medical Director Fees -$
Consulting Fees -$
Billing & Collection Fees/Expenses -$
Contract Administration Fees
Office Supplies & Equipment -$
Leased equipment -$
Occupancy leases, rents -$
Utilities and Telephone -$
Insurance -$
Performance Security Expense -$
Overhead Expenses -$
Taxes and Licenses -$
Travel Expenses -$
Office Capital Equp Depreciation -$
Misc Expenses -$
Operations
Dispatch and communication expense -$
Information technology expenses -$
Training/ QI expenses -$
Community Education Expenses -$
Vehicles
Fuel, oil, tires, disposable supplies -$
Repair and maintenance -$
Vehicle lease expense -$
Depreciation -$
Medical
Medical Equipment -$
Pharmaceuticals, oxygen -$
Medical Supplies -$
Depreciation -$
Other Expenses -$
TOTAL NON-PERSONNEL -$
TOTAL EXPENSES -$
YEAR 2 (Plan B)
Appendix 16
Expense Budgets (Plans A B)
Page 6 of 6
ANNUAL EXPENSES
Personnel
Wages
Paramedics -$
EMTs -$
QI/Training -$
Management/Supervisors -$
Other Personnel -$
Overtime Expense -$
Benefits -$
Other Personnel -$
TOTAL PERSONNEL -$
General and Administration
Professional Services -$
Medical Director Fees -$
Consulting Fees -$
Billing & Collection Fees/Expenses -$
Contract Administration Fees
Office Supplies & Equipment -$
Leased equipment -$
Occupancy leases, rents -$
Utilities and Telephone -$
Insurance -$
Performance Security Expense -$
Overhead Expenses -$
Taxes and Licenses -$
Travel Expenses -$
Office Capital Equp Depreciation -$
Misc Expenses -$
Operations
Dispatch and communication expense -$
Information technology expenses -$
Training/ QI expenses -$
Community Education Expenses -$
Vehicles
Fuel, oil, tires, disposable supplies -$
Repair and maintenance -$
Vehicle lease expense -$
Depreciation -$
Medical
Medical Equipment -$
Pharmaceuticals, oxygen -$
Medical Supplies -$
Depreciation -$
Other Expenses -$
TOTAL NON-PERSONNEL -$
TOTAL EXPENSES -$
YEAR 3 (Plan B)
Appendix 16Expense Budget Assumptions (Plans A B)Page 1 of 1Year 1 Year 2 Year 3Year 1 Year 2 Year 3Number of Paramedics (FTEs)Number of EMTs (FTEs)Average Annual Paramedic WageAverage Annual EMT WageBenefit PercentageAverage Weekly Staffed Unit-HoursFully Burdened Unit-Hour Cost Plan APlan BAssumptions
Page 112
Appendix 17
ONE TIME EXPENSE AND
CAPITAL BUDGET
TEMPLATE
AssumptionsPlan APlan BNumber of Staffed Ambulance at Peak Total Number of Ambulance in FleetNumber of Leased AmbulancesNumber of Purchased AmbulancesNumber of Existing Ambulances for CCCQty. Cost/ValueQty. Cost/ValueNumber of New AmbulancesMedical EquipmentSupply InventoryLeasehold ImprovementsIT Equipment (including mobile)Communications EquipmentOffice Furnishing/EquipmentShop EquipmentShop Supply/Parts InventoryWages & BenefitsEmployment CostsLeases/RentsLegal/Professional ServicesOther > $10,000 TOTAL ONE TIME COSTSPlan APlan BOne-Time Costs
Page 113
PRO FORMA BUDGET
SUMMARY TEMPLATE
Start-Up CostsYear 1 Year 2 Year 3Start-Up CostsYear 1 Year 2 Year 3RevenueExpensesGain (Loss)Plan APlan B
Page 114
Appendix 19
ALS INTERFACILITY
PRICE SHEET
APPENDIX 19
ALS Interfacility Charges
Page | 1
1. Patient Charges shall be submitted on this exhibit in Table A as is. Proposed patient
charges should take into consideration the cost of providing care to indigent patients.
No alterations or changes of any kind are permitted.
2. The County has adopted a “bundled” rate for ambulance services with a single base
rate, whereby most fees for service are included in the base rate, with the exception of
oxygen and mileage.
3. The patient charges quoted in Table A shall include all taxes and all fees charged to
patients or third party payers. Proposals should reflect a bundled rate structure and no
other charges for supplies, equipment, or procedures, or other services will be accepted.
Contractor shall comply with fee schedule and rates proposed in response to this RFP
and approved by the County.
Table A - Proposed Charges
Complete the proposed charge for each item listed below.
No other patient charges will be considered.
Ambulance ALS Interfacility Base Rate
Mileage/mile
Oxygen
Treat, Non-transport rate*
$______.___
$______.___
$___175.00_
$______.___
Proposer agrees that the prices quoted are the maximum that will be charged during the
term of any contract awarded, with the exception of increases or fee adjustments described
in the RFP.
FIRM: ___________________________________________________________________
SIGNATURE:___________________________________________________________________
DATE: ___/____/_____
PRINTED NAME:
___________________________________________________________________________
TITLE: ________________________________________________________________________
Page 115
1
Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
FACE SHEET
2
Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
3
Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
TABLE OF CONTENTS
Section II. Submission of Required Forms .................................................................................................................................... 8
A. Insurance Certificates........................................................................................................................................................ 8
B. Debarment & Suspension Certification ............................................................................................................................. 9
C. References ...................................................................................................................................................................... 11
D. Investigative AUthorization-Individual ............................................................................................................................ 13
E. investigative Authorization-Entity................................................................................................................................... 17
Section III. Qualification Requirements ...................................................................................................................................... 21
A. Organizational Disclosures .............................................................................................................................................. 21
B. Experience as Sole Provider ............................................................................................................................................ 24
C. Demonstrated Response Time Performance .................................................................................................................. 28
D. Demonstrated High Level Clinical Care ........................................................................................................................... 30
Section IV. Core Requirements ................................................................................................................................................... 33
A. Two Service Plans are to be addressed ........................................................................................................................... 33
B. Contractor’s Functional Responsibilities ......................................................................................................................... 33
C. Clinical ............................................................................................................................................................................. 33
D. Operations ...................................................................................................................................................................... 40
E. Personnel ........................................................................................................................................................................ 42
F. Management ................................................................................................................................................................... 45
G. EMS System and Community .......................................................................................................................................... 46
H. Administrative Provisions ............................................................................................................................................... 47
Section V. Competitive Criteria ................................................................................................................................................... 50
A. Clinical ............................................................................................................................................................................. 50
B. Operations .................................................................................................................................................................... 100
C. Personnel ...................................................................................................................................................................... 131
D. Management ................................................................................................................................................................. 159
E. EMS System and Community ........................................................................................................................................ 164
F. Integration with Healthcare Providers .......................................................................................................................... 177
4
Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
SECTION 1. EXECUTIVE SUMMARY
The delivery of Emergency Medical Services is evolving in Contra Costa County.
The present and future needs of Contra Costa County’s Emergency Medical Services (EMS) presents unique opportunities for
innovation and resource alignment. In response to these opportunities, Contra Costa County Fire Protection District (CCCFPD)
is delighted to submit a proposal to become the Exclusive Operator for Emergency Ambulance Services for Contra Costa County
(hereafter referred as the “County”). As the primary bidder, we recognized the power of existing system leaders and have
strategically aligned with American Medical Response West (AMR) through a subcontracting agreement. Together, our
organizations form Contra Costa County Fire and EMS, or “the Alliance.”
Never before has the County’s EMS system been fully-integrated as presented by Contra
Costa County Fire & EMS - the Alliance. This system design offers innovative and
collaborative enhancements that will positively impact the overall system performance
and quality of patient care.
We found AMR to be best suited to join us in serving the County because they have been providing reliable, sustainable EMS
services as your local provider for many years. Their experience as your current provider, along with their successful record of
accomplishment locally and nationally was integral in our decision to form the Alliance. In addition, we already have an
established and trusted relationship with AMR because we respond together. Therefore, it makes sense that we would
leverage our combined resources and expertise to execute on identified/needed operational improvements, increasing quality
of care and decreasing costs for the County.
Both our organizations have paved the way for historical improvements in the County’s EMS System. We have shared the
roads together and both possess an intimate understanding of emergency medicine in the County. Together, no other provider
can match our combined existing infrastructure, organizational leadership, customer service, or commitment to public
protection. These distinguishing attributes, along with experienced caregivers and local knowledge, make clear that Contra
Costa County Fire and EMS is the logical solution for pre-hospital care in the County.
For the purpose of this proposal and for the ease of review, we will refer to ourselves as Contra Costa County Fire and EMS
or the Alliance. This terminology shows our intent to combine the resources of our two entities (CCCFPD and AMR) to deliver
integrated solutions to the County. Henceforth in this proposal, we will only reference CCCFPD and AMR in sections that
required full transparency or if we specifically refer to items that are trademarked or proprietary to one of the organizations.
Contra Costa
County Fire and
EMS - the Alliance
5
Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
On the Road Together: A Rich History of Service and Experience
Our history, both independently and jointly, prove our longstanding investment to improve and serve the County. We
understand the delicate balance of emergency medicine practice and effective and timely EMS system delivery. The Alliance
represents the County’s most established and essential response organizations. We have an extensive history of taking every
opportunity to advance the quality and level of First Response and EMS for hundreds of thousands of families and individuals
who live, work, and recreate in the County.
As a Fire Protection Services agency, we have been a reliable, respected public safety provider for over 50 years, dating back
to the merger between the Central Fire Protection District and the Mt. Diablo Fire Protection District. As a local EMS provider,
we have nearly 70 years of experience through predecessor companies. Collectively, the Alliance brings over 120 years of
unmatchable service and experience in the County.
Furthermore, our commitment to hire and retain competent personnel paints a picture of our historical growth to meet the
needs of the community. Since our inception, our Fire Protection Services organization has grown significantly, currently
staffing 335 personnel of which 101 are Paramedics and 158 EMTs, operating out of 24 fire stations. As a reliable, sustainable
local EMS services provider, our local operations currently employs approximately 275 paramedics and EMTs and handles an
average of 80,000 ambulance calls annually. Across the Alliance, we have over 500 personnel, meeting the needs of the sick
and injured in the County.
Through the years of service, we have gained invaluable experience serving the County while continually evaluating our
operational standards and practices to ensure excellence in all-hazards service. Additionally, we have developed strong
relationships with the Local Emergency Medical Services Authority (LEMSA), patients, government officials, citizens, healthcare
providers, and many of the individuals for whom we have provided care.
An Integrated Alliance Forms to Share Reliable Resources
The Alliance will work hand-in-hand with the County and LEMSA, to offer full
system integration for the community. This level of cohesion will blend all of
our strengths to maximize the level of support provided to the community. This
integrated system will achieve the following features and enhancements:
Single-source dispatch
Integrated oversight for first response and transportation
Consistent training for all providers
Common and shared language and response culture
Eliminate redundancy in service
Single command structure
Collective approval of operations, logistics, planning, and finance activities
Cooperative response environment
Shared facilities, reducing response costs, maximizing efficiency, and minimizing communication breakdowns
One (1) consolidated Incident Action Plan (IAP) for responders
AT-A-GLANCE
24 Fire Stations
335 Fire Personnel
275 Paramedics and EMTs
80,000 Ambulance Calls
Over 120 Years of Combined Service
6
Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
An Innovative and Sustainable Solution for the Future of Contra Costa County
Ultimately, this next generation EMS model is designed to ensure the County’s patients safe and timely medical care and
transportation while creating a positive patient experience through caregivers and responders who are trained to provide
comfort during the most vulnerable times of need. Regardless of any challenges we may face, the Alliance will strategically
resolve them together.
Our vision for Contra Costa County EMS is a system that is Sustainable, Reliable, Integrated, Innovative, and Experienced.
Throughout our proposal, we focus on this vision as the framework for our future system management.
Our EMS experience in the County uniquely positions us with capabilities that extend beyond the RFP requirements. We know
and understand the citizens of Contra Costa County, the structure and landscape of the communities, the healthcare system,
and the culture of the region. This familiarity qualifies us as a beneficial, long-term contributor to the continued sustainability
of the local EMS system. A few of the benefits of selecting us as your EMS partner include the following:
Unparalleled Local Experience and Workforce – Our extensive history and proven track record of meeting response
time standards in the County uniquely positions us to build upon our success and better serve the needs of the County.
In addition, our personnel are intimately connected to the community because the County is their home.
Compassionate and receptive to the needs of the County, we will invest in the trust built throughout our longstanding
partnership.
Tenured, Dedicated Leadership Team - Our leadership team consists of a group of highly qualified, dedicated, and
experienced individuals who live and work in the local community, delivering hands-on customer service and
care. During our decades of providing services in the area, our dynamic and experienced local leadership team has
proven its commitment and will ensure that we provide successful prehospital patient care for the County’s residents
and visitors in the years ahead.
System Innovation – We are a pioneer of implementing new, innovative technology that is designed and proven to
improve operational and clinical practices. As your partner, we will remain dedicated to investing capital in technology
and equipment to guarantee we have long-term, sustainable solutions for the constant changes in healthcare.
Through this dedication, we will ensure exceptional EMS services, providing you with world-class patient care in a
compassionate and financially responsible manner
The Alliance’s
EMS System for
the County
7
Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
A Higher Level of Commitment to the County
We also understand the importance of reviewing a provider’s experience, financial stability, available resources, and
commitment and dedication to the community. We kept this in mind when we developed our proposal, showcasing our
commitment to the County now and in the years ahead. Throughout our proposal, we highlight value-added solutions that not
only align with the RFP’s Competitive Criteria, but also display our higher level of commitment to the County.
As you read through our responses to your RFP requirements, please note our “Contra Costa
County Higher Level of Commitment Callouts” (an example pictured to the right). These callout
symbols align with our vision for the future of EMS in the County, while bringing attention to
sections of our proposal that highlight our higher level of commitment as your provider.
As an authorized representative of the bidding entity, CCCFPD, I am legally authorized to
contractually bind the firm. With this Executive Summary, CCCFPD specifically affirms its full understanding and acceptance of
all terms set forth in the RFP, including the financial projections in our proposal. We certify the completeness and accuracy of
all information supplied. We have not violated any conflict of interest statutes or ordinances. Our proposal is a firm and binding
offer to perform the services stated under the conditions specified.
We view this opportunity to submit a proposal as both a privilege and a responsibility. With experienced local caregivers and
responders, a knowledgeable leadership team, and a customer-focused organization with regional and national expertise, we
are confident that we will be an enthusiastic and collaborative partner with the County. We encourage you to contact us with
any questions or concerns and are happy to meet in person to discuss our proposal and/or elaborate on any particular aspects
of our submittal. We are truly honored to submit this proposal to become the County’s Exclusive Operator for Emergency
Ambulance Services.
Respectfully submitted,
Name: Jeff Carman
Title: Fire Chief
Phone: 925-941-3500
Email: jcarm@cccfpd.org
8
Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
SECTION II. SUBMISSION OF REQUIRED
FORMS
A. INSURANCE CERTIFICATES
CCCFPD Insurance
We have provided a letter and our insurance certificate as Exhibit No. 1 of this proposal’s Exhibits Binders.
AMR Insurance
For a copy of AMR’s current insurance certificate, please refer to Exhibit No. 1 of this proposal’s Exhibits Binder.
9
Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
B. DEBARMENT & SUSPENSION CERTIFICATION
.
10
Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
11
Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
C. REFERENCES
12
Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
13
Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
D. INVESTIGATIVE AUTHORIZATION-INDIVIDUAL
14
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E. INVESTIGATIVE AUTHORIZATION-ENTITY
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SECTION III. QUALIFICATION REQUIREMENTS
A. ORGANIZATIONAL DISCLOSURES
In the spirit of transparency and to display our compliance with all specifications listed in Section III. Qualifications
Requirements, A. Organizational Disclosures, we have provided detailed responses for both organizations that form the Alliance
- CCCFPD and AMR.
CCCFPD’s Organizational Ownership & Legal Structure
CCCFPD is legally organized under the California Fire District Law of 1987 (Health & Safety Code §13800, et seq.) and is a
dependent special district governed by the County Board of Supervisors acting as the Board of Directors. CCCFPD was formed
in 1964 after merger of Central Fire Protection District and the Mt. Diablo Fire Protection District. CCCFPD is funded primarily
through its own share of property tax revenues with supplemental funding through charges for services in certain business
areas such as cost recovery for certain emergency responses and fees or permits charged through the fire prevention bureau.
AMR’s Ownership & Legal Structure
The legal entity in alliance with CCCFPD for this proposal is American Medical Response West (AMR West), a California
corporation doing business as American Medical Response (AMR). AMR West is a wholly-owned subsidiary of American
Medical Response, Inc. (AMR, Inc.), a Delaware corporation which was established in August 1992 and is nationally
headquartered in Greenwood Village, Colorado. AMR West was incorporated on May 27, 1992 and is regionally headquartered
in Livermore, California.
CCCFPD’s Continuity of Business
Contra Costa County Fire Protection District (CCCFPD) is the legal name of the entity bidding on this contract. CCCFPD is a
special district formed in 1964 after merger of Central Fire Protection District and the Mt. Diablo Fire Protection District. Since
then, CCCFPD has grown in part through the merging of other fire agencies that have become a part of our organization.
AMR’s Continuity of Business
American Medical Response West (“AMR West”) is the legal name of the entity in alliance with CCCFPD. AMR West was
incorporated as PMI Acquisition Corp in California on May 27, 1992. The name was changed to American Medical Response
West on November 5, 1992. Our organization grew in part through the acquisition and consolidation of various ambulance
companies, dating back to 1959. As a result, we have had many prior DBA names during our history, and as time has passed,
we have transitioned legacy DBA names to either American Medical Response or AMR.
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CCCFPD’s Licenses & Permits
CCCFPD is a fire protection district existing under the laws of the State of California, specifically Health and Safety Code 13800,
et seq., also known as the Fire Protection District Law of 1987. Therefore, as a government agency, CCCFPD is not obligated to
obtain a business license in Contra Costa County.
AMR’s Licenses & Permits
AMR fully attest, with no exception, to our future compliance with all required business and professional licenses, permits, and
certificates. AMR has provided a copy of our current business license for Contra Costa County as Exhibit No. 2.
CCCFPD’s Government Investigations
CCCFPD is not the subject of any current government investigations. CCCFPD represents and certifies that it has not been
convicted of any conduct that constitutes grounds for mandatory exclusion as identified in 42 U.S.C.§ 1320a-7(a). CCCFPD
further represent and certify that they are not ineligible to participate in Federal health care programs or in any other state or
federal government payment program. If the County has questions or needs more information, we are happy to provide that
information upon request or make our counsel available.
AMR’s Government Investigations
Information on legal related matters is publicly available at the U.S. Securities and Exchange Commission’s website
http://www.sec.gov/edgar.shtml by reviewing the 10K filings, 10Q filings and other filings of our ultimate parent company,
Envision Healthcare Holdings, Inc. (symbol: “EVHC” or search “Envision Healthcare”). The information below relates to AMR
and its subsidiaries nationwide. If County would like to discuss these matters in more detail or needs clarifications, we are
happy to provide more information or make ourselves and/or our counsel available to discuss at your convenience.
Like others in the industry, AMR and its subsidiaries have from time-to-time been contacted by government agencies in
connection with their regulatory or investigational authority. We have implemented policies and procedures that we believe
will assure that we are in substantial compliance with the laws that these governmental agencies regulate. Any past matters
have been resolved with the appropriate governmental agency. Additionally, local AMR operations receive inquiries from state
and local health departments, EMS bureaus, and other regulators regarding vehicle inspections, personnel and other day-to-
day operational matters. AMR has cooperated with these authorities and resolved their inquiries. AMR and its subsidiaries
have not been sanctioned or fined by any federal or state authorities but have paid administrative assessments to state and
local agencies from time-to-time related to vehicle inspections, personnel and other day-to-day operational matters.
For the past three years we have listed non-routine and formal matters with government agencies as follows: )(i) we received
a subpoena from the Federal Aviation Administration in February 2013 related to our operations as an indirect air carrier and
relationships with Part 135 direct air carriers and we produced documents to the FAA; and (ii) we received a subpoena from
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the New Hampshire Department of Insurance in November 2013 related to ambulance services provided to insureds involved
in motor vehicle accidents, and in March 2014, we were notified that the investigation was concluded and closed.
AMR and its subsidiaries represent and certify that they have not been convicted of any conduct that constitutes grounds for
mandatory exclusion as identified in 42 U.S.C.§ 1320a-7(a). AMR and its subsidiaries further represent and certify that they are
not ineligible to participate in Federal health care programs or in any other state or federal government payment program.
AMR and its subsidiaries compliance policies and Code of Conduct are available at http://www.amr.net/About-AMR/Corporate-
Compliance.aspx. If the County has questions or needs more information, we are happy to provide that information upon
request or make our counsel available.
CCCFPD’s Litigation
Over the years and in the ordinary course of business, CCCFPD has been involved in litigation and have had claims made against
us, principally relating to auto accident and workers compensation claims. An abstract of all litigation (open and closed) for the
last five years can be found as Exhibit No. 3. For privacy, confidentiality and settlement agreement reasons, we have included
summary information only and have provided the information in the manner in which we track the information which does not
include the court or case number.
As of the date of this submission, we believe there is no outstanding or pending litigation that would affect our ability to fully
perform all requirements of the RFP. At this time, we believe that any pending litigation or claims that may be asserted against
us are without merit and/or adequately provided for by insurance and will not have a material effect on the operations or the
services that we would provide under this RFP. If the County has questions or needs more information, we are happy to provide
that information upon request or make our counsel available.
AMR’s Litigation
Over the years and in the ordinary course of business, AMR and its subsidiaries have been involved in litigation and have had
claims made against us, principally relating to professional liability, auto accident and workers compensation claims. An abstract
of all litigation nationally (open and closed) for the last five years can be found as Exhibit No. 3. For privacy, confidentiality and
settlement agreement reasons, we have included summary information only and have provided the information in the manner
in which we track the information which does not include the court or case number.
As of the date of this submission, we believe there is no outstanding or pending litigation that would affect our ability to fully
perform all requirements of the RFP. At this time, we believe that any pending litigation or claims that may be asserted against
us are without merit and/or adequately provided for by insurance or reserves and will not have a material effect on the
operations or the services that we would provide under this RFP. Additionally, AMR maintains insurance that is significantly
higher than any other provider in the emergency medical services industry. There are several layers of excess insurance for
professional liability, auto liability and general liability reaching into the high eight figures. If the County has questions or needs
more information, we are happy to provide that information upon request or make our counsel available.
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Contra Costa County Fire & EMS
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B. EXPERIENCE AS SOLE PROVIDER
CCCFPD has provided EMS services in the County for over 50 years and is the single largest provider of ALS response services
in the County, serving nearly 60% of the population. We currently provide all aspects and essential functions as specified in
the RFP with the exception of the transportation component, which is identified in the Fitch modernization report as one of
the least important when evaluating patient outcomes.
When a 9-1-1 call is received in the County, the call is transferred to CCCFPD’s communications center, which functions as the
secondary PSAP. Once the call is transferred, CCCFPD Dispatchers, who are specially trained in EMD call screening and
processing, dispatch the appropriate resources for that incident. Dispatchers continually monitor the active incidents as well
as the overall system needs and utilize a “system status management” model to ensure appropriate coverage of all first
responder resources.
As the largest ALS first responder agency, the CCCFPD maintains an EMS Division that provides the same level of quality
processes as the incumbent ambulance provider. In the proposed EOA, first responders in the County responded to over 77k
calls in 2013. Of those, 58,911 were transported to local emergency departments. CCCFPD is qualified to bid this RFP based
upon their experience of providing emergency medical services for a population of over 600,000 individuals. This includes all
components of the EMS system management with the exception of transportation. To better position our organization,
CCCFPD has aligned with AMR (referred to as “the Alliance”) to provide an integrated EMS system program that cannot be
matched by any other provider.
Through the Alliance, we have built and continue to cultivate a solid reputation as the leading provider of Advanced Life Support
(ALS) services throughout the nation. We are the industry leader in ability to leverage the industry-leading expertise and
financial support of our national resources, paired with devoting 100% of our local operations to serving the specific needs of
the County’s patients, residents, and visitors. This aspect, alongside our collaboration with EMS stakeholders and community
partners, is among the numerous qualities that differentiate us from all other providers.
To demonstrate our comparable services, we have provided reference letters attesting to our dependability providing the
requested services from comparable contracts as Exhibit No. 4. If the County desires to see more letters, we will happily
provide upon request.
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Selected Comparable Services
The Alliance has extensive experience providing the highest quality ALS services to residents and visitors in diverse areas, some
of which are similar to the County. We consistently meet and exceed the contract-required response time compliance. The
following outlines service areas similar to the County for which we currently and successfully manage emergency 9-1-1 ALS
services under performance-based contracts:
Contra Costa County
POC: Patricia Frost, RN, MS, PNP
Title: EMS Administrator
Address: 1340 Arnold Dr. #126, Martinez, CA 94553
Phone number: 925-313-9554
Type and Level of Service Provided: ALS
Population: 900,000
Description: In Contra Costa County, we provide emergency medical transportation services to the citizens and visitors of the
County. Through predecessor companies, we have maintained a strong presence in the County for nearly 70 years. Over the
years, our operational footprint has grown significantly. We currently employ approximately 275 Paramedics and EMTs and
handle an average of 80,000 ambulance calls annually.
In addition to providing emergency medical transportation, our County operation has been active participant in the community,
providing medical standby services to local events as well as supporting and sponsoring local health initiatives and programs.
Napa County EMS
POC: Brian Hendrickson
Title: Health Officer
Address: 2344 Old Sonoma Road, Building G
Napa, CA 94559
Phone number: (707) 253-4270
Type and Level of Service Provided: 9-1-1 ALS and IFT ALS
Population: 150,000
Description: In Napa County, we provide emergency and non-emergency medical transport services to all of Napa County, CA.
Founded in 2012, our Napa County operation employs approximately 80 paramedics and EMTs and handles on average 14,000
calls annually.
Our Napa County operation offers state-of-the-art STEMI and stroke care programs, as well as Basic and Advanced Life Support
training courses for EMS professionals. This operation is also working on developing an intermediate level EMT program for
volunteer fire agencies.
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Sonoma County
POC: Bryan Cleaver
Title: EMS Administrator
Address: Coastal Valley EMS Agency, 195 Concourse Boulevard, Santa Rosa, CA 95403
Phone number: 707-565-6501
Type and Level of Service Provided: 911 ALS and ALS IFT Services
Population: 485,000
Description: Sonoma Life Support AMR is the contracted provider of paramedic ambulance services to an exclusive operating
area in central Sonoma County stretching from Penngrove through Larkfield and Freestone through Kenwood. The service area
is broken into six geographic zones to ensure services are equitably distributed to the entire community. We serve
approximately 80% of the overall Sonoma County 911 EMS calls.
We provide emergency and non-emergency paramedic and ambulance services to more than 2,400 patients each month.
Emergency services are provided under a performance based Exclusive Operating Area (EOA) contract with the County of
Sonoma. Dozens of requirements are met on a daily, monthly and annual basis. Response times are monitored daily and
reported to the Coastal Valleys EMS Agency. Since starting the current service agreement in 2009, SLS consistently met and
exceeded the contractual requirements each month.
In addition to emergency services, SLS provides non-emergency BLS, ALS and CCT inter-facility transportation between hospitals
and other medical facilities. We provide specialized event standby services for many of the county’s special events, such as the
Sonoma County Fair, Gran Fondo, AMGEN Tour of California, Wine Country Century, Santa Rosa’s Rose Parade and Festival and
many other community events. In partnership with the area’s law enforcement agencies we provide assistance managing and
transporting combative subjects and collecting blood for analysis by the state’s crime labs. A partnership with the Santa Rosa
Fire Department allows our agencies to deliver lifesaving advanced life support care to the community in a prompt and efficient
manner. A dynamic deployment system ensures rapid responses to all of the all areas we serve. We are currently in our third
consecutive EOA agreement, having served the area consistently since 1991.
Under a separate agreement, AMR provides management, staff and daily operations of the Redwood Empire Dispatch
Communications Center (REDCOM). This 9-11- (secondary PSAP) dispatch center receives and dispatches more than 31,000
EMS and Fire calls annually to agencies across the county.
Through the Alliance, we offer a depth of experience with ambulance service government contracts that is unmatchable by any
other provider. We currently have over 170 9-1-1 contracts with cities, counties, and special districts nationwide. On the
following page, we have provided a list of our ambulance service government contacts operated in the state of California.
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Like others in the industry, in their day-to-day operations we have been involved in contract disputes with customers, vendors,
payers, patients and others. For the last 10 years, we have not had any non-routine and formal contract related disputes.
If the County has questions or needs more information, we are happy to provide that information upon request or make our
counsel available.
Emergency Ambulance Service Government Contracts
Community
Served Contracting Entity Types/Level of
Service
Approx.
Population
Served
Contract Term
Dollar Amount
Agreement
(annual)
Exclusive
(Yes/No)
Contra Costa
County
Contra Costa
County 911 ALS 900,000 12/31/2015 $38,000,000 Yes
Alameda County Alameda County ALS, BLS, CCT 1,050,000 10/31/2011 $51,000,000 Yes
Napa County Napa County EMS
Agency
9-1-1 ALS and
IFT ALS Services 150,000 1/31/2017 $7,600,000 Yes
Monterey
County Monterey County ALS and CCT 425,000 1/31/2017 $15,000,000 Yes
Placer County Placer County ALS and BLS 250,000 12/16/2015 $16,900,000 Yes
San Benito
County Hollister County ALS 55,000 6/30/2019 $1,800,000 Yes
San Joaquin
County
San Joaquin
County ALS and BLS 685,000 4/30/2021 $33,500,000 Yes
San Mateo
County San Mateo County ALS 725,000 6/30/2019 $30,000,000 Yes
Santa Barbara
County
Santa Barbara
County ALS,BLS, and CCT 425,000 12/31/2017 $18,700,000 Yes
Santa Clara
County Santa Clara County ALS 1,800,000 6/30/2011 $40,000,000 Yes
Santa Cruz
County Santa Cruz County ALS 270,000 12/31/2015 $8,600,000 Yes
Sacramento
County
Sacramento Metro
Fire District ALS and BLS 600,00 Evergreen $7,500,000 No
Sonoma County Sonoma County 911 ALS and ALS
IFT Services 485,000 6/30/2016 $16,000,000 Yes
Stanislaus
County Stanislaus County ALS and BLS 520,000 4/30/2018 $25,000,000 Yes
Tulare County Tulare County ALS and BLS 450,000 06/30/2019 $6,000,000 Yes
Yolo County Yolo County ALS and BLS 200,000 02/1/2019 $11,600,000 Yes
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C. DEMONSTRATED RESPONSE TIME
PERFORMANCE
In the spirit of transparency and to display full compliance with all specifications listed in Section III. Qualifications
Requirements, C. Demonstrated Response Time Performance, we have provided detailed responses for both organizations that
form the Alliance - CCCFPD and AMR.
CCCFPD’s Demonstrated Response Time Performance
In the interagency agreement with the LEMSA, our service plan outlines that we shall endeavor to assure paramedic response
to 90% of emergency medical calls in our jurisdiction within 10 minutes of dispatch for those calls categorized as requiring
emergency paramedic level response according to emergency medial dispatch protocols. Below, we have provided a table that
displays evidence of CCCFPD’s five (5) years of compliance to that standard.
Incident YR Code3 Central_90 Central_Count East_90 East_Count West_90 West_Count Total_90 Total_Count
All 2014 code 3 00:08:59 (18360)20583 00:09:01 (16853)19085 00:08:43 (6988)8232 00:08:57 (42201)47900
All 2013 code 3 00:09:00 (17912)20052 00:09:03 (16150)18311 00:08:29 (7056)8206 00:08:57 (41118)46569
All 2012 code 3 00:08:24 (18285)20295 00:08:51 (16128)18249 00:08:27 (7017)8238 00:08:35 (41430)46782
All 2011 code 3 00:08:03 (17880)19774 00:08:32 (15501)17558 00:07:50 (6731)7799 00:08:12 (40112)45131
All 2010 code 3 00:07:54 (18161)19948 00:08:23 (15434)17571 00:07:50 (6698)7827 00:08:04 (40293)45346
All 2014 code 2 00:12:06 (3396)4823 00:11:48 (2602)3502 00:11:03 (1347)1724 00:11:51 (7345)10049
All 2013 code 2 00:12:11 (3768)4661 00:11:56 (2780)3496 00:10:40 (1325)1623 00:11:52 (7873)9780
All 2012 code 2 00:10:59 (3945)4712 00:11:41 (2735)3306 00:10:39 (1307)1573 00:11:10 (7987)9591
All 2011 code 2 00:10:50 (3784)4547 00:11:17 (2621)3161 00:10:09 (1308)1560 00:10:56 (7713)9268
All 2010 code 2 00:10:37 (3794)4589 00:10:51 (2520)3142 00:09:47 (1334)1603 00:10:35 (7648)9334
Data YR Code3 Central_90 Central_Count East_90 East_Count West_90 West_Count Total_90 Total_Count
EMS 2014 code 3 00:08:59 (17424)19526 00:09:01 (15642)17754 00:08:43 (6418)7368 00:08:57 (39484)44648
EMS 2013 code 3 00:09:00 (16867)18891 00:09:03 (14740)16760 00:08:29 (6257)7076 00:08:57 (37864)42727
EMS 2012 code 3 00:08:24 (17254)19163 00:08:51 (14843)16858 00:08:27 (5999)6849 00:08:35 (38096)42870
EMS 2011 code 3 00:08:03 (16958)18768 00:08:32 (14213)16177 00:07:50 (5866)6601 00:08:12 (37037)41546
EMS 2010 code 3 00:07:54 (17181)18853 00:08:23 (14248)16273 00:07:50 (5774)6562 00:08:04 (37203)41688
EMS 2014 code 2 00:12:06 (802)923 00:11:48 (642)733 00:11:03 (357)397 00:11:51 (1801)2053
EMS 2013 code 2 00:12:11 (1437)1571 00:11:56 (967)1099 00:10:40 (411)449 00:11:52 (2815)3119
EMS 2012 code 2 00:10:59 (1533)1673 00:11:41 (982)1099 00:10:39 (386)440 00:11:10 (2901)3212
EMS 2011 code 2 00:10:50 (1480)1607 00:11:17 (881)1000 00:10:09 (370)411 00:10:56 (2731)3018
EMS 2010 code 2 00:10:37 (1470)1598 00:10:51 (831)951 00:09:47 (406)437 00:10:35 (2707)2986
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AMR’s Demonstrated Response Time Performance
In addition, AMR has maintain compliance with all requirements during their time as your EMS provider. For example, from
January 1st of 2014 to December 31st of 2014, their response time compliance in the County was 94.10%. As a leading provider
of emergent and non-emergent medical transportation, all of our operations adhere to stringent response time requirements
as part of the commitment to the communities we serve. Please see the list of Urban, Suburban and Rural communities that
are similar to the County below.
Urban, Suburban, and
Rural Communities
January 1, 2014 -
December 31, 2014
Exclusive
Operating Area
(EOA)
Population AMR
Compliance
Contra Costa County YES 900,000 94.10%
Napa County YES 150,000 97.58%
San Mateo County YES 718,451 93.90%
Santa Cruz County YES 270,000 91.90%
Placer & Shasta Counties YES 750,000 91.22%
To further demonstrate our capabilities, we have provided examples of our Response Time Compliance reports as Exhibit No.
5.
In addition, you can view our response time compliance in the County at our website by visiting the following URL:
http://amrcontracosta.com/#/system-performance/response-time-data/
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D. DEMONSTRATED HIGH LEVEL CLINICAL CARE
Quality Improvement for Consistent, High Quality Clinical Care
Through our years of dedicated service, we have consistently demonstrated high level of clinical care in the County. We pledge
to remain committed to an operation of clinical sophistication, high levels of performance and positive patient outcomes.
To achieve this commitment, we will utilize our proven and reliable Quality Improvement (QI) program. The fundamental
objective of this program is to improve the quality of care delivered to our patients. We are committed to the highest EMS
performance possible and employ advanced, award-winning strategic planning and performance management techniques. Our
expertise in these disciplines has been helpful in developing the current systems in place in the County as well as throughout
California and the United States. Our program is built from a systematic assessment of core performance metrics and clinical
guidelines, as defined by the LEMSA, California EMS Authority, and National Association of EMS Officials. We also respect the
capabilities and desires for accountability and planning processes of our colleague EMS and public safety organizations, and
our QI program will interface, and work collaboratively, with LEMSA to be responsive to current and ongoing needs of the
system.
Our overall approach to QI includes four key segments following:
Segment I: Developing a Foundation of Care
Segment II: Monitoring the Care
Segment III: Local Quality Management Talent
Segment IV: The PDSA Cycle
We have developed and implemented a process that encourages collective problem identification and solutions from all levels
of our organization and the California community. Our locally-based Quality Improvement and Education Team will administer
this process under the ongoing guidance of our local Medical Directors.
For a quality program to support high-performance, it must provide people with the education, resources, timely support
needed for quality service and patient care. This is best accomplished through observation, review, discussion, and the
exchange of ideas when areas for improvement have been identified. We match educational offerings to systemic issues and
individual caregiver needs, based on leading indicators, ensuring effective and efficient behavior management.
Segment I: Developing a Foundation of Care
The first step in our QI process is to provide employees with performance expectations and give them the tools they need to
preplan their response to given situations, incidents and patient conditions. We do this through written patient care protocols,
evidence-based practice guidelines, clinical and operational policies, performance scorecards, and continuing education.
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The goal of our training methodology is to ensure our field personnel have the training, tools, and performance expectations
to meet the demands of high-performance EMS service. We begin with our new hire selection and skills verification process
and our comprehensive orientation program. Once out of orientation, it is imperative that we support our “learning
organization” and provide ongoing training and education to keep our personnel at the forefront of EMS care. In addition to
standardized initial training, we have a learning management system that streamlines certificate management and access to
online continuing education for our personnel. Our Quality Improvement and Education Team will utilize this system to
distribute locally developed courses created for the specific needs of our personnel. We welcome input from the LEMSA in
creating the curriculum for these courses.
Segment II: Monitoring the Care
We use a variety of monitoring tools to evaluate our services and identify clinical and customer service issues, allowing us to
develop the most effective solutions to ensure the best possible patient care and customer service. Our objective is to verify
and document clinical competency and performance improvement activities. The key monitoring and identification tools we
use are:
Data Collection and Analysis. Our clinical data is generated from our MEDS electronic Patient Care Report (ePCR) system. This
NEMSIS Gold compliant system allows for rapid real time and retrospective identification of issues at the individual level as well
as overall system performance as it pertains to clinical practice. MEDS is capable of sending messages to supervisors and even
caregivers notifying them of quality issues such as failure to use EtCO2 with an advanced airway. This system also gives
immediate notification of any sentinel event to clinical and operational leadership. Our data collection system is designed to
fit any data reporting requirements set by the County, giving applicable personnel real-time access to hundreds of customized
reporting metrics.
Peer Review. We schedule periodic peer review sessions, where our personnel retrospectively evaluates their colleagues’
cases to identify trends or issues. The review focuses on non-punitive approaches to education and system redesign to
decrease the perceived threat of openly discussing challenging situations.
Field Supervisor Evaluations. EMS Field Supervisors, selected for their leadership role based on clinical performance, spend a
majority of their time in the field, allowing them to observe personnel directly as they are caring for patients and interacting
with the public. The EMS Field Supervisors respond on calls with field personnel crews to observe, evaluate, and provide
support, as well as to review patient care reports for completeness, accuracy, and compliance to local protocols.
Segment III: Local Quality Management Talent
Every member of our leadership team plays a key role in our performance improvement process. In the County, this
responsibility starts with the Fire Chief. As our leader, he is responsible for setting strategic direction in conjunction with LEMSA
and LEMSA’s Medical Director. He gives direction to our local leadership and operations team, who is supported by our Quality
Improvement and Education Team and the EMS field supervisors. This group will work collaboratively to streamline our local
operation with the aid of local resources such as our Field Training Officer’s (FTOs) and various regional and national clinical
experts.
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The following committees and personnel play a key role in fulfilling our clinical and operational missions:
Quality Steering Committee. A key component of other successful partnerships has been the establishment of a Quality
Steering Committee. This committee would be chaired by the Fire Chief and AMR’s General Manager. They will be supported
by our operations personnel and Quality Improvement and Education Team. To ensure a system-wide approach, this
committee will also consist of the local Medical Director, various County representatives, and local hospital staff. Activities for
the Committee include reviewing system performance in all key areas, generating ideas for improvement projects, and guiding
and monitoring progress on improvement projects. Our overall focus is on system-wide performance for our patients and for
the community.
Field Training Officers (FTOs). Our FTOs play an important role in our quality program. Selected through a formal interview
process, the FTOs currently function under the guidance and direction of our Quality Improvement and Education Team.
Together they identify and develop training methods to implement new procedures, improve performance, and address
identified individual training needs. The FTOs function as the tactical unit for the implementation of clinical innovation and
performance improvement in our organization. They provide instruction in orientation programs, conduct field orientation for
new employees, assist in teaching in-service education programs, and provide ongoing field observation and mentoring for our
caregivers. In addition, the FTO role provides advancement opportunity for people seeking leadership experience and career
development.
Segment IV: The PDSA Cycle
We have adopted the Plan/Do/Study/Act (PDSA) cycle, a simple framework for responding to opportunities for performance
improvement. All of our performance improvement projects evolve through the PDSA cycle, described in detail below.
Plan. The Plan step involves identifying the goal for improvement. In other words, what are we trying to accomplish? We
identify interventions that might improve overall performance and measure the degree of improvement. Emphasis is on small,
incremental projects where results can be gathered and theories tested quickly. This small, rapid-sequence testing framework
is based on the successful work of the Institute of Healthcare Improvement (IHI).
Do. The Do step tests the intervention proposed and measures the results.
Study. The Study step compares the actual results of the intervention with those that were expected. In this step, we learn
whether or not the test had desired results.
Act. Finally, the Act step follows quickly after the study step. If the intervention had the desired effect, the appropriate action
is to adopt the intervention as the new standard process. If the intervention failed to meet expectations, it is appropriate to
adapt or simply modify the intervention, return to the planning step, and then repeat the PDSA cycle.
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Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
SECTION IV. CORE REQUIREMENTS
A. TWO SERVICE PLANS ARE TO BE ADDRESSED
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.A.
B. CONTRACTOR’S FUNCTIONAL RESPONSIBILITIES
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments contained
in Section IV.B. (1.-2.)
C. CLINICAL
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.C. (1.-2.)
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.C.3.
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Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
Through the Alliance’s experience serving the County, we currently maintain all minimum clinical levels and staffing
requirements as specified in the RFP. As your partner, we will continue to meet or exceed these standards.
Ambulance Staffing Requirements
We agree to staff a minimum of one (1) state licensed and locally accredited Paramedic and one (1) California EMT-Basic for all
transport units responding to requests from the County designated PSAPs. This Paramedic will be the ultimate responsible
caregiver for all patients and will accompany patients in the back of the ambulance during transports as required by protocol.
Personnel Licensure, Certification & Training Requirements
The success of any EMS system depends on the skill, experience, and character of its Paramedics, EMTs, and managers. All of
our ambulance personnel responding to medical requests will be appropriately licensed, accredited, and credentialed to
practice in the County. We strive not only to recruit and retain the best EMS personnel in the nation, but also seek to recruit a
diverse workforce that reflects the areas we serve. We will retain copies of current and valid licenses and/or certifications on
file at all times for all emergency medical personnel in the County. Our County personnel will be required to complete and
maintain many of the following training programs and certifications:
Required Trauma Training
We commit to maintaining the current County policy to have all County
Paramedics and Advanced EMTS certified in Pre-hospital Trauma Life
Support (PHTLS), International Trauma Life Support (ITLS) or a
comparable training approved by the EMS Medical Director(s). This
commitment will occur upon hire, and all credentials are tracked in our
credentialing database, currently handled by an online management
system. We will retain records of the training documentation and valid
certifications of all PHTLS or ITLS qualified Paramedics performing
services under this Agreement.
Required Pediatric Training and Performance
We commit to maintaining to continue to staff each ALS ambulance with a minimum of one (1) paramedic certified in Pediatric
Education for Prehopstial Personnel (PEPP) or Pediatric Advanced Life Support (PALS). This commitment will occur upon hire,
and all credentials are tracked in our credentialing database, currently handled by an online management system. We will
retain records of the training documentation and valid certifications of all PEEP or PALS qualified Paramedics performing
services under this Agreement.
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Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
Required Institute of Healthcare Improvement (IHI) Certificate of Patient Safety, Quality and Leadership
We commit that our Quality, Clinical and Supervisory personnel will complete an IHI Open School online certificate in Patient
Safety, Quality and Leadership. This commitment will occur upon hire or within eighteen (18) months for current personnel,
and all credentials are tracked in our credentialing database, currently handled by an online management system. We will
retain records of the training documentation and valid certifications for specific personnel under this Agreement. Currently,
our Quality Improvement and Education Team has completed this program.
Company & EMS System Orientation & On-Going Preparedness
We will ensure all new personnel are properly oriented before responding to an emergency medical request. Our new hire
orientation will include, at minimum, the following:
Contra Costa County EMS system overview
EMS policies and procedures including patent destination, trauma triage, and patient treatment protocols
Radio communications with and between the ambulance, base hospital, receiving hospitals, and County
communications centers,
Map reading skills, including key landmarks, routes to hospitals, and other major receiving facilities within the County
and surrounding areas
Ambulance equipment utilization and maintenance
Continual orientation of customer service expectations, cultural awareness, performance improvements and billing
and reimbursement processes.
Below, we have provided a description of our baseline orientation program that is currently utilized in the County.
Once selected for employment, each new employee undergoes a comprehensive orientation program, which includes
approximately ten days or 80 hours of classroom and hands-on instruction in company policies and procedures, local protocols,
and legal and compliance issues as well as specialized safety and risk management and disaster training. In addition, personnel
spend time as a third person on the ambulance and are mentored by Field Training Officers (FTO) for up to 240 hours to ensure
practical application and evaluation of all aspects of ambulance operation. Subjects addressed during orientation include the
following:
Company Structure Philosophy, Mission, and
Values
Quality Improvement Program (CQIP)
Injury and Illness Prevention Program
MCI Training & ICS/NIMS Training
Critical Incident Stress Management
Workplace Health and Safety
Violence in the Workplace
Diversity in the Workplace
Harassment-Free Workplace
Medical and Legal Guidelines
Emergency Vehicle Operations (EVOC) 16 Hour
Training
Customer Service
Mobile Data Terminal Instruction and
Communication
Dementia and Elderly Citizen Training
New Contract Equipment Training
EMS System Overview
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Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
Local Operational, Clinical and EMS Policy,
Procedures, and Protocols
ePCR/MEDS Training
Code of Conduct
Overview of Field Training
Human Resources: Benefits, Payroll, and
Scheduling
Patient Privacy/Confidentiality (HIPAA)
Tuberculosis Screening /Hepatitis B Immunization
Vehicle Maintenance
Documentation Standards
Equipment Use, Checkout, and Troubleshoot
Local County Geography Overview
Hazardous Materials and Weapons of Mass
Destruction
Preparation for Multi-Casualty Incidents
Training
All EMS Field Supervisors are trained in accordance with the Incident Command System, MCI response, Strike Team leader, and
hazmat operations. We will provide ICS Medical Command Levels 300 and 400 training to all of our EMS Field Supervisors. All
supervisors will attend one (1) disaster exercise and two (2) hours of disaster training per year. Management will be trained in
accordance with NIMS (100, 200, 300, 400, 700, 800) to provide staffing to Incident Command and EOC posts. Field staff will
be trained in PPE, Hazmat Awareness, NIMS (100, 200, 700, and 800), two (2) hours of additional disaster training per year, and
attend two (2) hours of annual disaster training to ensure interoperability with Fire and Law enforcement and one (1) annual
Communications Center evacuation drill.
Additionally, our New Hire Academy includes training, and as an enhancement for this proposal, we are requiring all new hires
to complete ICS 100, 200, 700, and 800 training within 90 days of hire. All members of our team will be trained in their roles
and responsibilities under the Contra Costa County Multi-Casualty Incident Medical Response Plan and will be prepared to
function in a medical role under the Incident Command System. In preparation for an MCI, AMR develops partnerships and
collaborative training as well as run drills. We work seamlessly with incident commanders to ensure that the best patient care
is provided under various field conditions and circumstances.
Assaultive Behavior Management Training
We agree to provide our personnel with the training, knowledge, understanding, and skills to effectively manage patients with
psychiatric, drug/alcohol or other behavioral or stress related problems. We teach a variety of skills and techniques to defuse
and manage potentially difficult scenes in the New Hire Academy as well as our “Hot Topics” and other ongoing education. Our
assaultive management training—a course called “Defusing the Assaultive Behavior”—is based on assessing four different
levels of behavior, learning each appropriate response to the respective level, and incorporating this new knowledge in role
play. There is an analysis of the trainee's personal tendencies (done individually) when in conflict and what happens when the
trainee is unprepared and frightened in a situation. While our focus remains on identifying and diffusing situations and
personality traits of individuals with assaultive behavior, we teach proven techniques to ensure violent situations are handled
safely for the patient, bystanders, and all responders on scene.
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Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
Driver Training
Following the classroom component, Emergency Vehicle Operating Course (EVOC) students move into eight (8) hours of
behind-the-wheel instruction in which they drive an ambulance under close observation. The hands-on field-training
component gives students the opportunity to practice the techniques taught in the classroom on a controlled course, under
the direct supervision of EVOC instructors. Students experience the forces involved in actual maneuvers and learn the
characteristics of the vehicles. The EVOC instructors provide feedback on their performance, begin to incorporate real
experience lessons, and give students ample time to practice their new skills. Training objectives for this part of the module
include the following:
Collision Avoidance – Split-second decision-making drills and simulations of potential accident conditions
Controlled Speed – Line-of-entry, hand positions on the steering wheel, apexing, vehicle dynamics, and braking
techniques
Precision Maneuvering – Parallel parking, off-set lanes, three-point turnaround, backing in and out of parking stalls,
and serpentines
Our EVOC program is designed to instill in personnel the internal motivation to continually learn and seek to improve their
abilities as professional emergency vehicle operators, thereby reducing the likelihood that an EVOC- trained driver will become
involved in a traffic collision. Injuries and even death can be averted by teaching true defensive driving and due regard for the
safety of others.
Infection Control
Our actions and philosophy about safety and communicable disease prevention go above and beyond industry norms because
we think of our personnel’ safety and health in relation to the health of our patients and our community. Traditionally, EMS
systems use “Universal Precautions” and “Personal Protective Equipment” to protect their providers from acquiring infections
while at work. We will continue these employee-protective practices and will also implement an expanded infection control
program aimed at decreasing cross-contamination among patients. Every employee receives training during our new hire
orientation on infection control, including how to use personal protective equipment as well as practices to reduce cross-
contamination between themselves and patients and patient-to-patient. We maintain a set of ongoing practices to further
reduce risk of infection and re-infection including the following:
Infection Control Training
Cleaning, Disinfection and Disposal
Sharps Exposure Prevention
Personal Protective Equipment
Post-Exposure Management
Respiratory Protection Program, including the Cal
OSHA 5199 Aerosol Transmissible Disease (ATD)
Standard
Employee vaccinations including H1N1 Flu
In addition, we provide all supervisors with a strong foundation in safety and risk management training. This training includes
instruction on how to handle and provide timely, proper treatment of blood and airborne pathogens as well as contact
exposures.
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Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
Critical Incident Stress Management
Through the Alliance, we maintain a group of peer counselors with specialized training in Critical Incident Stress Management
(CISM) to be available for personnel who need help following stressful and/or traumatic events. EMS Field Supervisors will
remain as the first point of contact for any issues. CISM is initiated by call-type in our computer-aided dispatch system, or by
request of employee. Immediately following notification of an incident where they may be needed, a CISM team member
and/or Supervisor responds to the scene or the hospital to hold a defusing session with the crew involved. Approximately two
days after the event, they also hold debriefings in a group setting to refresh coping skills and identify any additional help that
may be available. Personnel also receive one-on-one confidential aid from peers if they wish. The CISM program provides
stress education sessions for all EMS providers and will interface with other existing public safety and health care CISM
programs for additional resource support.
Homeland Security
We train our personnel to recognize and safely responds to homeland security issues including Weapons of Mass Destruction,
Nerve Agents, Post-Exposure Protocols, Incident Command Structure, and others in the New Hire Academy. Additionally, we
participate in National, State, and County drills. Our Supervisors and management personnel are trained in ICS levels for
medical command ICS 300 and ICS 400, and as an enhancement for this proposal, we require all personnel to be trained in ICS
100, 200, 700, and 800 within 90 days of hire. Our training conforms to the National Incident Management System (NIMS) for
training and operational purposes.
HIPAA Compliance
We are committed to strict compliance with all local and federal regulations regarding billing and collection. Reflecting our
long-standing commitment to protecting the privacy of the patients we treat and transport, we have established a
comprehensive HIPAA compliance program related to safeguarding protected health information (PHI). The requirements for
protecting patient privacy continue to evolve with the implementation of state privacy statutes and the recently enacted
HITECH Act. Our HIPAA Compliance Program remains well-positioned to meet the increased expectations of patient privacy
and electronic data security and includes the following:
A Privacy Officer to implement, oversee, and enforce the HIPAA program
A set of HIPAA compliance policies and procedures that provide all employee s with the appropriate procedures and
protocols to ensure compliance with the Privacy and Security Rule
Mandatory new-hire and annual HIPAA education and training for all personnel
A dedicated HIPAA Helpline number to report concerns or questions available to all personnel, patients and customers
and vendors
State-of-the-art information technology systems with encryption capabilities to protect the electronic patient data
maintained by our organization
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Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
Compliance
We transport patients each day. These transports range from emergency 9-1-1 calls and specialized critical care transports to
non-emergency wheelchair transports. It is imperative to us that our personnel are committed to ensuring compliance with all
of the regulatory requirements related to operating a company. The center of this commitment is the existence of the Ethics
& Compliance Program. This program is implemented by the Ethics & Compliance Department and is tasked with providing
personnel, contractors and third party vendors with the education and information needed to comply with the complex
healthcare regulations as well as the tools needed to compete for business with the highest level of business ethics and
integrity.
Ethics & Compliance Program
The Ethics & Compliance Program is based on the seven (7) elements of an effective compliance program published by the
Federal US Sentencing Guidelines as well as the recommended guidelines by the Department of Health and Human
Services. Our program is in accordance with the OIG Compliance Program Guidance for Ambulance Suppliers. The program
includes the following:
The existence of a Chief Compliance Officer to implement, monitor and evolve the Ethics & Compliance Program
Compliance Policies and Procedures that provide all personnel with information on regulatory requirements and
appropriate business practices and procedures
A Code of Business Conduct and Ethics, called Vital Signs
Education and training programs for all personnel including general compliance, HIPAA, Code of Conduct, and job
specific training related to billing, dispatch, communications and the anti-kickback statute
Monitoring and auditing processes to ensure compliance with all billing regulations including Medicare, Medicaid and
CHAMPUS regulations;
An Ethics & Integrity Helpline for personnel to report potential concerns anonymously
Disciplinary action and accountability for personnel determined to have violated compliance policies and procedures
Open lines of communication between personnel and management to assist with questions and potential concerns
These program elements help the Ethics & Compliance Department prevent, detect, and mitigate compliance issues within the
company as well as provide its personnel with the necessary tools to conduct themselves with the highest level of
professionalism.
For additional information or questions regarding our Ethics & Compliance Program, please feel free to contact our Chief
Compliance Officer, Mr. Ross Ronan at (303) 495-1263.
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Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
D. OPERATIONS
a) Emergency Response Zones
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.D.1.a.
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.D.1.a.
b) All Emergency and Non-Emergency ALS Ambulance Calls
c) Primary Response to Isolated Peripheral Areas of the EOA
d) Substantial Penalty Provisions for Failure to Respond
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments contained
in Section IV.D.1. (b.-d.)
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.D.2. (a.-b.)
a) Description of Call Classification
b) Response Time Performance Requirements
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.D.3. (a.-b.)
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Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
a) Summary of Response Time Requirements
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.D.3.c.
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.D.3.c.
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.D.4 and IV.D.5. (a.-i.)
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.D.6. (a.-c.)
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.D.7. (a.-b.)
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.D. (8.-9.)
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Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
E. PERSONNEL
A key benefit of selecting the Alliance is that the County will retain the
incumbent workforce who have built and maintained strong relationships
throughout the County. Because most of our personnel live and work in the
communities we serve, they are passionate about providing professional,
courteous service at all times. Also, we pledge to continue to seek to recruit
and retain the best personnel in the nation. We are dedicated to providing
our personnel with a work environment built on respect, integrity, and
service. This is evident by our high retention rates.
Employee retention begins with recruiting the most highly qualified individuals to fill the roles required. In most of our
communities, we have “waiting lists” of potential personnel. People want to work for our companies because of our reputation
in the industry, our employee-centered programs, a competitive wage and benefit package, and management’s commitment
to providing a quality place to work - no matter where or when they work.
Compensation & Benefits
The Alliance will offer to our employees a compensation and benefits package designed to attract and retain highly qualified
field personnel and communications center personnel. We have provided information on our compensation and benefits
package in the following response.
Our workforce and their families will enjoy the ability to select benefits that meet their individual and family needs. In addition
to our benefits package, we offer the incumbent workforce compensation consideration based on time served with the current
employer. Our wages, earnings and benefits are considered among the most competitive offered by medical transportation
providers. Our core benefits package for full-time personnel includes the following:
Medical, dental, and vision plans, with dependent coverage available
The majority of employee healthcare coverage cost is assumed by our organization
Life insurance and accidental death and dismemberment insurance at two times the employee’s annual base salary,
with the option to purchase supplemental coverage
Company-paid long-term disability insurance and optional short-term disability insurance
Paid time off, escalating with years of service
A flexible spending program, allowing personnel to use pre-tax dollars to pay for dependent care and qualified
healthcare expenses
Eligibility for personal leaves of absence for education purposes
401(k) retirement plan with an employer match
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Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
All full-time and part-time personnel also receive the following benefits:
In-house continuing education available through sponsored courses
Uniform sets, as well as replacement uniforms
Employee Assistance Program (EAP) to support employees with family issues and financial concerns
Critical Incident Stress Management Program to mitigate the personal and professional impact of critical incident
stress
A Web-based employee portal, which provides employees with not only information and an on-line store, but also
interactive training modules, benefits management services, and electronic communities for mutual support
Paid Leave
We offer paid leave to our employees; there are a number of ways to use paid leave:
Paid Time Off (PTO): Paid time off is granted to all of our full-time employees. Accumulation of paid time off can range
from two weeks per year for newly-hired employees and up to six weeks per year for an employee who has been with
the company for more than 11 years. As one of the leading health care providers in the nation, we acknowledge the
importance of maintaining our team members’ health and well-being. We also understand the significance of having
periods of rest and relaxation
o At all times, we encourage our employees to use PTO time they have accrued during the year. Paramedics,
EMTs and Dispatchers have the opportunity to cash-out accrued time should they desire
Holidays: We have eight paid holidays a year: New Year’s Day, Martin Luther King, Jr Day, Memorial Day, Independence
Day, Labor Day, Thanksgiving Day, the day after Thanksgiving, and Christmas Day. If an employee works on a
recognized holiday, they are paid premium pay
Leaves of Absence: We recognize all leaves allowed by law, including medical, family, military, bereavement, jury duty,
and personal. According to applicable state and federal law, we provide benefits for these employees
Additional Benefits
Our benefits package includes a variety of other programs designed to enhance the well-being of our team members. These
programs include:
Back injury prevention program
Return-to-work program
Harassment-free workplace program
Workplace violence prevention program
Employee wellness programs that include reduced-fee health club memberships
Discounts on personal motor vehicles, cell phone contracts and numerous other products and services (even back-to-
school supplies)
Group rates on auto, homeowner, and legal insurance
Tuition reimbursement
Pet insurance
Our comprehensive benefits package and exceptional wages provide our team members with a total compensation value that
is extremely competitive, ensuring employee satisfaction and workforce stability in the County.
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Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
Employee Assistance Program
We are involved in a variety of programs designed to support the mental well-being of our personnel and their families. These
programs are provided at no cost to eligible personnel. All personnel and their immediate family members are entitled to use
this assistance program. The Employee Assistance Program (EAP) is designed to help with any type of personal problem(s) that
may be affecting their life (i.e., alcohol/drug use, physical abuse, emotional problems, etc.). This service is completely
confidential and can be used 24/7.
The EAP also provides life-management consultation services in a variety of areas, including federal tax consultation, legal
matters, and financial problems. In addition, it acts as a supplement to other mental-wellness programs, such as the chemical
dependency recovery programs, included in the health plans described previously.
Employee Input & Recognition
We will hold monthly open forums to hear concerns from the local workforce. We make it clear that the opinions of our team
members truly matter and take every step to address ongoing ideas and concerns presented by personnel. For any specific
issues within our operations that may not be addressed in the open forums, we will utilize Guiding Teams, which was discussed
earlier in our proposal. This program empowers our personnel to bring forward new ideas and collaborate in ways that will
bring renewed energy and excitement to our local operation. Our personnel often go above and beyond the scope of their
everyday responsibilities, and we value, encourage, and celebrate this level of initiative. Both the company leadership and
peers recognize crews that provide exemplary service, and their efforts are highlighted in our monthly employee newsletter
as an example for others to follow. These crews also often receive commendations from local government agencies and
community service organizations.
Extracurricular Activities
Our management provides personnel with the opportunity to build relationships outside of the workplace. Examples of
employee relation efforts include the Running Team, competitive food challenges, and various charity events that benefit the
local community in which personnel work and live. Below, we have provide examples of our extracurricular activities.
Running Team (developed in conjunction with the
Change of Pace Foundation)
Competitive nutrition challenges
Heart Walks
Cancer Walks
Toys for Tots
CPR Challenge
Feed a Needy Family
Home for Christmas
And various charity events that benefit the local
community in which personnel work and live
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Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
One example of recent community classes and training is our involvement in the CPR World Challenge. The numbers are
staggering. Every year, almost 350,000 Americans are victims of Sudden Cardiac Arrest (SCA). Research has shown that if more
citizens were trained in CPR, more people would live. We saw that as a challenge, and on May 21, 2014, in honor of EMS Week,
80 of our operations in 40 states and two international operations in India and Trinidad and Tobago hosted the second annual
World CPR Challenge. Our teams trained an astounding 61,883 people, including 1,000 individuals in the County.
The goal of the World CPR Challenge was to train as many people as possible in compression-only CPR in one day. We
accomplished that goal, and in so doing made the communities it serves a little safer. Our teams trained more than 60,000
people how to save lives using compression-only CPR, a new technique that does not require mouth-to-mouth resuscitation.
Compression-only CPR takes a short time to learn and has been shown to improve
Sudden Cardiac Arrest (SCA) survival rates. Our caregivers trained people at
schools, businesses, YMCAs, and numerous other locations. They trained
elementary school students, teens, adults, and grandparents. Training was
provided in small groups by the thousands.
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.E.1.
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.E.(2.-5.)
F. MANAGEMENT
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.F.1. (a.-d.)
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Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
G. EMS SYSTEM AND COMMUNITY
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.G. (1.-2.)
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.G. (3.-4.)
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.G. (5.-6.)
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.G. (7.-8.)
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Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
H. ADMINISTRATIVE PROVISIONS
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.H.1.
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.H.2.
As your partner, we will not be requesting a subsidy for this contract.
Plan A vs. Plan B
The EMS Modernization Project Report issued June 2014 (Conducted by Fitch & Associates) outlined
several issues that “could” make the current system unsustainable. One of the items listed was the
closing of an area hospital that would greatly impact the EMS system and ambulance task times.
Since that time the system has in fact seen such a closure with an increase in required ambulance
unit hours to remain compliant. For this and other reasons listed below, CCCFPD and AMR believe
that Plan “A” represents the best option for the residents and visitors of the County.
Our submission under Plan “A” provides shorter response times than provided for under option B and we believe that is what
the public wants and demands. Our submission addresses the concerns that the LEMSA has for system sustainability, while
simultaneously providing what the public wants in their ambulance delivery model, which is an efficient, cost-effective
emergency response. Our plan is designed to meet the public’s desire and does not require any subsidy from the County.
We have also provided a Plan “B” that includes longer response times for responding ambulances, thus decrease the cost of
providing the service through reduction of unit hours. We would like to highlight that this plan comes at a significant cost to
not only the patient that is required to wait longer for the arrival of the ambulance but also the County’s first responders from
all agencies as they will be required to remain on scene until the ambulance arrives. This includes all first responder such as
fire, police, sheriff and highway patrol. Diminished resources due to increased response times for transport providers is not
in the best interest of any of the County’s stakeholders. Our submission of Plan “A” provides for all the needs identified in the
modernization report at no cost to the County.
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Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.H.2.
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.H. 3. (a.-b.)
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.H. (4.-10.)
Through the Alliance, we meet all insurance requirements specified in the RFP.
CCCFPD’s Insurance
CCCFPD has provided a copy of our certificate of insurance as Exhibit No. 1 of this proposal’s Exhibits Binders.
AMR’s Insurance
AMR offers a full range of insurance coverage to reduce the financial risk to the company and our contracted customers,
exceeding the minimum RFP requirements in several areas. Our professional liability coverage is $20 million per occurrence
and $20 million aggregate, and our general liability coverage is $3 million per occurrence and $6 million aggregate. We maintain
medical malpractice coverage in the form of a $20 million excess policy with a $3 million SIR. Our auto policy has a $5 million
combined single limit and $10 million aggregate, and our worker’s compensation policy is for statutory limits plus a $1 million
employer’s liability policy. All of our policies have deductibles or self-insured retentions that are higher than $10,000. We do
not provide copies of the policies, as it is against our company policy to do so because of the proprietary nature of the
information that they contain. For a copy of our certificate of insurance, please see Exhibit No. 1.
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Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.H. (10.-16.)
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.H. (17.-23.)
We have thoroughly reviewed and agree to all general provisions of the contract, taking no exceptions.
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section IV.H.24 (a.-o.)
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Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
SECTION V. COMPETITIVE CRITERIA
A. CLINICAL
a) Minimum Requirements – Demonstrable Progressive Clinical Quality Improvement
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section V.A.1.a.
Through the experience of the Alliance, we are committed to the operation of a comprehensive clinical quality improvement
process guided by quality leadership. The fundamental objective of this program is to continually monitor a nd improve the
quality of care delivered to our County patients.
LEMSA sets standards and defines the clinical indicators for the entire EMS system in collaboration with First Responders,
receiving hospitals, and the Contractor. We are committed to provide the most robust EMS data and to supporting LEMSA’s
quality monitoring. We have processes in place to ensure that we provide the Core Measures data. In addition, we will continue
to work with LEMSA to develop improvement plans. We look forward to working with the County caregivers and commit to
the same collaboration, cooperation and commitment to clinical excellence we have demonstrated in practice and describe
here.
We are committed to clinical excellence that incorporates high performance standards using advanced, evidenced-based
techniques. For example, all STEMI, Stroke, Pediatric, Burn, and Trauma activations are audited. Feedback is provided to the
Paramedic who authored the report and feedback is provided for either improvement or encouragement to continue the same
standard of care and documentation.
Another example is our commitment in the collection and review of CPR analytic data for sudden cardiac arrests. This is
completed by evaluating CPR annotations that are conducted by LEMSA and reviewed by our clinical coordinator(s). The CPR
annotations are then scored, and sent out to the field personnel with feedback provided. An incentive program has been
developed to reward those personnel who show above average performance in resuscitations. The communities that are ready
to utilize the powerful combination of physiologic data collected from our monitor/defibrillators and performance data, are
able to transmit ECGs to a cloud based application where CPR quality is assessed and metrics (the CPR Quality report) returned
to the clinical leaders and crews in a short turnaround period. Our expertise in cardiac arrest as well as other disciplines has
helped us to develop the current systems that will be used to demonstrate ongoing clinical quality improvement in the County.
We will follow the lead of LEMSA and respect the capabilities and desires for accountability, sharing of responsibility and data,
and planning processes of our colleague EMS and public safety organizations.
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Clinical Quality Improvement Program
Our overall approach to clinical quality management includes the following four key segments:
Segment I: Developing a Foundation of Care
Segment II: Monitoring the Care
Segment III: Local Quality Management Talent
Segment IV: The PDSA Cycle
We will continue to work with LEMSA and all system participants to implement
and maintain a comprehensive CQI program. As your partner, we have developed
and maintained a customizable process that encourages collective problem
identification and solutions from all levels of our organization, including the
County EMS community. Our Quality Improvement and Education Team will
administer this process under the guidance of LEMSA Medical Directors and our
Medical Directors, with ongoing input from our Quality Steering Committee.
For a CQI program to support a high-performance system, it must provide people with the education, resources, and the
support needed for quality service and patient care. This outcome is best accomplished through observation, data collection,
review, discussion and the exchange of ideas when areas for improvement have been identified. We match educational
offerings to systemic issues and individual caregiver needs, based on leading indicators, ensuring effective and efficient
behavior management.
Segment I: Developing a Foundation of Care
Our first step in our quality process is to provide personnel with expected performance standards and ensure they have the
tools they need to preplan their response to given situations, incidents and patient conditions. We do this through written
patient care protocols, evidence-based practice guidelines, clinical and operational policies, performance scorecards, and
continuing education and training.
During the new hire selection process and comprehensive orientation training program, we ensure our field staff have the
training, tools, and performance expectations necessary to meet the demands of high-performance EMS service. Once out of
orientation, it is imperative that we create a “learning culture” and provide ongoing training and education to ensure our
caregivers remain at the forefront of EMS care. We offer a catalog of clinical and operation learning opportunities on a myriad
of topics that are available from our SuccessFactors platform.
There are different learning opportunities in SuccessFactors, including high quality resuscitation skills, Crew Resource
Management during Resuscitation (Pit Crew) current status of targeted temperature management for cardiac arrest victims,
and the importance of bystander CPR including assertive dispatcher-assisted CPR instructions.
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In addition to video-based educational content, we have a company-wide learning management system that streamlines
certificate management and access to online continuing education for our personnel. Our Quality Improvement and Education
Team will utilize this system to distribute locally-developed courses created for the specific needs of the personnel of the
County.
Segment II: Monitoring the Care
Our CQI program is designed specifically to ensure every patient receives the best care and customer service possible. To do
this, we utilize a variety of monitoring tools to evaluate our services and identify clinical issues, allowing us to develop the most
effective solutions and ensure the best possible patient care.
The key monitoring and identification tools we use are the following:
Data Collection and Analysis – Our clinical data is generated from our MEDS/ePCR system. Our Medical Directors and
Quality Improvement and Education Team have access to the monthly performance improvement measurement tools,
which currently track core measures for the Things that Matter, our current set of process improvement metrics. This
NEMSIS-compliant ePCR system allows for rapid real time identification and retrospective review of individual-level
issues and overall system performance. MEDS is capable of sending messages to supervisors and even caregivers
notifying them of quality issues such as failure to use EtCO2 monitoring with an advanced airway. This system also
gives immediate notification of any sentinel event to clinical and operational leadership. Our data collection system is
designed to exceed data reporting requirements set by LEMSA.
Field Training Officer (FTO) Audits — Along with the peer review group, our FTOs will randomly audit field
documentation, reviewing both stored records and performing random real-time audits in the field with our
caregivers. Documentation excellence is currently one of our major initiatives.
Observation and Evaluation -- Field supervisors, selected for their leadership role based on clinical performance,
spend a majority of their time in the field, allowing them to directly observe their colleagues as they are caring for
patients and interacting with the public. The supervisors respond on calls with field crews to observe, evaluate, and
provide support, as well as reviewing patient care reports to ensure completeness, accuracy, and compliance to local
protocols. EMS Operation Managers and EMS Field Supervisors will follow up with the Quality Improvement and
Education Team on observed issues as well as address these issues with personnel.
Customer Feedback – An important part of evaluating our collective performance is soliciting feedback from those
individuals and organizations we interact with as part of the system. This includes our patients, receiving hospital
staff, Law Enforcement and Fire Department staff, County officials, and the medical community. Customer surveys
are mailed to our patients and entered into a database to enable trend recognition and provide feedback to our
personnel.
Segment III: Local Quality Management Talent
Every member of our leadership team plays a key role in our quality management process. In the County, this responsibility
starts with Fire Chief. As the key leader for our Contra Costa County operation, the Fire Chief will lead our management team,
setting strategic direction in conjunction with our local Medical Directors and key LEMSA personnel. Supporting the Fire Chief
is our Operations leadership personnel and Quality Improvement and Education Team, who will work collaboratively to
streamline our local operation and will be supported by local resources such as our Field Training Officer’s (FTOs) and various
regional and national clinical experts. Moreover, our quality improvement processes involve all our caregivers and responders.
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We provide care to the same patient, even if we do wear different uniforms. The following committees and personnel play a
key role in fulfilling our clinical mission:
Quality Steering Committee: A key component of other successful partnerships has been the establishment of a
Quality Steering Committee. This committee would be chaired by the Fire Chief and AMR’s General Manager as well
as supported by our operations personnel and Quality Improvement and Education Team. To ensure a system-wide
approach, this committee will also consist of the local Medical Director, various County representatives, and local
hospital staff. Activities for the Committee include reviewing system performance in all key areas, generating ideas
for improvement projects, and guiding and monitoring progress on improvement projects. Our overall focus is on
system-wide performance for our patients and for the community.
Peer Review Committee: All of our personnel are encouraged to become involved in making improvements. Our Peer
Review Committee plays an important role in overall quality for our local operation, from evaluating new equipment,
to providing feedback on new protocols, fine-tuning deployment plans, and assessing the performance of our
caregivers. Peer involvement is an important component of engaging personnel. By having personnel involved in all
these elements, they are able to “own” new concepts, procedures, standards, and other progressive activities, and
are actively engaged in improving the system and the overall quality of care. As the day-to-day frontline caregivers,
these personnel often hold the key to innovative solutions for challenging issues
Field Training Officers (FTOs). Our FTOs play an important role in our CQI program. Selected through a formal
interview process, the FTOs currently function under the guidance and direction of our Quality Improvement and
Education Team. Together they identify and develop training methods to implement new procedures, improve
performance, and address identified individual training needs. The FTOs function as the tactical unit for the
implementation of clinical innovation and performance improvement in our organization. They provide instruction in
orientation programs, conduct field orientation for new personnel, assist in teaching in-service education programs,
and provide ongoing field observation and mentoring for our caregivers. In addition, the FTO role provides a
promotional opportunity for people seeking leadership experience and career development
Segment IV: The PDSA Cycle
We have adopted the Plan/Do/Study/Act (PDSA) cycle, a simple framework for responding to opportunities for improvement.
All of our process improvement projects evolve through the PDSA cycle.
The “Plan” step involves identifying the goal for improvement. In other words, what are we
trying to accomplish? We identify interventions that might improve overall performance, as
well as metrics that measure the degree of improvement. Emphasis is on small, incremental
projects where results can be gathered and theories tested quickly. This small, rapid-
sequence testing framework is based on the successful work of the Institute of Healthcare
Improvement (IHI)
The “Do” step tests the intervention proposed and measures the results
The “Study” step compares the actual results of the intervention with those that were expected. In this step, our
company learns whether or not the test had desired results
Finally, the “Act” step responds quickly after the study step. If the intervention had the desired effect, the appropriate
action is to adopt the intervention as the new standard process. If the intervention failed to meet expectations, it is
appropriate to adapt or simply modify the intervention, return to the planning step, and then repeat the PDSA cycle
e
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b) Higher Levels of Commitment – Quality Management
Through the Alliance, we are the only provider that can offer the County a proven and reliable quality management
program. This experience equips our personnel with a unique understanding and familiarity of the County’s citizens’ needs,
affording us the opportunity to effectively evaluate our current CQI program and make appropriate adjustments as needed.
In addition, the Alliance’s integrated approach offers the County pathway management from the
moment a call is received by our dispatcher to the moment a patient is transported safely to the
hospital. Through our shared methodologies and resources, this integrated approach will enhance
our quality management and our ability to ensure a positive patient experience, while meeting or
exceeding the County’s emergency ambulance service needs. Below and on the following pages, we
have outlined our higher levels of Commitment for Quality Management.
Commitment to a Comprehensive Model of Quality Management
As noted in the RFP, the majority of American EMS systems limit their quality management processes to retrospective
evaluation of patient care reports. Even more problematic, is that some EMS systems limit their review to a “put out the fire”
approach where cases are only reviewed when a concern has been raised, usually by an outside agency or hospital.
We are presently building an internal CQI approach that favors prospective and concurrent review in addition to retrospective.
Current targets include high-frequency, high-risk cases such as cardiac arrest, stroke, STEMI and severe trauma as well as low-
frequency high-risk cases, such as pediatrics or endotracheal intubation. Retrospective review is performed as a combined
effort between our Quality Improvement and Education Team and Medical Directors.
Our CQI program is fundamentally designed to evaluate and optimize structure, process and outcome, i.e. the Donabedian
model. Prospective and concurrent review is performed by our Quality Improvement and Education Team and Medical
Directors, through education and identification of areas of potential need, as well as during active ride-along and field response
by our medical director. We have found these to be a powerful tool in helping us to identify potential opportunities for
education and improvement that are otherwise not detectable by simple chart review. This extra level of physician involvement
in the field with crews has been invaluable for our CQI process and has been very well received by the crews. It also is the only
way to fully evaluate the structure, processes and outcomes of our system. A clear picture of a system’s complexities cannot
be gleaned from simple review of data.
In addition to intensive review with crews in whom opportunity for improvement has been identified, we are also directing
educational efforts at high yield topics to improve the quality of the system at large. For example, two (2) of our KPI metrics
are compression fraction and rate in cardiac arrest. The evaluation process includes reviewing the cardiac arrest assessment
reports provided to us by the LEMSA, determining the quality based on those metrics, and then performing focused reviews
with the crews who performed the patient care, particularly when an opportunity for improvement has been identified.
Simultaneously we have ongoing educational efforts to the department at large to reinforce the importance and rationale
behind the quality measures that we are using. These reviews are performed in person with the crew at their station and
attended by our Medical Directors and Quality Improvement and Education Team. We are finding that this type of near real-
time feedback is welcomed by the crews.
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Additionally, we are in the process of developing a comprehensive review program that will incorporate EMSA Core Measures
as well as local protocol adherence. This review process will include formulated Microsoft Excel worksheets that will measure
fractal and percentile performance. To facilitate this program we are working to create a pathway to populate treatment data
into the worksheets to create weekly comprehensive reports.
We recognize that a shift has occurred in first response and pre-hospital care, and with the introduction of Paramedics in the
Fire Service, we have transitioned from being a group who provides first aid as a secondary added value to being licensed and
accredited healthcare professionals. As such we are held to a high standard of care.
Responder and patient safety are always the first priority when responding to and managing any emergency. Training,
education, communicable disease policy, medical waste management, immunizations, annual physicals and personal protective
equipment are several ways in which we provide for the safety of our personnel and patients. Our approach to safety includes
the safety of all responders. This outcome is achieved by a Company Officer serving as the Incident Commander on all calls,
maintaining situational awareness at every scene. This model will not only be continued but enhanced through the Alliance,
with the ultimate goal of increasing the safety of everyone.
The healthcare system is in the midst of a comprehensive structural overhaul in the United States. At the same time, essential
services need to remain intact to provide continuity of care during this major renovation. We are also under pressure to derive
greater value for the resources devoted to their service delivery model. Aging populations, increased longevity, and chronic
health problems are not going to go on hiatus while a new system is developed. We recognize that our all hazard service has
moved us into the field of healthcare and we are proud to assume the identifier of healthcare professionals. It is going to be
essential to maintain the ability to continue to provide quality care while we evolve to define a more efficient model of service.
In the meantime, we will remain the constant safety net that much of the public relies on for entrance into the healthcare
system.
Approach
We are in a unique position where our longstanding presence in the community, along with our valuable organizational
foundation and infrastructure can be the cornerstone of a more efficient delivery system emphasizing the Triple Aim. We
believe that we need to address all three of the Triple Aim dimensions at the same time.
The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement
that describes an approach to optimizing health system performance. It is IHI’s belief that
new designs must be developed to simultaneously pursue all three dimensions of the “Triple
Aim”:
Improving the patient experience of care (including quality and satisfaction)
Improving the health of populations
Reducing the per capita cost of health care
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We can improve the health of populations by leveraging our ability to partner with other healthcare departments within the
County that will allow for identification of target populations and help define system aims and measures that are adapted to
meet local needs and conditions. For the Alliance to do this work effectively, it is important to harness a range of community
determinants of health; empower individuals and families; substantially broaden the role and impact of primary care and other
community based services; and, assure a seamless journey through the whole system of care throughout a person’s crisis. This
narrowing down of redundant providers will create an opportunity to carry those patient experiences and outcomes to their
healthcare records through advanced technological processes. It is important to emphasize that we will work collaboratively
with other essential services, not in place of. We offer a 24 hour standing workforce who has the capacity to fill in the gaps
after traditional staffing hours and on weekends making essential services and follow up much more simple to achieve.
Our role in reducing the per capita cost of healthcare will be realized by taking advantage of future community paramedic
models where paramedics can make proactive scheduled visits to chronic or recent hospital discharge patients, thus reducing
the need for transport for an emergency room visit. Savings will be experienced by the reduction of ambulance transports.
Those dollar savings are in line with CMS efforts to reduce total health care cost.
Benefits to an Approach in Line with the IHI Triple Aim
Organizations and communities that attain the Triple Aim will have healthier populations, in part because of new designs that
better identify problems and solutions further upstream and outside of acute health care. Patients can expect less complex and
much more coordinated care and the burden of illness will decrease. Importantly, stabilizing the Alliance and its EMS delivery
model will provide a robust system that will not only provide for the daily system needs but will build in a depth of service that
will meet the needs of abnormally high demands and disaster services. Additionally, community service programs such as
citizen CPR, pre-season cardiac screening for high school and college athletes, and partnerships with prevention programs will
come together to achieve overall better health for our communities.
To deliver on the Triple Aim, our approach to EMS delivery is based on reliability, customization, access, and coordination of
care. We will work towards effectively delivering the Triple Aim by providing a tiered implementation of this service which will
include the following:
Unity of command – to streamline communication and patient care
Establishing working relationships with other public health providers – to improve overall community health
Integration communication and resource tracking – reduce overall system cost
To continue the use of first responder squads – to improve patient care and reduce overall system cost
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Institute for Healthcare Improvement (IHI) Open School
Developing the next generation of leaders is critical for the long-term success of any organization, especially one such as the
Alliance, which is labor-driven and strives to promote within whenever possible. Within 18 months of contract commencement,
all full-time staff dedicated to quality management and education will complete the IHI Open School Basic Certificate.
Currently, our Quality Improvement and Education Team have completed IHI Open School program. As your partner, we will
continue to enroll our personnel in this program.
The IHI Open School program is designed to advance healthcare improvement and patient safety competencies in the next
generation of health professionals worldwide. Launched in September 2008, the IHI Open School provides students of
medicine, nursing, public health, pharmacy, health administration, dentistry, and other allied health professions with the
opportunity to learn about CQI and patient safety. The online, educational community features a growing catalog of online
courses, extensive content and resources, and a network of local chapters that organize events and activities on campuses
around the world. We will enroll our Quality Improvement and Education personnel, EMS Operations Managers, EMS Field
Supervisors and FTOs in the IHI Open School program.
Technology Advancements
As you partner, we are positioned to offer the County the following:
Fire MEDS
Our San Mateo operation is in the implementation stages of a new, innovative ePCR data collection
software called “Fire MEDS.” The program software was designed by recognized external software
development companies, supported by our development team and most importantly guided by a
team of local fire paramedic first responders. The goal of this program was to create first responder-
specific ePCR data collection software that enables the ability to document and share data with the
transporting agency’s MEDS ePCR platform. Additionally, this software operates on Apple iPad
hardware, enhances user experience, and supports clinical reporting.
Fire MEDS will benefit first responders in the following ways:
User friendly design
Fast - PCR completion flows logically with the care provided
Photo integration into the ePCR of trailing documents such as the ECG
Data reporting for clinical improvement functions and electronic viewing of the ePCR
Capability if desired to complete ePCR on-scene and transmit
Capability to facsimile transmit ePCR to hospital
Meets NEMSIS 3 GOLD standard of data collection
If awarded the contract, we are willing to implement a similar program with all Contra Costa County fire agencies who respond
in the EOA.
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Tableau
Our business intelligence-reporting interface, Tableau is a powerful data visualization and analytics software program that is
central to our compliance-reporting system. Tableau gives us the ability to respond to dynamic situations in real-time with
data-driven decision-making and allows our front-end managers to report a variety of different elements within the system
that are not typically captured in a regular reporting system including data, billing, and payroll. The following are some ke y
benefits of Tableau:
Creation of meaningful and actionable representations of complex data from multiple sources.
Addresses challenges ranging from real-time operations management to retrospective performance reporting, to
include national KPI reporting
Analyzes CAD data so we can better understand the root causes of compliance issues
User-friendly and intuitive
Tableau’s variety of capabilities has numerous positive impacts on our overall performance, but ultimately will ensure that we
continue to exceed the County’s needs.
Other Quality Management Measures
Through the Alliance, we are able to maintain and evolve the quality management programs in practice in the County. The RFP
encourages proposers to exceed minimum requirements, especially in Clinical Quality management. Our expanded scope of
clinical quality management exceeds the minimum requirements in several important ways, beginning with the aspects
suggested in the RFP and ending with six (6) enhancements unique to the Alliance:
AMR Foundation for Research and Education (AMR FRE)
AMR Medicine™, which serves as a philosophy of clinical care for our patients. Through the Alliance, we strive to
ensure our patients receive the best evidenced-based care.
Pairing Clinical Performance Indicators with Education Systems
Incorporation and Pursuit of National Quality Recognition Programs including the Baldridge Award and Institute for
Healthcare Improvement Initiatives such as “Open School.”
Partnership in the HeartRescue Project, a five-year commitment to improve survival from sudden cardiac arrest in the
communities we serve. This partnership is accompanied by a 5-year grant from the Medtronic Foundation, the
philanthropic arm of the Medtronic Corporation. Grant funds are used to improve survival from sudden cardiac arrest
in the communities served by AMR. The County would be eligible to apply for a grant if so desired.
Project, a five-year commitment to improve survival from sudden cardiac arrest in the communities we serve.
Every initiative, program and process we implement is aimed to improve the overall health of our patients; they are our number
one focus. This mindset brings robust national and local resources together in executing clinical quality improvements. We
bring the full scope and scale of our performance management programs and processes to achieve clinical excellence in the
County.
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AMR Foundation for Research and Education (AMR FRE)
We have recently established the AMR Foundation for Research and Education (AMR FRE). This 501c3 foundation is funded
both by grant funds awarded to us and by charitable donations from individuals and organizations. The AMR FRE funds are
used to support personnel who wish to conduct and present individual research projects at local and national EMS meetings,
and to foster educational opportunities, such as some of the programs offered by the Institute for Healthcare Improvement.
AMR Medicine™ – Our National Program for Medical Excellence
EMS is a practice of medicine. An important part of any medical practice is an ongoing commitment to measuring performance
and implementation of appropriate actions based on the analysis of that performance. AMR Medicine™ is the culture that
drives the clinical care we provide in every community we serve. Every initiative, program, and process we implement is aimed
to improve the overall health of our patients; at all times, they are our number one focus.
AMR Medicine™ provides the benefits of robust national and regional resources, as well as a unique
ability to share best practices between local operations. We have developed a clinical quality
management program that has proven to be extremely valuable in the County.
The advantage of our national size and diversity is that it allows for significant expertise in all facets of the art and science of
out-of-hospital care. Emphasizing our commitment to continually use best practices to improve our patient care, our team will
continue to be supported by, and will become part of, several of our organization’s national clinical leadership groups. These
groups provide expert direction and oversight for process improvement efforts in strategic planning, patient/community focus,
staff focus, measurement and analysis, process management, and organizational performance. Additionally, the groups have
identified content-area experts that have made themselves available to our operations in other communities to assist with
program implementation. Examples include the implementation of the Cardiac Arrest Registry to Enhance Survival (CARES)
data initiative, which links process measures to actual patient outcome, and the evaluation of advanced airway techniques and
devices. The groups themselves are composed of designated leaders from operations all over the country. Unique in the
industry, these groups provide an unparalleled resource to all operations.
Clinical Leadership Council
The Clinical Leadership Council (CLC) is composed of clinical and educational services leaders representing all regions within
our company, including a few of our key personnel, and key representatives from our clinical data and education teams, our
Vice President of Clinical Practices and Research, AMR’s Chief Medical Officer, and Senior Vice President of Professional
Services. The CLC uses national clinical data in concert with contemporary medical literature to identify quality improvement
initiatives as well as the strategies, programs, and standards necessary to achieve desired clinical results. This committee has
been instrumental in developing training tools and guidelines for clinical and safety programs across the company.
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Research Partnerships
We have partnered with multiple academic institutions to participate in emergency medical services research. For example, in
March 2014, the following evidence-based guideline for EMS was published in Prehospital Emergency Care with input from
AMR’s national clinical leaders, “An Evidenced-Based Prehospital guideline for External Hemorrhage Control: American College
of Surgeons Committee on Trauma.” We have collaborated with Dr. Daniel Patterson from the University of Pittsburgh on
clinical safety initiatives, with Drs. Dan Spaite and Ben Bobrow on the ACTIONS study to improve survival from sudden cardiac
arrest. Additionally, we support research in local practices that has assisted many local operations to develop research
presentations for the Society of Academic Emergency Medicine and the National Association of EMS Physicians.
Our active participation in research underscores their collective commitment to contributing to the science that drives the out-
of-hospital practice of medicine. We are the only National EMS provider partner in the Medtronic Foundations HeartRescue
Project. This project assembles the nation’s leading emergency and resuscitation experts committed to improving how Sudden
Cardiac Arrest (SCA) is recognized, treated and measured in the United States. As a partner in the HeartRescue Project, we
support local clinical activities pertaining to cardiac arrest improvement and communities in which we have a presence are
eligible to apply for a HeartRescue grant.
In collaboration with local communities and customers, these national leadership groups have contributed greatly to the
planning and oversight of some key initiatives over the past several years including:
A strategy for piloting CPAP in response to clinical data suggesting that CHF patients experienced marginal
improvement with conventional therapies
Creation of an online training program coupled with a workbook of case examples in response to concerns within
clinical practices that clinical documentation was inconsistent
A pilot test of two devices that assisted in replacing the H tank oxygen supply in ambulances in response to increased
frequency of employee injuries related to this awkward and difficult task of replacing tanks
Pairing Clinical Performance Indicators with Educational Systems
We have studied effective adult learning processes and has tailored its educational and staff development strategies to fit the
needs of learners at various stages in their development.
Classic approaches to continuing education assume the learner possesses the base knowledge and skills to effectively deliver
care, but has lost some of the specifics or details over time. Classic continuing education re-exposes the learner to the initial
training curricula. Our continuing education model offers some of this as it is the baseline, but advances further recognizing
this type of training is limited in value. Through the Alliance, we will utilize the foundation of our continuing education program.
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Adult professionals want to learn what is relevant to them, and are bored with repeating what they already know. To address
this need, we have developed a continuing education model that uses our CQI process to identify problem areas or
opportunities for improvement and lets those topics drive the education curricula. When observations of key performance
indicators identify a system-wide issue; we adjust the CME training schedules and online content and provide instruction on
the topic to all caregivers in the system. This pairs the clinical indicators with locally-derived educational content throughout
the local EMS operation.
In addition to our group continuing education training, we also use one-on-one training opportunities through our Field Training
Officers (FTOs) and Field Supervisors. Our FTOs and Supervisors function as facilitators and coaches, working collaboratively
with our care-givers to identify opportunities for improvement and implement learning objectives and performance
improvement plans that lead to professional development. Learning opportunities are available for interested individuals in
the form of the IHI Open School as well as by participating in mentored improvement projects.
A key factor in this model is problem identification and reliable feedback.
Individualized performance report cards are needed for optimal benefit. Report
cards compare individual caregiver performance to that of their peers, as well as
benchmarking performance against comparable practices in the community and
our network. We are developing the scorecard and report card systems necessary
to pair individual performance indicators and educational content, and we will
continue to introduce these programs to County caregivers should we be awarded
the contract.
Incorporation and Pursuit of Quality Recognition Programs
As further evidence of our commitment to embody a quality-focused organization, we commit to include the County in our
application for the prestigious California Quality Award, the state’s version of the Malcolm Baldrige National Quality Award,
within the first three (3) years of the start of a new contract. We will utilize the Malcolm Baldrige Quality Program as a model
to guide the organization’s quality efforts and to evaluate progress in the County.
In March of 2011, we were the first EMS provider to win the California Council on Excellence
Prospector Award, which followed the Malcolm Baldrige National Quality Award Criteria.
Through our experience with Baldrige, we have learned how to effectively and efficiently meet
our mission and achieve our visions.
The Baldrige approach to quality emphasizes system improvement through error elimination and behavior modification
through training. This system has been tried and tested in a variety of industries, including health care, quite successfully, and
has brought about phenomenal internal practices that have led the respective organization’s quality initiatives.
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GOLD Stevie Award
We were awarded a GOLD Stevie® award in the category of “Corporate Social Responsibility Program of the Year in Canada and
the U.S.A.” for its 2013 World CPR challenges. For the County, we will continue to serve our communities through our existing
health initiatives and programs, such as our CPR Challenge as well seek to develop new programs that are designed to improve
the health of community.
Mission Lifeline® Emergency Medical System (EMS) Recognition Award
We were the recipient of the 2014 Mission Lifeline® Emergency Medical System (EMS) Recognition. This award acknowledges
the work, training and commitment by Ambulance agencies and Medical First Responders (MFRs) to improve overall quality of
care for the STEMI patient, by directly influencing the STEMI System of Care.
“Caring for Maria”-- Experience with the IHI Quality Improvement Process
In December 2013, our National Leaders presented the first EMS-based improvement project “Caring for Maria” at the Institute
for Healthcare Improvement National Forum. Caring for Maria employs the “Breakthrough Collaboratives” strategy utilized by
the Institute for Healthcare Improvement since 1996 to achieve quality breakthroughs in diverse challenges such as reduction
of Cesarean section rates, ED visits for asthma, adverse drug events, and inventory levels/supplier management.
The IHI improvement project process uses the concept of the Triple Aim as the framework for the approach to optimizing health
system performance. In this approach, it is necessary to simultaneously pursue three dimensions of the Triple Aim:
Improving the patient experience of care (including quality and satisfaction)
Improving the health of populations
Reducing the per capita cost of healthcare
In most healthcare settings today, no one is accountable for all three dimensions of the IHI Triple Aim. For the health of our
communities, the health of our populations, and the health of our all our patients, we need to address all three of the Triple
Aim dimensions at the same time.
Five-Year Commitment to improve survival from sudden cardiac arrest in the communities we serves
In 2012, we became a full partner and the only EMS-based partner in the Medtronic Foundation’s HeartRescue Project, along
with five others. The original HeartRescue partners include the University of Arizona, University of Pennsylvania Resuscitation
Science Center, University of Minnesota Resuscitation Consortium, Duke University, and University of Washington, including
Seattle Medic One and King County.
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The HeartRescue Project is a concerted effort by experts in resuscitation science to improve the survival rate from sudden
cardiac arrest. The project’s approach is to build on decades of best practices at the bystander, pre-hospital, and hospital levels,
combining them under one program in order to expand geographic reach. The key elements include the following:
Publicly stated/measureable goals (a 50-percent increase in survival rates over five years in funded geographies)
A common set of data elements used to measure performance and outcomes
State-based reach, to include every size of community
Highly collaborative environment, bringing together leaders, influencers, and hundreds of stakeholders in each state
A focus on incremental system quality improvement via demonstrable, data-driven evidence
A commitment to sharing information and publishing results
As a partner in the HeartRescue project, we strive to bring all of its practices and its communities into the Cardiac Arrest Registry
to Enhance Survival to allow measurement, benchmarking, and improvement of local Sudden Cardiac Arrest (SCA) survival
rates. Additionally, the program offers our HeartRescue grants to communities in which we have a presence. HeartRescue’s list
of partners can be found on the HeartRescue Project’s webpage at the following URL:
http://www.heartrescueproject.com/heartrescue-program/heart-rescue-project-partners/index.htm
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a) Minimum Requirements—Clinical and Operational Benchmarking
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section V.A.2.a.
Clinical & Operational KPIs
Our commitment to capture, mine, analyze and operationalize data is embedded in our culture. We have thoroughly reviewed
and agree to provide the 18 KPIs listed in the RFP.
Periodic Report
We will provide the County with all elements of information requested, at least monthly, to ensure their ability to benchmark
KPIs against standards. We will also commit to working with the County and LEMSA to develop KPIs as needed to ensure the
evolution of targeted and effective patient care.
We will also work with LEMSA to determine an appropriate reporting schedule for protocol compliance. Using treatment
bundles for specific protocols and through data extraction from MEDS, these reports will allow us to determine compliance
with specific protocols, including protocol challenges. Through the use of our Clinical Data Analysts and CAD Data Analysts, we
are able to develop new and custom SQL reports, which is currently the most accepted program for interrogating relational
databases. These reports can be created on an as-needed basis and can be constructed to run automatically on a daily, monthly
or other interval basis, as required. LEMSA will continue to have the ability to actively oversee the system performance through
the use of our MEDS system and will be able to pull data as required to meet their reporting needs.
b) Higher Levels of Commitment—Clinical and Operational Benchmarking
With the overall system approach to patient care as defined by our proposed CQI system, we will significantly expand system-
based benchmarking processes that includes not only clinical care, but also a variety of other elements that indicate overall
system performance.
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Additional Benchmarking
Clinical benchmarking allows us to evaluate our performance as compared to other systems state and
nationwide, provided that we all use the same metrics. We are currently gathering data for the following
clinical measures which are core measures from the state EMSA and therefore can be compared to other
systems statewide:
Scene time for trauma (TRA-1)
Direct transport to a trauma center (TRA-2)
Aspirin for Chest Pain (ACS-1)
12 Lead EKG performance (ACS-2)
Scene time for STEMI (ACS-3)
Direct transport to a STEMI center (ACS-5)
Out of hospital ROSC, survival to ED and Hospital discharge (CAR-2, CAR-3, CAR-4)
Glucose for suspected stroke (STR-2)
Scene time for stroke (STR-3)
Direct stroke center transport (STR-5)
Beta agonist for Adult or Pediatrics (RES-2, PED-1)
Pain intervention and response (PAI-1, PAI-2)
Intubation success, End Tidal CO2 measurement (SKL-1, SKL-2)
Ambulance Response times by zone, Dry runs (RST-1, RST-2, RST-3)
In addition to state core measures, we have other agency measures, for example:
Documentation of prehospital stroke score, i.e. LAMS, FAST, Cincinnati by prehospital providers
Survival to hospital discharge in out of hospital arrest with CPC 1 or 2
Early epi cycles 1, 2 and 3. (NEMSIS E18_01)
Correct delay in intubation for 3 cycles
Compression rate for CPR
Compression fraction for CPR
Standard for the installation, maintenance, and use of Emergency Services Communications Systems (NFPA 1221)
Standard for the organization and deployment of fire suppression operations, emergency medical operations, and
special operations to the public by career fire departments (NFPA 1710)
While not all of these metrics are required, nor are all of them able to be benchmarked on a wide scale as they are not measured
by all systems, they are some of the measures we use as indicators of higher performance, or an optimized system. For
example, there is evidence to support that early epinephrine might improve outcomes in non shockable cardiac arrest.
Likewise, there is evidence that delaying intubation for three (3) cycles (or more) might improve outcomes in cardiac arrest.
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Furthermore, there is growing and very strong interest in utilizing EMS to selectively route a subset of stroke patients to
Comprehensive Stroke Centers, bypassing Primary Stroke Centers, to receive early interventional therapy. We have begun
looking at not only the frequency, but also the accuracy with which our crews are performing a prehospital stroke scale, as well
as documented the “time last seen normal” as these two (2) assessments will be the key determinants in the destination of
such patients.
Superior medical outcomes are critical to establishing community peace of mind and confidence in the value of their overall
investment in the EMS system. Therefore, we utilize outcome-based metrics over process-based metrics. Outcomes provide a
clearer “bottom-line” objective for goal setting. Process-based measures, especially input measures such as resources
consumed and cost, are also important for management. We consequently use a mix of process and outcome metrics in our
KPIs.
Commitment to Technology and Personnel
Our commitment to benchmarking KPIs extends to and is evidenced by our investment in technology skilled data analysts.
Through the Alliance, we will utilize a comprehensive suite of tools to gather the data needed for our system performance
reports and statistical analyses, and to ensure compliance with medical protocols. These tools include the MEDS ePCR system
for every ambulance, a CAD program, and Medical Priority Dispatch SystemsTM (MPDSTM) /ProQATM telephone triage systems
for the Communication Center. These robust tools and combined with our IT talent, provide a reliable platform for advanced
data warehousing and management.
In addition, we employ dedicated Clinical Data Analysts and CAD Data Analysts, who have attained the Structured Query
Language (SQL) Developer competency level. Clinical data and CAD data are two distinctly different databases, which is why
we maintain separate analyst positions, rather than diluting competency by trying to have one person do all.
Proposed Higher Level Benchmarking Process
Like the County, we are committed to using patient-focused performance metrics to drive clinical care improvements. As such,
we are proposing to enhance our current benchmarking system by working with the County to share metrics with EMS agencies
and hospitals to add additional benefit to the local system. With our experience in collecting data, we have the potential to
review the impact of systems of care on chronic health-needs patients. Likewise, we can look at patient satisfaction and
experience methodologies used elsewhere in the country to implement a fully transparent review of patient perceptions of our
care in the local community. This collaborative approach to performance measurement is beneficial for the following key
reasons:
It ensures that the entire system is working together around care that benefits patients
It ensures focus throughout the organization on initiatives that actually improve clinical care
It enables open discussion about performance, benchmarking with other out-of-hospital communities, and
identification of best practices and areas for improvement
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High Impact Clinical Conditions – Things that Matter
We will aggressively focus significant efforts on high impact clinical conditions identified through a comprehensive review of
medical literature by the Alliance and non-Alliance physicians and clinical leaders. These “Things that Matter” are those
conditions that, when treated appropriately, can be dramatically improved in the out-of-hospital setting.
Airway Management
Goal: Improve the safety and efficacy of airway assessment and intervention
Strategies: Training, improved airway decision making, increased use of capnography and CPAP
Metrics:
Intubation frequency per 100,000 cases
Capnography utilization
Adequacy of patient intubation and ventilation as measured by EtCO2, SpO2, and RAPS score
Resuscitation
Goal: Optimize cardiac resuscitation strategies to improve long-term survival from cardiac arrest
Strategies:
Training on resource management (pit crew), evaluation and implementation of hypothermia, mechanical CPR,
and community resuscitation programs. Incorporation of Utstein data fields into ePCR system.
Metrics:
Cardiac arrest survival
Operational participation in the CARES registry (results shown below)
Operational participation in the Heart Rescue initiative that promotes community-wide approach to
resuscitation
MDLG/CLC/NEET evaluation and recommendation regarding resuscitation approaches such as hypothermia,
mechanical CPR, ResQPod, etc.
STEMI / Stroke
Goal:
Early recognition of STEMI/Stroke, early activation of community resources, patient transport to most
appropriate specialty center
Strategies:
Inventory of local community initiatives to identify best practices, incorporation of data fields related to
transport to specialty centers into EPCR system. Creation of national benchmark report based on
recommendations from the Consortium of US Metropolitan Municipalities’ Medical Directors.
Metrics:
STEMI/Stroke Benchmark report based on Consortium of US Metropolitan Municipalities’ Medical Directors
composite scoring
Respiratory Distress
Goal: Appropriate evaluation and safe management of patients complaining of shortness of breath
Strategies:
Increased utilization of capnography in evaluation of respiratory distress, increased utilization of CPAP,
documented improvement in patient condition for individuals with respiratory distress. Creation of national
benchmark report based on recommendations from the Consortium of US Metropolitan Municipalities’ Medical
Directors.
Metrics:
Respiratory distress and CHF Benchmark reports based on Consortium of US Metropolitan Municipalities’
Medical Directors composite scoring
Increase in the percentage of patients whose acuity improves during the prehospital encounter as measured by
EtCO2, SpO2 and RAPS score
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Severe Trauma
Goal: Early recognition of severe trauma with early activation of community resources, patient transport to most
appropriate specialty center
Strategies: Inventory of local community initiatives to identify best practices, incorporation of data fields related to
transport to specialty centers into EPCR system. Creation of national benchmark report based on
recommendations from the Consortium of US Metropolitan Municipalities’ Medical Directors.
Metrics: Significant trauma benchmark report based on Consortium of US Metropolitan Municipalities’ Medical
Directors composite scoring
Management of Pain and Discomfort
Goal: To reduce patient pain and discomfort
Strategies: Creation of business rules in the ePCR system that require pre/post evaluation of pain scale for patients with
primary impression of “pain” or who receive narcotic analgesics (except with CHF), creation of national data
report on impact of therapy for pain based on pain scales and RAPS. Identification of best practices in
operations with best results. Patient surveys and satisfaction measures
Metrics: Creation of business rules in ePCR system
Creation of national data report on pain/discomfort relief
Patient satisfaction
Identification of best practices within operations with best data
PDSA process to implement best practices
Patient Safety
Goal: Improve the safety of EMS evaluation, care, and transport
Strategies: Continue to provide employee training on patient advocacy and the process of informed consent for refusals
(Patient Focused Care and Advocacy program, in use since 2007), create a mechanism for measuring the
incidence of adverse events (including any events that may or do result in patient harm)
Metrics: Completion of PFCA training during new-hire orientation
Operational dry-run/non-transport goals and performance
Patient drop and vehicle accident rates (already monitored)
Establishment of a process for identifying cases to review for adverse events based on trigger conditions (as
described by the Institute of Healthcare Improvement)
Creation of an integrated patient safety report that incorporates patient drops, vehicle accidents, and adverse
events
CARES Data Initiative
The CARES Data Initiative program links process measures to actual patient outcome, and the
evaluation of advanced airway techniques and devices. In 2014, we produced a 10.7% overall
survival rate (485 patients). Our overall survival rate meets the national average. We also
produced a witnessed survival rate (Utstein Survival) of 33.8%; and a Witnessed, bystander
CPR survival rate (Utstein Bystander Survival) of 34.9%. In addition, our bystander CPR rate
was 37.9%.
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Improving Patient Health & Outcomes - Collaboratively
With this contract and through the Alliance, the current CQI program will continue to evolve and take into account the Just
Culture approach, which supports our clinical culture that is built around the specific needs of the local EMS system. We are
offering to collaborate with the County to develop a clinically sophisticated program that responds to local leadership priorities,
evaluates patient care using valid and meaningful data, and seeks to produce actual improvements in the health of patients
system-wide. This collaboration will be targeted towards the following:
Improving the patient experience of care (including quality and satisfaction)
Improving the health of populations
Reducing the per capita cost of healthcare
To succeed, CQI in the County’s system cannot be “supplied” by the Alliance, but must be developed and maintained in careful
collaboration with County and LEMSA. By definition, local priorities, local disease burdens, and local clinical practices will drive
the detail of this program. However, we offer to strong local and national experience from other EMS systems, expertise in
clinical care, and capable infrastructure to achieving the system’s goals and protecting its patients.
In this section, we seek to display to the County what will be possible and what our approach will be, knowing that the detail
and priorities will be established through active collaboration.
Assessing Compliance with Medical Protocols
The key to ensuring compliance with medical protocols is the development of robust protocol-based KPIs monitored through
our industry leading Institute of Health Improvement (IHI)-based CQI model, which we are offering as an enhancement to this
proposal. We will work with LEMSA and the Medical Director to ensure that all protocols are updated regularly and
communicated to our crews in the field, with the appropriate KPIs updated in the system. By monitoring the compliance of
treatment bundles through the MEDS program we are able to recognize areas of opportunity within the current system as well
as identify protocols that may have compliance issues.
Additionally, we will offer LEMSA a database with continually updated information on changes being made to medical protocols
by EMS systems that we currently serve across the nation. The database will provide the LEMSA Medical Director with a fast,
easy-to-use tool to track changing trends in medical protocols and ensure the system is fully informed as protocols evolve
nationally. Likewise, we would like to include in this database the LEMSA protocols so that EMS systems we serve can also
benefit from its improvements and evolution. Only the Alliance can offer such a step up in the sheer scope and quality of
information that can be provided to drive real evidence-based change.
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Taking a Step Up In Patient Care
We are currently collaborating with the IHI, and we have refined and simplified our CQI approach with a focus on making
measurable improvements that benefit patients clinically, improve their experience of care, and control costs. This new “Triple
Aim” approach to CQI places patients – the people we serve -- at the center of the model, as they remain our purpose and the
focus of our vision, our values, and our actions. The program has three main components:
Improvement Projects
KPI Monitoring
Management of Unusual Occurrences (UO)
We are offering this industry-leading quality management program as an enhancement to the system currently in place. Not
only will it fully meet and exceed the requirements of the system today, but also those of the future, for all elements of th e
operation, from the time the call comes in to the communications center to the time the patient arrives at the hospital. The
system is designed to evolve as we evolve as a mobile health care provider, taking the best in CQI practices and enhancing them
through the ongoing practice of medicine.
We look forward to developing this program in conjunction with LEMSA and participating in the growth and development of
the local EMS system. We also look forward to using the three (3) components of the IHI Triple Aim Quality Program to provide
a unique opportunity not only for further development for the County, but also to communicate the system’s successful
programs to other EMS communities we serve.
Part of the model is the Plan, Do, Study, Act (PDSA) approach. We propose to work with LEMSA
to test improvements on the smallest possible scale and refine the improvements before they are
implemented across the system. This commitment will allow for a more effective system-wide
implementation of new protocols with the assurance that they are producing the results intended.
This approach involves the following:
Plan for the test. The key part of planning is to make a prediction of the expected results
from the test
Conduct the test. During this phase we carry out the test and gather results/observations
Study the results. Here we compare the actual results of the test with the prediction
made during the planning phase
Act on the comparison of the results with the prediction and the observations from the
test. Based on what we learn we will either adopt this as a good practice to implement,
adapt the plan to produce better results and conduct another PDSA cycle, or abandon the
practice as something that does not work
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Another part of the IHI model, UOs, individual situations that require a comprehensive investigation to understand the nature
of what has happened. UOs are initiated through contact from patients, the public, system partners, through our near-miss
self-reporting system, and chart review. If a UO is identified, our team will immediately notify LEMSA’s Medical Director and
work with him to conduct an investigation. We will prepare a report on the results of the investigation describing what
happened and any recommendations for improvement, in line with our Just Culture approach. Once the recommended
improvements are in place, the case will be closed and a follow-up assessment will be scheduled to make sure that the
improvements are sustained.
This process is illustrated in the following diagram:
National Benchmarking
Through the Alliance, we will utilize clinical metric scorecards that are designed to focus our crews on providing better patient
care. These scorecards will be made available to the County as part of our CQI plan. The scorecard is built around the following
seven common themes in EMS, which has been incorporated into seven ‘Things that Matter’:
Safe & Effective Maintenance of Airway and Ventilation
o (We ensure optimal airway patency, ventilation, and oxygenation)
Reduction of Pain and Discomfort
o (We enhance patient comfort and reduce pain)
Relief of Respiratory Distress
o (We relieve respiratory distress and optimize ventilation and oxygenation)
Cardiac Arrest Resuscitation
o (We focus on prompt, appropriate and effective resuscitation)
Recognition and care of Ischemic Syndromes
o (We rapidly recognize and appropriately care for STEMI & Stroke)
Effective and Timely Trauma Care
o (We are timely and efficient in our recognition and treatment of severe trauma)
Ensuring Safe Patient Care and Transport
o (We ensure that patients are safe while in our care)
These metrics are displayed by local practice sites on a scorecard that allows baseline development and sets expectations for
accountability for documentation, CQI, and outcomes. The scorecards are customizable by location and begin by analyzing data
and displaying it on a dashboard in performance bands. Run charts are developed as data accumulates, and goals are
established to facilitate improvement.
UO Identified Investigation Report
Analysis
Improvement
Actions Follow-Up
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Below are examples of local charts that are currently available for our operations. These can be customized over time to meet
system oversight needs:
An additional benefit of MEDS implementation, and the PIM tool, is our ability to benchmark local system performance against
any other area of our operations nationally. We are proposing to offer this tool, which is updated monthly, to the County office
to allow for system benchmarking against other operations nationwide.
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EMS-CAHPS
We are proposing through the Alliance to continue to actively measure the patient experience with our
care in the County system using a validated patient experience satisfaction survey based on the
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey tool.
Standardized consumer experience metrics are an increasingly important component of value-based
health care evaluation and compensation. Over the past decade, healthcare system and provider
accountability for the patient experience and responsibility for transparent reporting has become an expectation of
organizations and individuals involved in patient care. EMS as an industry has typically been slow to implement any such
metrics, and where customers were surveyed, the survey tools have been un-identified and cannot be compared directly to
other health care organizations.
The HCAHPS survey tool is nearly universally implemented to collect patient experience ratings for hospital in-patients. It is
also now nationally reported by Medicare to permit consumers to directly compare local hospital choices against local, state
and national metrics via the Medicare.gov website. Although many elements of the HCAHPS tool are not applicable to EMS,
and conversely, important EMS measures are not included, using as much as possible of this validated tool will move EMS into
an appropriate position to be considered another valuable component of the continuum of healthcare. For this reason, we has
developed a survey instrument based on HCAHPS but relevant for EMS.
Through the Alliance, this survey is currently available to the County. In 2014, we sent out 5,321 surveys, receiving 638 patient
responses. We will continue to utilize this tool as it has proven to be extremely valuable in allowing both the Alliance and the
local system to demonstrate clearly superior patient experience ratings using a believable and recognizable tool accepted by
all elements of the healthcare system.
Non-Clinical Key Performance Indicators
We recognize the essential importance of subjective patient experience satisfaction as a measure of EMS quality. Since many
EMS patients do not face immediately life-threatening events, how they felt about the care they received by the EMS caregivers
is as relevant as “scientific” or clinical measures. Thus, through experience, we know monitoring customer satisfaction will be
a key indicator for measurement in the County system. We also believe that employee satisfaction is a clear indicator of the
system health and the type of care our patients are receiving.
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The following are examples of non-clinical KPIs that we are proposing to continue to monitor for the County:
Customer Satisfaction KPIs
Example questions collected and monitored from customer surveys:
o Did the Paramedics Arrive Quickly?
o Did the Paramedics Act in a Concerned and Caring Manner?
o Did the Paramedics Explain What They Were Doing and Why?
o Pain, Difficulty Breathing, or Discomfort Improvement
o Overall Care and Service Rating
Human Resources/Employee Satisfaction KPIs
Shift Holdovers Per Week
Turnover Rate
Turnover Factors/Employee Satisfaction
Community Health Partnership KPIs
9-1-1 calls for patient conditions targeted in community health awareness programs. Examples could be:
o Elderly falls
o STEMI transports
o Early onset stroke transports
Number of Community Health Improvement Activities
Home inspections
Fall prevention for Seniors
Track annual fire injuries/fatalities
Fleet KPIs
1. Critical Vehicle Failures per 100,000 miles
2. Preventive Maintenance Cycles
Safety KPIs
1. Employee Injuries per 10,000 payroll hours
2. Vehicle collisions per 100,000 miles travelled
Unusual Occurrences and Complaints KPIs
1. UOs and Complaint
Financial Sustainability KPIs
1. Unit Hour Utilization Ratio
2. Net revenue per transport
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We currently monitor a number of these KPIs, including employee injuries and type of vehicle accidents, as illustrated in the
following charts:
Operational Key Performance Indicators
We also reviews our operational KPIs on a regular basis. Operational benchmarking begins with establishing standards by which
we can effectively monitor changes that are made to improve outcomes such as response times, time at the scene of an
incident, and total time on a task. The result should be an efficient use of resources available.
These standards will be established in our local SSP, which will be used by all operational functions including Communications,
Caregivers, and EMS Operations Managers, to efficiently run the system on a daily basis. System status management (SSM) is
the deployment of ambulances on an hour-to-hour and day-to-day basis using demand analysis from the previous 20 weeks of
call data. The result is a system of “post” locations placing ambulances closest to the calls while moving resources based on call
locations.
Most of our ambulances are deployed using 12-hour rotations to maintain 24-hour coverage. This deployment uses each
ambulance to its highest efficiency, minimizing the overall number of ambulances necessary and the amount of time an
ambulance sits idle. In addition to these units, the system integrates 12-hour flex cars that increase ambulance coverage during
peak volume. These resources make up the core of the scheduled ambulance in a given day or week.
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All the plans, scheduling, and data analysis culminate to an orchestrated system of ambulances responding to calls with
strategic movement of resources, allowing us to meet the established response times. This high-performance system requires
monitoring with appropriate benchmarks designed to be measurable in an effort to improve outcomes.
a) Minimum Requirements – Clinical Leadership Personnel
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section V.A.3.a.
One of the many benefits of the Alliance is a broader base of support for clinical oversight. We are currently expanding our KPI
and benchmarks to allow us to perform more in depth analysis of the quality of care we provide as well as associated outcomes.
Guided by the senior management of the Fire Chief, we are establishing a comprehensive personnel structure to ensure the
oversight of organization-wide quality management and KPIs. Our Fire Chief’s designee along with a leadership complement
of Medical Directors, General Manager, Quality Improvement and Education Team, EMS Operations Manager, EMS Field
Supervisors, Field Training Officers (FTO’s), Data Analysts, as well as an on-call team of regional and national clinical experts
will actively participate in sustaining the EMS quality management system. Job descriptions for all clinical quality personnel
positions are included as Exhibit No. 6.
Our core clinical leadership personnel is comprised of our Medical Directors and our Quality Improvement and Education Team.
These individuals will have very active roles in teaching, case review, and feedback. Our Chief Medical Director, Dr. Peter
Benson, will lead our core clinical leadership personnel and will be responsible for aligning our medical direction with LEMSA
and providing medical oversight to our system. Dr. Benson, who has practiced in the County for over ten (10) years, has a
Master of Public Health (MPH) with formal training in epidemiology and biostatistics, and has authored several studies. He is
experienced in systematic data analysis and able to lead the “analysis of performance data and conduct improvement projects.”
Our Associate Medical Director is Dr. Gene Hern, is an attending physician at Highland Hospital in Alameda County, CA. He will
support Dr. Benson and provide additional medical expertise and oversight for the entire system, while working closely with all
local public safety agencies. He offers eight (8) years of experience practicing medicine in the County.
Our Quality Improvement and Education Team is comprised of two (2) individuals. The first member of this team is Greg
Kennedy, who offers nine (9) years of experience in the County. Mr. Kennedy is responsible for monitoring tasks such as the
on-going responsibility to review completed Patient Care Reports and data reports for adherence to proper protocols and to
assure that best practices and standards that are taught in the classroom are being performed in the field. He reviews
interventions, STEMI and CPR reports, and medicine administration, among other areas of care, to identify and correct any
deficiencies. He also acts as the Education Nurse and is available to provide targeted one-on-one training to District EMTs and
Paramedics.
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The other leadership member of our Quality Improvement and Education Team is Joanny All, who offers over 15 years of service
in the County, including 17 total years of urban and rural EMS experience. She will be responsible for the day-to-day
management of the continuous quality improvement system as outlined below:
A team of Field Training Officers (FTOs) and chosen field staff that help ensure performance standards, the
implementation of successful training programs, continuous performance monitoring within the field, and
participation in peer review audits
A stringent screening program for new personnel, careful review of equipment needs, and physician-approved
protocols
A comprehensive orientation academy that is followed by FTO-facilitated field training, evaluation, and continued
mentorship, as well as in-house continuing education programs
Monitoring, coaching, and feedback by FTOs, Field Supervisors, and Clinical staff
We also have dedicated Clinical Data Analysts and CAD Data Analysts, who have attained the Structured Query Language (SQL)
Developer competency level. The analysts will evaluate Patient Care Reports. Through the years of dedicated services, we have
established a clinical quality management program that has proven extremely valuable in the County, serving individuals within
its borders and from the surrounding commuter and medical facility populations. Our CQI is overridingly built on the belief
that we can improve what we measure and monitor, ultimately ensuring that every one of our patients receives the best care
possible. Additionally, we commit to eighty (80) hours per month for designated field personnel to participate in clinical
improvement activities.
International Institute of Health Open School
Developing the next generation of leaders is critical for the long-term success of any organization,
especially one such as the Alliance, which is labor-driven and strives to promote within whenever
possible. Within 18 months of contract commencement, all full-time staff dedicated to quality
management and education will complete the IHI Open School Basic Certificate. Currently, our
Quality Improvement and Education Team, Greg Kennedy and Joanny All, have completed IHI Open
School program. As your partner, we will continue to enroll our personnel in this program.
The IHI Open School program is designed to advance healthcare improvement and patient safety competencies in the next
generation of health professionals worldwide. Launched in September 2008, the IHI Open School provides students of
medicine, nursing, public health, pharmacy, health administration, dentistry, and other allied health professions with the
opportunity to learn about CQI and patient safety. The online, educational community features a growing catalog of online
courses, extensive content and resources, and a network of local chapters that organize events and activities on campuses
around the world. We will enroll our Quality Improvement and Education personnel, EMS Operations Managers, EMS Field
Supervisors and FTOs in the IHI Open School program.
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The table below provides an outline of the training topics provided.
Patient Safety
PS 100: Introduction to Patient Safety
PS 101: Fundamentals of Patient Safety
PS 102: Human Factors and Safety
PS 103: Teamwork and Communication
PS 104: Root Cause and Systems Analysis
PS 105: Communicating with Patients after Adverse Events
PS 106: Introduction to the Culture of Safety
PS 201: Partnering to Heal: Teaming Up Against Healthcare-Associated Infections
PS 202: Preventing Pressure Ulcers (professional catalog only)
Improvement Capability
CQI 101: Fundamentals of Improvement
CQI 102: The Model for Improvement: Your Engine for Change
CQI 103: Measuring for Improvement
CQI 104: The Life Cycle of a Quality Improvement Project
CQI 105: The Human Side of Quality Improvement
CQI 106: Mastering PDSA Cycles and Run Charts
CQI 201: Guide to the IHI Open School CQI Practicum (student catalog only)
CQI 202: Quality Improvement in Action: Stories from the Field
Quality, Cost, and Value
QCV 101: Achieving Breakthrough Quality, Access, and Affordability
Person- and Family-Centered Care
PFC 101: Dignity and Respect
PFC 102: A Guide to Shadowing: Seeing Care Through the Eyes of Patients and Families
PFC 103: Having the Conversation: Basic Skills for Conversations about End-of-Life Care
Triple Aim for Populations
TA 101: Introduction to Population Health
Leadership
L 101: Becoming a Leader in Health Care
b) Higher Level of Commitment – Clinical Leadership Personnel
While our organizations recognize the need to manage clinical direction locally, we also believes it is important to share
knowledge from clinical practices across the country. Our Clinical Leadership Personnel will have direct access to our national
clinical team and can draw from best practices and lessons learned from practices across the country. The national team has
members focused on specific areas we believe have the greatest opportunity to improve outcomes of patients in the
communities we serve.
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We are highly confident in the abilities of our team of clinical personnel. These individuals have a proven record of effectively
communicating their extensive medical knowledge to the rest of our staff. This entails the regular distribution of clinical
summaries with benchmarks for performance and evaluation, continuous measurement of cancelled call rates (including
individual remediation for especially high rates), in-depth compassionate remediation for personnel needing improvement,
and the retention of personnel over long-term periods, rather than eliminating staff from the workforce. Locally, these
measures create strong clinicians who are dedicated to the communities they serve.
Innovative Offerings
We also offer a variety of innovative opportunities for our clinical staff to build their skills and gain
additional clinical knowledge, including the following:
National Leadership Clinical Groups
Emphasizing our commitment to continually use best practices to improve our patient care, our local team is supported by and
is part of several of our organization’s national clinical leadership groups. These groups provide expert direction and oversight
for process improvement efforts in strategic planning, patient/community focus, staff focus, measurement and analysis,
process management, and organizational performance. Additionally, the groups have identified content-area experts that have
made themselves available to our operations in other communities to assist with program implementation. Examples include
the implementation of the CARES data initiative, which links process measures to actual patient outcome, and the evaluation
of advanced airway techniques and devices. The groups themselves are composed of designated leaders from our operations
all over the country. Unique in the industry, these groups provide an unparalleled resource to all operations.
Medical Director’s Leadership Group (MDLG)
Medical Directors play an essential role in establishing clinical priorities and guiding the clinical practice of our clinical staff
within their local communities. Our Medical Director’s Leadership Group (MDLG), which serves as a resource for all of our
Medical Directors, is led by AMR’s Chief Medical Officer, Edward Racht, M.D., and is comprised of selected Medical Directors
from each region, and will include our team of Medical Directors for the County. By design, the members of this group
represent diverse practice environments including urban, rural, frontier, academic, and private practice settings. In
collaboration with the Clinical Leadership Council (CLC), described below, the MDLG provides guidance on the medical practice
aspects of clinical excellence, including identification and integration of new clinical performance indicators.
The MDLG provides an internal “sounding board” for Physician medical directors to discuss complex issues with colleagues
across the country. It also offers our external academic and industry partners an opportunity to discuss ideas across a diverse
group of physicians. This has resulted in multi-center studies, position papers and a comprehensive, well referenced Medical
Director’s Resource Guide to assist all physicians with integration into their practices. We offer LEMSA Medical Director to join
our MDLG, improving communication and overall collaboration of our County operations.
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e-Grand Rounds
To maintain clinical excellence and provide updates on state-of-the-art medicine, we have instituted a monthly program called
e-Grand Rounds. The e-Grand Rounds format encourages the invited presenter to showcase his/her information via live
webinar in the first 45 minutes of the hour-long program. This is followed by an interactive discussion facilitated by a
moderator. One of the goals of this unique program is to help our teams learn about cutting-edge medical, including the ‘art’
of implementing clinical science into daily operations. These seminars are recorded for later viewing by personnel unable to
attend the live presentation. A list of the topics and class description is provided below.
e-Grand Rounds Recent Topics
Topics Speakers
AHA Guidelines Dr. Ed Racht
Sudden Cardiac Arrest Lynn White
Care of the Prehospital Stroke Patient Dr. Ed Jauch
Patient Safety Scott Bourn
Capnography in the EMS World Dr. Baruch Krauss
STEMI and 12-Lead EKG transmission Dr. Brian Hiestand
Management of Pain and Discomfort in EMS Dr. Angelo Salvucci
Update on Trauma Care in EMS Dr. Michael Cudnik
EMS Quality Improvement Mike Taigman
AMR Medicine Clinical Initiatives Dr. Racht, Scott Bourn, Lynn White
2011 Field Triage Guidelines E. Brooke Lerner
Dispatch-Assisted CPR Dr. Tom Rea
On Scene Resuscitation Dr. Brent Myers
The National Drug Shortage Dr. Ed Racht
Traumatic Brain Injury Dr. Ben Bobrow
Cardiac Devices Encountered by EMS Dr. Brian Hiestand
Prehospital Hemorrhage Control Dr. Eric Ossmann
Safety Stories: Creating a Culture of Safety Cathy Jaynes, Scott Bourn
CPR Analytics and Quality of Resuscitation Care Rob Walker, Fred Chapman
Great EMS Data: The Power to Answer Cool Questions Alan Craig
Stroke Dr. Todd Crocco
Capnography Dr. Jeff Goodloe
Oxygen Dr. Mike Levy
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E-Case Review
As an innovator in clinical care, we developed and implemented a Web-based educational seminar in August 2012 called, E-
Case Review. The one-hour webinar focuses on a single case presented by a local caregiver. Discussion about the case occurs
locally in each participating practice and is followed by a ‘mini lecture’ by a national expert on the topic. The discussion is
focused on the case itself, not on critiquing how the caregiver managed the case. Presenters find E-Case Review to be an
informative and useful venue for learning more about the case, as well as how different locations will manage comparable
patients. There are typically 50 to 70 participants reviewing five to seven individual practices in multiple states, and sometimes
with guest experts from throughout the world.
Safety & Clinical Competition
We believe that safety and clinical excellence must be considered together, and we aim to ensure that safety is always a
component of any clinical training. To reinforce this approach, we host an annual Safety and Clinical Competition. The goal of
the competition is to increase safety awareness among personnel while lifting patients and maneuvering ambulances, with and
without patients on board, in a simulation of the surroundings and situations our EMS crews encounter on a daily basis.
Participants also are evaluated in medical and trauma scenarios appropriate for their respective EMT certification. The friendly
competition brings together personnel and reinforces and supports our operations in achieving safety and clinical excellence.
Alliance Policies & Procedures
A workgroup is being assembled, through the EMS Committee, to align the response policies and
procedures for the Alliance to assure that no conflicting direction is present. Furthermore, that
document will be brought into alignment with the County’s EMS Policy and Procedure manual to
further guarantee a cooperative system approach to emergency medical response.
Methods for Communicating With Our Team
Effective communication with the workforce is particularly important as well as challenging in EMS, where personnel are often
in motion throughout much of the day. Our communication philosophy puts the burden on the quality/leadership team to
reach out to personnel in ways that are engaging and easy to access.
Organizational excellence is a top priority for the Alliance. Top down leadership includes strategic planning, fiscal stability,
customer service, accountability, and quality improvement throughout the organization. Several meetings occur weekly where
the Fire Chief and other members of senior staff visit fire stations and operations to meet with the workforce in their own
environment. These meetings provide the workforce face time with the Fire Chief and other leadership staff and allow for
open, face-to-face, honest dialogue on the state of our organization and plans for the future.
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Additionally, each Battalion Chief is assigned a City that the organization protects. One of the responsibilities of that assignment
is to attend monthly City Council or other relevant meetings to provide City official’s access to a representative of the Alliance.
This access provides for real time information exchange and facilitates communities trust in the service that we provide.
The EMS Battalion Chief is engaged in local, State, and National programs and conferences. Emergency Medical Care
Committee, Medical Advisory Committee, Stroke committee, STEMI meetings, Pre-Trauma Advisory Committee are some of
the local meetings attended. At the State level regular attendance occurs at the State Emergency Medical Services Commission
as well as their annual conference. He also serves as the Deputy Director for the California Fire Chiefs EMS Section, Northern
Branch and attends several annual conferences where EMS is the focus of study.
Lastly, he participates in National EMS Conferences where latest trends, best practices, and advanced topics such as Community
Paramedics are the emphasis of discussion.
Communication Process and Channels
Below, we have provided a communication flowchart the displays our value and appreciation for effective communication,
whether it originates from our Executive Level down to our Personnel or from our Personnel up to our Executives.
Communication Flowchart
Organization (mission and values)
Executive Level
Operation Level
Personnel
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To ensure we capture all effective communication that is essential to our success, we utilize a number of different
communications channels, such as the following, for communicating the same information to make sure that our field crews
receive information:
True open-door policy where personnel are encouraged to bring issues and ideas to management regardless of the
employee’s level or status within the company/organization
Individual company email / personal email
TeleStaff – an electronic staffing management software suite
Clinical E-rounds
Regular town hall meetings
Management ride-along in the field
Posting on employee bulletin boards and break areas
Cell phone / Pager
Social networking sites
Memos posted in public areas as well as placed into employee mailboxes
Performance Improvement Tool (PIT), which allows for direct and contextual feedback directly to the creator of a
specific ePCR
Employee Portal – a wealth of information, educational material and self-service employee tools are located on the
Envision Portal. From linking to training and compliance programs, to online education and much more, the Portal is
a one-stop shopping source for our personnel
Guiding Teams
Peer Review Committee (more detail below)
Quality Steering Committee (more detail on the following page)
“Insight” Videos
Peer Review Committee
All of our personnel are encouraged to become involved in making improvements. Our Peer Review Committee plays an
important role in overall quality for our local operation, from evaluating new equipment, to providing feedback on new
protocols, fine-tuning deployment plans, and assessing the performance of our caregivers. Peer involvement is an important
component of engaging personnel. By having personnel involved in all these elements, they are able to “own” new concepts,
procedures, standards, and other progressive activities, and are actively engaged in improving the system and the overall
quality of care. As the day-to-day frontline caregivers, these personnel often hold the key to innovative solutions for challenging
issues.
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Quality Steering Committee
This committee consists of dedicated local caregivers, EMS agency staff including the LEMSA Medical Director, our Medical
Directors, various First Responder representatives, and local hospital staff. Activities for the Committee include reviewing
system performance in all key areas, generating ideas for improvement projects, and guiding and monitoring progress on
improvement projects. Our overall focus is on system-wide performance for our patients and for the community.
Methods for Assessing Efficacy of Communications
We want our communications to continue to effectively support the County’s purpose to ensure patients receive the best
possible pre-hospital care. One of the methods we use for assessing our effectiveness is monitoring changes in performance.
Our operations across the country are now implementing CPR Quality Analytic programs. Using this program, our local
operation can upload the continuous monitor recording to a Cloud-based application and receive back within 24 hours in most
cases, an annotated report of CPR Analytics. Clinical leaders are using these to provide feedback to their crews on their
performance during resuscitation, and they are powerful and sought-after learning tools. Currently the annotations are being
done by the LEMSA and then sent back to us to provide feedback to the crews. We have taken it a step further and have added
a reward program incentive for those that are high performers.
Gathering Performance Data & Communicating to Personnel
We use our Performance Improvement Tool (PIT) to identify, assess and track CQI events. PIT seamlessly integrates with our
MEDS ePCR system to quickly identify clinical trends and documentation deficiencies and provide real-time feedback to
caregivers and supervisory staff. PIT provides the mechanism to deliver feedback directly to the caregiver, as well as a scorecard
to show overall performance. If further review of a caregiver’s performance is needed, PIT’s Incident Tracking provides the
ability to monitor, track and escalate incidents (see illustration on below). We propose to provide the LEMSA Medical Director
access to this tool to assist in EMS system monitoring and further EMS system development.
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Once an issue is identified, we select the method to communicate performance data and information with our team based on
its urgency and/or time sensitivity. We focus on communicating performance information relevant for performance
improvement, workplace morale, and employee growth and education, as shown in the following chart:
Performance Data Communication
Performance Data Type of Information Frequency of Communication
Composite Clinical
Scores
Percentage of patients treated in
compliance with composite checklists
Included monthly in Performance Report for all crews
and on data display in deployment
Crew Chute Time The time between unit alerted and wheels
turning
Ongoing real-time feedback for Supervisor to provide
field coaching
Customer Survey Quantitative and qualitative information
from survey
Ongoing feedback to relevant personnel
Summarized quarterly in Performance Report
Unusual Occurrences Various including customer service-related
and clinical
Immediate contact with relevant personnel and EMS
Agency consistent with protocol
Key Performance
Indicators
Control charts reflecting system-wide
performance
Included monthly in Performance Report for all crews
Response Time
Performance
Month-to-date-response time compliance Daily notification to on-duty crews
End of month performance reports
Promotion of Legal & Ethical Behavior
Promotion of legal and ethical behavior is a top priority for our organization, beginning with the hiring process, which includes
peer-interviews and thorough background checks. Our values of being “Service, Teamwork, Professionalism, Leadership,
Safety and Preparedness, and Integrity.” all encompass ethical behavior. The Alliance offers extensive ethics component to
our orientation program, along with online ethics classes and tests required for all personnel on an annual basis.
Our personnel are required to undergo corporate compliance training annually throughout their employment, new employee
orientation and annually as well. Core to this programming is developing employee understanding and knowledge of the
following:
Cultural diversity
Corporate Integrity
HIPAA
Patient Focused Care and Advocacy
Workplace Violence and Prevention
As benefit to the Alliance, we have an ethics hotline number, is available 24 hours a day, seven days a week for personnel to
call to express concerns and receive guidance. Alleged breaches of ethical behavior are fully investigated. If a breach is found,
then immediate corrective action is taken, ranging from remediation to termination.
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Handling Adverse Events
We maintain a simple, straightforward process for managing adverse events that is integrated into our CQI process and
incorporates the elements of Just Culture. Though adverse events are rarely identical, the process to receive, investigate,
analyze and communicate should be similar so that vital pieces of an event are not missed.
Once we receive notification of an adverse event, we document the details of the event. The next step is to conduct a root
cause analysis to determine if the issue is a system problem or isolated to a single employee. The analysis and decisions are not
done in a vacuum, but rather in consultation with Operations, our Quality Improvement and Education Team, our Medical
Directors, LESMA Medical Director, Safety and Risk Management, and the communications team. All decisions are fed back and
appropriate actions taken.
In the event of an adverse event impacting members of the public, we will continue to work with the LEMSA to resolve the
issue and ensure proper notification in a unified fashion.
a) Minimum Requirements – Medical Direction
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section V.A.4.a
To assure adherence to the highest clinical standards, we offer a highly-qualified pair of Medical Directors –Dr. Peter Benson
and Director Dr. Gene Hern - to lead and support our medical direction for the County. Under this structure, Dr. Benson will
operate as our Chief Medical Director and Dr. Hern will support him as our Associate Medical Director. For further review of
our Medical Directors, we have provided their CVs as Exhibit No. 7. Additionally, we have provided a contract/job
responsibilities as Exhibit No. 8.
b) Higher Levels of Commitment—Medical Direction
As your partner, we will follow the medical direction of LEMSA and collaboratively work with
LEMSA’s Medical Director. In coordination with LEMSA, our Chief Medical Director Dr. Benson
will provide continuous medical oversight for our entire system. Dr. Benson, who has practiced
in the County for over ten (10) years, has a Master of Public Health (MPH) with formal training in
epidemiology and biostatistics, and has authored several studies. He is experienced in systematic
data analysis and able to lead the “analysis of performance data and conduct improvement
projects.”
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For the County, he will contribute to three (3) primary areas to effectively serve the County, which are the following:
Quality Assurance - Dr. Benson will actively oversee our ongoing CQI Program at the County. An active Quality Assurance
Program is essential to a meaningful Education Program that prepares our personnel for all job duties/responsibilities.
Educational Program –Dr. Benson will continually assess education strengths and weaknesses of new hires as well as develop
training programs for any identified deficiencies. New crews will be trained to meet our standards, including training regarding
Life-Pak 15, CPAP, as well as national programs such as ACLS, PALS, ICS, ITLS, and others.
Relationships with EMS Teams - Dr. Benson’s medical direction is informed by his extensive experience working collaboratively
with all levels of EMS staff, from first responders to Paramedics. To effectively maintain oversight of a program, our Medical
Director places value in having a strong presence and approachable demeanor among EMS staff as both an educator and an
ED physician who receives ambulance traffic.
In addition, Dr. Benson will be supported by our Associate Medical Director Dr. Hern, who is an attending physician at Highland
Hospital in Alameda County, CA. He will be responsible for coordinating with Dr. Benson, providing additional medical expertise
and oversight, as needed. Collectively, our Medical Directors offer over 18 years of medical experience in the County. Also,
both of our Medical Directors are board certified in Emergency Medicine and have completed the NAEMSP Medical Director’s
Course.
As a result of this collaborative medical approach, all personnel will benefit from an improved system integration, enhanced
communications, and a higher continuity of care among the County’s emergency medical responders. Also, a team of Medical
Directors will ensure availability to the needs of the County at all times.
a) Minimum Requirements— Focus on Patients and Other Customers
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section V.A.5.a.
Customer Access Hotline
We will establish a Customer Hotline that will connect customers directly with the on-duty EMS Field Supervisor, who will
document the concerns and begin research immediately. In the event the caller leaves a message, the call will be returned
within 30 minutes, 90 percent of the time. This hotline is especially helpful when there are concerns of lost or misplaced items
that the patient had with them at the time of transfer over to the hospital staff. We will call back the customer within 24 hours
to gather additional information to make sure we completely understand the concern.
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Those timelines would only extend if we are not able to reach the customer, or if involved personnel are on vacation or
otherwise unavailable within the 48 hour window. The phone number for this hotline will be publicized on our website, the
local telephone directory, and disseminated to healthcare facilities, fire stations and other public safety agencies.
Complaint Resolution
Complaints or concerns can be submitted from a variety of sources. Sometimes, they come in directly to an on-duty EMS Field
Supervisor, or even sometimes to our Customer Service Advocate in the billing department. Regardless of the way of which the
call is received, the research begins immediately with gathering of basic information such as call back number, name of the
complainant, and nature of the issue and is immediately forwarded to a Supervisor for review.
All complaints in the County are received by our EMS Battalion Chief, who will receive the complaint either verbally or in writing.
Once the complaint is received, his designee will call the complainant to obtain information and to review expectations for re-
contact and feedback. Clinical care concerns or complaints are forwarded to our Quality Improvement and Education Team to
review and investigate. The LEMSA Medical Director is contacted, and a review is completed by our Clinical team, or by the
LEMSA Medical Director with our Quality Improvement and Education Team assisting. Findings are documented on a Clinical
Meeting closure form. This form is forwarded to the LEMSA Medical Director office as well as to our Quality Improvement and
Education Team.
All customers are contacted at the completion of the review with our findings and resolution. All original documents are then
sent to our Quality Improvement and Education Team for safekeeping and for entry into our tracking system, currently a
Quickbase application. All local complaints also are entered into an Excel database as a back-up system. The Quickbase
application allows us to trend complaints by crew member, as well as types of complaints.
Complaints that involve employee-employee issues may be forwarded on to the Human Resources department for review
depending on the severity of the complaint. Although the Human Resources department maintains its files separately for
confidentiality reasons, its staff will inform our Quality Improvement and Education Team of the type of review and the involved
parties for entry into the excel database.
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The following chart summarizes our Complaint Resolution process:
All complaints are logged and tracked electronically, and include the following information:
Date of the complaint
Calling party’s name
When contact was made with complainant
Nature of the complaint
Crew involved
Action taken/resolution
Date on follow up with customer
Additionally, all complaints are reviewed monthly at the CQI Steering Committee to identify trends and development of
improvement action plans.
Receiving: Complaints reach us through a variety
of channels including phone calls, emails, website
feedback, supervisor personal reports, and regular
meetings with customers and employees.
Investigating: When a complaint is received, we log
it into our compliance management system, a custom
Quickbase application. The assigned investigator will
call the customer within 60 minutes to gather
additional/amplifying information to make sure we
fully understand the concern, and to let the customer
know that we take all complaints seriously.Reviews
involve gathering all relevant information and
identifying causes.
Resolving: Methods to resolve complaints include
meeting with relevant parties, offering apologies,
correcting the issue, and taking appropriate action to
ensure the issue does not occur again. Our Medical
Director is notified within 24 hours of receipt of all
complaints and resolutions.
Tracking: Our complaint management system
tracks issues and allows us to provide analysis,
reports, and ongoing monitoring of any potential
patterns.
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Over the years, our complaint tracking system and the subsequent analysis have produced several system changes and process
improvements. For example, at one of our operations, a analysis of one of our operations showed an increase in complaints
associated with the cost of ambulance transportation in January and February of 2013. We reviewed the information and
compared with previous months and noted a similar rise in the beginning of 2012. Upon further analysis, including interviews
with the complainant, we determined that patients experienced higher anxiety levels associated with ambulance bills at the
beginning of the year due to the rise in co-payments. With the increase in healthcare costs over the past several years, many
health plans have enacted large deductibles or co-payments. In the beginning of the year, when faced with large out-of-pocket
expenses, patients became angered over high ambulance bills. To address this rising concern, we initiated a program in our
Patient Billing Services department to proactively offer payment plans to patients in the hope of alleviating their anxiety and
avoiding a customer dissatisfaction issue.
b) Higher Levels of Commitment— Focus on Patients and Other Customers
EMS-CAHP
We are proposing through the Alliance to continue to actively measure the patient experience
with our care in the County system using a validated patient experience satisfaction survey based
on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey
tool.
Standardized consumer experience metrics are an increasingly important component of value-based health care evaluation
and compensation. Over the past decade, healthcare system and provider accountability for the patient experience and
responsibility for transparent reporting has become an expectation of organizations and individuals involved in patient care.
EMS as an industry has typically been slow to implement any such metrics, and where customers were surveyed, the survey
tools have been un-identified and cannot be compared directly to other health care organizations.
The HCAHPS survey tool is nearly universally implemented to collect patient experience ratings for hospital in-patients. It is
also now nationally reported by Medicare to permit consumers to directly compare local hospital choices against local, state
and national metrics via the Medicare.gov website. Although many elements of the HCAHPS tool are not applicable to EMS,
and conversely, important EMS measures are not included, using as much as possible of this validated tool will move EMS into
an appropriate position to be considered another valuable component of the continuum of healthcare. For this reason, we has
developed a survey instrument based on HCAHPS but relevant for EMS.
Through the Alliance, this survey is currently available to the County. In 2014, we sent out 5,321 surveys, receiving 638 patient
responses. We will continue to utilize this tool as it has proven to be extremely valuable in allowing both the Alliance and the
local system to demonstrate clearly superior patient experience ratings using a believable and recognizable tool accepted by
all elements of the healthcare system.
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In addition, our billing and accounts receivable department will track customer feedback using its regular surveys. Shown on
below, these surveys are mailed directly to patients along with service and billing invoices.
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Website Feedback
As a public safety leader, we truly value our customer’s feedback because it is a direct reflection of our service. To ensure we
reach all of our customers, we designed a user-friendly, intuitive website that presents multiple communication channels for
them to provide feedback. Below, we provided a few examples of the communication channels that are on our website.
Telephone number
Email address
Service survey (as shown below)
Customer Experience Training
Focusing on the customer is one of our core values. Selecting personnel who have a natural disposition to providing customer
service is the first step in ensuring excellent customer service. To maintain this value we train all new hires in the customer
experience and provide ongoing intensive customer service education.
During this course, we encourage personnel to think “outside the box” and to find creative ways to help patients while ensuring
they stay within the bounds of our clinical and operational guidelines. We support personnel who find safe and effective ways
to improve the circumstances of our patients.
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As a result of these courses and our proven support of personnel who take the customer-focused approach to heart, our
personnel feel empowered to make customer service decisions. Below, we have provided success stories from the utilization
of our training course.
One employee who participated in our customer service course was on a 9-1-1 call in which
the patient was clearly distressed that the soiled sheets in her bedroom would smell on
her return from the hospital. Acting on her own initiative, the EMT collected the patient’s
sheets and put them in the washing machine for the patient before transporting the
patient to the hospital. This action resulted in the patient feeling much more comfortable
leaving her residence.
Working with the fire department, the crew recognized the need for social services support
that could only be offered by staff at one of the local hospitals. Although the patient had
no medical needs that required hospital care, the team transported her to the hospital and
arranged with social workers to help her with public assistance, including finding
temporary housing for the patient.
We value, encourage, and celebrate this level of initiative. Both the company leadership and peers recognize crews that provide
exemplary service and their efforts are highlighted in our monthly employee newsletter as an example for others to follow.
These crews also often receive commendations from local government agencies and community service organizations.
Identifying Key Consumer Groups
We will continue to develop beneficial relationships with these customers to ensure effective interpersonal communication to
quickly identify and resolve issues. Additionally, all members of our local management team have company-provided mobile
phones to increase our availability to key customers and to quickly respond to customer service concerns. We participates in
multiple regional and local EMS committees with other key customers where there are opportunities for direct feedback and
conversation. In addition to patients, we have identified the following key customer groups, all of whom must remain convinced
of our desire to serve the system to the highest possible level:
Contra Costa County/LEMSA
First Responders
Healthcare organizations, including, but not limited to the following:
o Hospitals
o Clinics (primary care, urgent care, dialysis, other specialty)
o In-patient treatment facilities (mental health, alcohol/drug dependence, County Jail)
o Assisted living facilities
o Adult foster homes
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Government elected officials
Advocacy groups
Insurance providers
Board of Directors Meeting
We feel that patient experience is the single most sensitive indicator of the quality of our care and of our acceptance in the
communities we serve. In addition to the proposed patient satisfaction survey, we want to hear directly from our patients and
are proposing to continue to invite the public to quarterly community ‘town hall’ style meetings. We propose to provide the
meeting venue as well as advertise the town hall meeting in the local press or other appropriate communication media one
month before the meeting date. We will extend invitations to local First Responder agencies and health care facilities, and the
meetings will be opportunities for local residents to interface with their local emergency health care providers and receive
education on 9-1-1 access, CPR training, and so on.
In addition, we will participate in local EMS committees, other key customer meetings, and by developing personal relationships
with key stakeholders in the system. In this way, we actively solicit feedback and are able to respond directly to our non-patient
customers.
Demographic Data Striation
Working collaboratively with LEMSA, we have recently partnered with Contra Costa County
Medical Center to offer future integration with the EPIC software. While it is important to
capture and analyze a broad range of data, it is also important to striate the data to determine
if any segment of our patient population receives different levels or types of service.
With MEDS, CAD, and future integration with the EPIC healthcare software program being used by some local hospitals, we
can measure key indicators and striate by gender, ethnicity, age and any number of geographic, demographic and socio-
economic layers to determine if any group statistically varies from the norm of the overall population. Our approach to
“community equity” goes beyond ambulance response times, and dives into the question of whether any population segments
receive different levels of care, present with different clinical challenges, or any number of variations.
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a) Minimum Requirements—Continuing Education
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section V.A.6.a
Our in-house comprehensive Continuing Education (CE) program ensures that our personnel stay abreast of advances in
emergency medicine, maintain the clinical skills they need to provide superior patient care, and meet the evolving needs of the
EMS system.
Our in-service training programs exceed California and LEMSA recertification requirements, and will be provided to our
personnel and to local First Responders at no charge. Our local Quality Improvement and Education Team will oversee the CE
program and works closely with partners to ensure all our training, including in-service CE, OTEP and PCEP, meet the
certification requirements and state regulations and needs, while being responsive to changes in local operational and clinical
activities.
While the core of our CE program is designed specifically to exceed system requirements and proposed enhancements, it will
be developed throughout the term of the contract in concert with the County, and in alignment with the findings of our
comprehensive CQI program.
To help our personnel maintain all required certifications, we offer a variety of CE and certification classes throughout the year,
allowing them to complete their educational training at their convenience and at no cost. The following is a list of just some of
the courses that are available to our personnel and to system responders in 2015:
ALS Support
BLS Support
Pediatric ALS Support
International Trauma Life Support
MCI/Start Triage review
MEDS/Documentation classes
Field /Base Communication Review
Communicable Diseases
Certification Monitoring
All of our personnel are required to maintain their certifications as a condition of employment. We track all records, including
training documentation and certifications in our credentialing database. This database is managed through a cloud-based
human resources information system that is linked to our local scheduling software, ensuring that personnel, who have not yet
completed their probationary status, are not allowed to be scheduled without being assigned to a field training officer until
they successfully completed all phases of their training. Using this system, we can also plan and conduct the appropriate CE
courses as needed to make sure all personnel continue to meet state requirements. We notify personnel well in advance of
certification expiration and provide monthly updates regarding the status of their licenses and certifications.
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b) Higher Levels of Commitment— Continuing Education
CE Connect—Custom Training for Contra Costa Personnel
The Alliance brings cohesive, collaborative and comprehensive training to the entire Contra Costa County EMS system, resulting
in a progressive curriculum designed to enhance the knowledge of all personnel caring for the sick and injured. Our proposed
enhanced continuing education (CE) offerings—CE CONNECT—exceed RFP requirements and create custom training for all
Contra Costa County EMS personnel. In addition, we cover the costs of all courses and pay personnel to attend all mandatory
courses, including Advanced Cardiac Life Support (ACLS), Prehospital Trauma Life Support (PHTLS), Pediatric Advanced Life
Support (PALS), etc.
Innovative Educational Methods
We recognize that current technology and leading edge partnerships allow for more
opportunities to enhance our personnel’s access to available training. Additional educational
offerings will be provided to facilitate a more balanced educational experience for personnel.
Pre-Hospital Education & Evaluation Readiness Solutions Program (PEERS) Program
We have collaborated with Cascade Healthcare Services (CHS) to implement the PEERS Program, a training management
solution that integrates required continuing education training with quality improvement customized to our personnel and the
area. CHS is accredited through the Joint Commission and authorized by the American Heart Association and provides medical
staff and medical training services to Hospitals, Medical Centers, Medical Clinics, EMS authorities, Fire Departments, Federal,
State and Local Government Agencies, including correctional facilities, and individuals in the community.
CHS hires local prehospital and clinically based instructors who represent all phases in the continuum of patient care. PEERS is
a turnkey solution that immediately reduces liability while simultaneously improving the quality of EMS education provided.
The PEERS Programs includes EMS Training Program Management, Infection Control, Paramedic Preceptor & Field Training
Officer Workshops, Policy Updates and Continuous Quality Improvement, and State of the Art Mobile Simulation custom
designed and built for the Alliance to use in the Contra Costa County system.
Web-based Learning Series: e-Grand Rounds and e-Case Review
To maintain clinical excellence and provide updates on state-of-the-art medicine, we have instituted web-based educational
seminar featuring a series of one-hour webinars.
During e-Grand Rounds, the invited presenter showcases information via live webinar, followed by an interactive
discussion facilitated by a moderator. One of the goals of this unique program is to help our teams learn about cutting-
edge medical, including the ‘art’ of implementing clinical science into daily operations. A list of the topics and class
descriptions can be found online via the following URL: http://www.amr.net/e-GrandRounds
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E-Case Review focuses on a single case presented by a local caregiver. Participants at multiple sites throughout the
country view these webinars. Discussion about the case occurs locally among participating viewers and is followed by
a ‘mini lecture’ by a national expert on the topic. The discussion is focused on the case itself, not on analyzing how the
caregiver managed the case. Presenters find the format to be an informative and useful venue for learning more about
the case, as well as how different locations will manage comparable patients. There are typically 50 to 70 participants
reviewing five to seven individual sites in multiple states, and sometimes with guest experts from throughout the
world. Presentations and more information can be found online at http://www.amr.net/About-AMR/AMR-
Medicine/e-Case-Reviews
Both online learning series, are recorded for later viewing by personnel unable to attend the live presentation. We invite all
area first responder agencies to participate in these seminars at no cost.
Learning Portal
As an organization committed to the learning needs of our workforce, a learning portal has been developed to serve as a
gateway for accessing the Learning Management System (LMS). The objective of the portal is to provide a one-stop solution
for the personnel to get the answers to all the issues they face while accessing learning online. The portal will also provide
personnel with the latest information on new releases of educational opportunities. The Learning Portal is a communication
and knowledge hub with multiple information channels. The design is responsive and made for use on portable devices. Below
is the list and description of the widgets:
“My Guide to the LMS” - This includes How to Guides, FAQs, checklists for personnel on using the LMS. Allows search
for reference materials within the system. The “FAQs” will present short answers for the frequently asked questions
and the “How to Guide” has a video presentation to explain step by step action on common questions regarding the
LMS
Spotlight - A monthly feature presenting the focus of the month for continuing education
“Know Your Experts” - Allows the personnel to seek expert advice and address questions on continuing education
offerings. Using this widget questions can be communicated to subject matter experts within the organization. The
sites keeps the collection of questions answered earlier and shows this collection prior to typing a new query for the
expert. Personnel can search for matching text in the collection of previously answered items or if not satisfied with
the existing collection of question-answers they can type a new query to the expert
News & Announcements - Posting of news/articles/announcements to enhance the learning of our workforce and
familiarize them with various initiatives. This widget contains information in the form of images, video, text and links
to internal and external sites
Education Programs - Provides up to date information on training programs occurring periodically to include
compliance, human resources, or IT security
Links - Offers a list of links to connect with the LMS, social communication channel used for learning, and Education
sites
Continuing Education Credit - Consists of continuing education training programs offered to support
licensure/certification renewal. Provides a list of the continuing education courses offered in the LMS. The site will
show the program name and associated credits. When clicking on the name, the system opens a popup explaining
the curriculum and the distribution of the credits by category
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Targeted Education Programming
Our local CQI findings form the basis of much of our CE program, as will our conversations with the LEMSA Medical Director
and other responders in the system. We will continue to work closely with our system partners to update our offerings to meet
current and evolving system care needs. We will also collaborate with LEMSA to create forward-thinking educational
programming delivered in innovative ways to ensure that all system responders provide the highest level of patient care. The
information we gather will help us to develop targeted educational programs that reflect the unique needs of the County, such
as the following programs:
Specialized education designed in cooperation with local trauma, STEMI, and stroke centers
Annual hospice education
Timely news-style CEU vignettes through our Learning Management System
Protocol review sessions
Initial and refresher 12-lead ECG courses
Remedial training packages
Posting of relative evidence-based articles and studies through social media
Web-based Training
Using emerging technologies has made education more accessible for our personnel s. Utilizing a Web-based platform, each
course will be geared toward knowledge enrichment and offer one or more specific methods to validate learning or course
completion. We also offer several paid online courses that personnel must complete, including:
Hazardous Communication
Fire Extinguisher Training
General Compliance Training
Creating Professional Documentation
IT Security Training
General Corporate Integrity Agreement (CIA)
Requirements
General CIA - Code of Business Conduct and
Ethics
General CIA - General Compliance
Harassment Prevention for personnel
Harassment Prevention for leaders
(Supervisory Training)
Workplace Violence Prevention
Workplace Violence Prevention for Leaders
(Supervisory Training)
Prevention of Sexual Abuse
Understanding affirmative action
Supervising (non-union & union
environment) - HR General Supervising
Supervising: Union Basics - HR Union
Fundamentals
General Business Knowledge
Overview of the Alliance and Contra Costa
County EMS System
Introduction to AMR Medicine
Patient Focused Care and Advocacy
Things that Matter™
Quality and Performance
Documentation
Safety Risk Management (SRM) 5199
California ATD
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SRM Airborne Pathogens (three courses)-
1. SRM Airborne Pathogens: Epidemiology
(part 1)
2. SRM Airborne Pathogens: Routes of
Entry (part 2)
3. SRM Airborne Pathogens: Control and
Protection (part 3)
SRM Bloodborne Pathogens Training
Cleaning & Disinfection
Handwashing
Infection Control Nugget
SRM Fire Extinguisher Nugget
SRM Fire Extinguisher and Emergency Action
Plan
Lifting Techniques
SRM HazMat Emergency Response
HAZ COMM and GHS Training (Revised)
Heat Illness - SRM
Emergency Vehicle Operators Course (EVOC)
Driving Policies and Emergency Vehicle
Operation Laws
EVOC Basic Driving
EVOC Vehicle Dynamics and Backing Up
EVOC Emergency Mode Driving
EVOC Beginning of Shift Check
EVOC Road Safety Nugget
Information Technology Information Security
Annual Training
Just Culture
Expanded Content Training
Disaster Training
All EMS Field Supervisors who serve the County are currently trained in accordance with ICS, MCI response, Strike Team leader,
and HazMat communications and hazardous materials response. They will also be trained in ICS 300 and 400 before the start
of the new contract. Field staff will be trained in Personal Protective Equipment (PPE), Hazmat Awareness, and NIMS (100, 200,
700, and 800), plus two hours of additional disaster training per year.
Pit Crew Training
The Pit Crew concept of resuscitation is intended to organize EMS responder’s efforts towards improving patient resuscitation.
Responders are most likely arriving at different times and from different agencies, needing to rapidly and effectively prioritize
and provide the most critical elements associated with successful resuscitation. By learning the Pit Crew Concept roles, the
responders should be able to more rapidly integrate themselves into a resuscitation effort.
Depending on the design and resources of the local EMS system a single individual may be the only responder initially available.
However, if more resources are recruited an understanding of the Pit Crew Concept will help ensure timely and efficient
integration into the resuscitation.
Whether it is one, two or many responders the goal of this concept is to facilitate each responder’s knowledge of the priorities
that will increase the chances of successful resuscitation.
We will offer to lead this program if desired by LEMSA and assist in the development of the curriculum.
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B. OPERATIONS
a) Minimum Requirements— Dispatch and Communications
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section V.B.1.a
For the purpose of this contract, the Alliance will utilize a single medical dispatch solution at our Contra Costa Regional Fire
Communications Center (CCRFCC) located in Pleasant Hill. CCRFCC is a state-of-the-art PSAP that services the majority of fire
and EMS calls for all jurisdictions in the County, excluding San Ramon Valley, Richmond, and El Cerrito. In addition, the center
operates as the hub for all fire and EMS resources including interacting with neighboring jurisdictions of Alameda County, the
City of Richmond, and San Ramon Valley. By acting as the hub, the center is equipped to provide better situational awareness
and communication within the County. This communications center meets and exceeds the minimum requirements outlined
in the RFP.
b) Higher Levels of Commitment— Dispatch and Communications
As a higher level of commitment, we will offer the County the following:
National Academy instructor for EMD classes
Priority Dispatch EMD Advancement series (Continuing education available by CD subscription) to assist in meeting 24
hour continuing education requirements for all EMD certified personnel
Access to Emergency Medical Dispatch Quality Assurance (EMD-Q) reviewers to assist with monthly QA call reviews
Below and on following pages, we have provided additional higher level of commitment offerings for Dispatch and
Communications that will benefit the County.
Consolidated Dispatch Center
Traditionally, a fire agency and ambulance provider will operate two (2) independent systems, each system unaware of the
coverage being provided by the other system or the commitment and drawdown of the other’s resources at any one time. This
independent approach has proven to be ineffective as it leads to miscommunication between the two (2) systems, and potential
duplication of work, which can ultimately affect the patient’s experience and/or outcome.
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As a benefit to the County and to improve call processing times, the Alliance will operate
through a consolidated dispatch center that will encompass fire and ambulance dispatch
services. Utilizing this collaborative approach, ambulance dispatch personnel will be co-located
at CCRFCC, providing improved situational awareness and instantaneous communication as
well as enhanced coordination of resources and responses. Additionally, this approach will
allow us to proactively identify potential issues in both systems, fire and EMS, enabling decision
makers and dispatchers to distribute resources to improve gap management in times of peak
demand.
All dispatchers are certified Emergency Medical Dispatchers (EMD) allowing our center to appropriately prioritize EMS calls
using a medical priority dispatch system (MPDS), thereby matching the responding resource configuration with the level of
service required, as well as the ability to facilitate pre-arrival instructions to the caller for CPR events or other emergencies
where bystander intervention can have a positive effect on patient outcomes.
The CCRFCC is self-sustaining with an emergency power supply to support the center for long periods in the event that primary
power is lost. The center has a large kitchen area and sleeping facilities to support our personnel on a daily basis as well as for
long operational periods.
Ambulance and first responder resources are equipped with mobile data terminals or computers (MDT) and automatic vehicle
location (AVL) which provides fire and EMS dispatchers, working together cohesively, to both see the real time resource
coverage of the County. In addition, crews in the field are able to monitor response times, view locations of other adjacent
resources, use GIS maps to provide for quicker response, see other responding resources in real-time to avoid potential
emergency vehicle collisions, and help resolve potential gaps in coverage before it becomes an operational issue.
Dispatch Center Methodologies & Equipment
East Bay Regional Communications System Authority
We are a founding member of the East Bay Regional Communications System Authority (EBRCS). The system provides secure,
robust, resilient, and redundant communications to all public safety agencies in Contra Costa and Alameda
Counties. Additionally, our communications center maintains a VHF conventional repeated system as a backup in the event of
the EBRCS failing or becoming overloaded. This system provides fire and EMS resources the ability to be agile and resilient in
times of heavy system load or primary communication failure. Additionally, by including VHF capabilities in all of the
ambulances, the units have better interoperability with other mutual aid resources from outside the county operational area
who normally operate on a VHF system. For example, the ambulances will be able to communicate with State and mutual aid
resources operating within the County for a wildland fire or large disaster.
TriTech Inform 5.5 CAD
Multi agency delivery models typically require two (2) agencies to exchange information with a CAD-to-CAD interface. The
interface is often a point of failure, and because it is shared between two (2) disparate CAD systems, the information may not
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flow seamlessly. This outcome can cause the interface to provide incomplete information or simply “go down”, resulting in
delays.
The Alliance will utilize TriTech Inform 5.5 CAD to manage all of the fire and EMS units, the call details, and accurate response
time information. The information will be seamlessly passed from call takers and fire dispatchers, to ambulance dispatchers,
to units in the field in near real time. Information, including dispatcher comments, changes of call type or location, and all
other data, is shared comprehensively through the benefit of operating on the same system.
Utilizing the Tri-Tech Inform 5.5 CAD with a Live Move up Module or equivalent system status management tool, we are able
to provide better coverage of EMS and fire resources. Utilizing a Live Move up Module will detect and display holes in unit
coverage by listening to CAD in real time. This software enables dispatchers to instantly view weaknesses and strengths in
coverage in real time. The algorithm utilizes statistics of the system for unit commit time and statistical call history.
We will provide each ambulance with a mobile interface into the CAD allowing the unit to accurately assign status and see call
details with only a few second delay. This technology provides crews direct access to incident data as the dispatchers or units
create the information. In addition to the mobile CAD interface, the ambulances will be equipped with automatic vehicle
location (AVL). AVL provides dispatchers the ability to see the location of units with only a few seconds delay. The Tri-Tech
Inform CAD recommends the closest unit by type and its calculated response time.
Navigation Software
Referencing similar mapping information can be a challenge with separate agencies. We will enable all of the ambulance
resources the ability to navigate utilizing turn-by-turn navigation software. This navigation software will be able to route units
with turn by turn directions to a latitude and longitude point already verified by the CCRFCC CAD. This software provides a
higher level of accuracy because the address has been verified with an up to date geodatabase file. The device can then route
to a static point on the map without an address lookup. We will be sharing our mapping data digitally with all units in the field
so that ambulances can see the same mapping layers as dispatchers and fire resources. This commitment puts all units on the
same plane for situational awareness. The CCRFCC provides GIS resources to ensure maps are current and integration with
CAD is working properly.
Interoperable Templates
To benefit the County, we will provide improved interoperability with training, equipment, supplies, radios, radio channels, and
operating procedures for all personnel. The first step to enhance interoperability for the County’s system will be in
communications. We will be the primary dispatch center for both fire and EMS. This strategy will provide a better
understanding of the call details between fire and ambulance dispatchers as well as field units. Additionally, radio configuration
and channel configuration will provide full interoperability, allowing fire and EMS units to interoperate seamlessly as a cohesive
unit.
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Mobile Data Terminals (MDT)
We agree to provide MDTs as described in the RFP. The MDT permits the communications center to track ambulance resources,
send status changes electronically, and receive dispatch information electronically. With the use of MDT/AVL devices and voice
communication systems, we will report key time indicators to LEMSA. Key time indicators will include, but will not be limited
to, the following:
Call received
Start of response time measure
Crew en route time
On-scene time
Cancellation time
Transport time
Hospital arrival time
Unit available
Call Taker performance
Dispatcher performance
EMD protocol compliance
Emergency call answer times
We will serve as our point-of-contact (liaison) and will communicate with LEMSA key personnel to ensure we are continuously
meeting the needs of the of the EMS system in the County. Our Epidemiologist along with LEMSA personnel will analyze and
evaluate late calls to see where improvements are needed through a rigorous CQI program. We will provide all necessary
resources to the LEMSA in order to assure that the communication system is well integrated and the performance requirements
can be achieved
Other Strategies to Reduce Response Times
For over 35 years, we have been utilizing System Status Management (SSM) techniques to ensure our emergency medical
services models are successful. We use the most advanced EMS system modeling method available in the industry to create
System Status Plans that allow us to consistently meet and exceed response time requirements. This type of sophisticated
deployment modeling leads to improved productivity (improved response time compliance), lower costs of operations
(efficient unit hour utilization), and more efficient use of limited resources. We use the deployment modeling tool in the
following ways:
Simulation: allowing “dry-runs” of different strategies on computer models, to investigate scenarios and test
improvement ideas
Optimization: mathematical models used to select the best possible solutions, from thousands of possible choices
Data Analysis: detection of patterns and connections in data, providing insights for forecasting to help with
optimization of patient care and outcomes
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Our SSM techniques ensure that we will meet and exceed all contractual response time requirements within this RFP. The
following components are used to develop SSM analysis:
The number of calls the system must respond to varies by time-of-day and day-of-week. This number typically changes
over time and may have strong seasonal trends
The location of the calls varies, generally having underlying patterns based on time-of-day and day-of-week, as well as
seasonal variation
The type of calls (or call mix) vary by time-of-day, day-of-week, and may vary seasonally
The availability of suitable resources depends on staff schedules, and therefore varies by time-of-day, day-of-week,
and is further complicated by staff shifts potentially starting at different geographical locations
The time taken to drive throughout the service area (either to calls or to a destination) is highly variable, depending
on factors such as traffic congestion and road networks
Where and when a vehicle becomes available (after transporting) is impacted significantly by whether the call requires
transportation to a facility providing specialty services, the location of that facility, and how long the transfer of care
process takes
The capability of different vehicles, and the requirement for different types of calls to have different skill-sets
dispatched (including First Responders) to the scene
The mandated/contracted operational policy, such as how to respond to the different types of calls, and the required
personnel at-scene
Required response time performance measures that are applied to different types of calls and to different
geographical zones
We propose to continue work with LEMSA to develop and build a SSM plan within the Tri-Tech CAD system that allows for rapid
deployment and unit placement.
a) Minimum Requirements—Vehicles
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section V.B.2.a.
All ambulances shall meet the standards of Title XIII, California Code of Regulations.
All of our ambulances will meet the standards of Title XIII, California of Regulations.
Ambulance vehicles used in providing contract services shall bear the markings of the County logo and "Contra Costa County Emergency
Medical Services" in at least four (4) inch letters on both sides. Such vehicles shall display the "9-1-1" emergency telephone number and
state the level of service, "Paramedic Unit,” on both sides.
All of our units will bear the markings of the County logo and “Contra Costa County Medical Services” in at least four (4) inch
letters on both sides. Our vehicles will display the “9-1-1” emergency telephone number and state the level of service
“Paramedic Unit” on both sides.
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Ambulance vehicles shall be marked to identify the company name, but shall not display any telephone number other than 9-1-1 or any
other advertisement.
Our units will advertise our company name and will not display any telephone number other than 9-1-1.
Overall design, color, and lettering are subject to the approval of the Contract Administrator.
We understand that the overall design, color and lettering of the units are subject to approval of the Contract Administrator.
We will collaboratively work with the County to ensure any existing or new designs are approved.
Proposer shall describe the ambulance and supervisory vehicles to be utilized for the services covered under the Agreement.
Currently, through the Alliance, our operation maintains a fleet of 78 vehicles, including the following:
48 Type III state-of-the-art ambulances designed and equipped to provide Advanced Life Support, and a specialized
Bariatric transport units (for patients in excess of 500 lbs)
Five (5) Supervisor vehicles
Sixteen (16) Battalion Chief vehicles
Three (3) support vehicles
Four (4) Disaster unit
Two (2) Decon units
These vehicles were selected for many unique reasons. Of paramount importance is their ability to offer a comfortable and
safe ride for patients and improved working conditions for our crews. In addition, through our existing partnership with Ford
and American Emergency Vehicles, we are able to leverage our buying power to bring the best of ambulance manufacturing to
our patients. Our fleet will continue to be equipped with leading edge safety features to ensure the safe transport of the sick
and injured and to protect our caregivers.
Ambulance replacement shall occur on a regular schedule and the proposers shall identify its policy for the maximum number of years and
mileage that an ambulance will be retained in the EMS System.
We will replace all frontline dedicated units to the County once they reach five (5) years or 195,000 miles. Each week, our fleet
team will document the vehicle mileage of every ambulance in our County fleet. We will use these mileages to schedule routine
maintenance and to compare mileage to contract parameters. Using this system, we can predict when ambulances will hit our
contract mileage thresholds and plan their replacement accordingly. This system also allows us to track all repairs made and
parts used by vehicle ensuring a detailed replacement/repair history for every vehicle.
Each ambulance shall be equipped with GPS route navigation capabilities.
All ambulance units dedicated in the County will be equipped at all times with GPS route navigation capabilities, tracked
through the dispatch center.
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b) Higher Levels of Commitment— Vehicles
Environmentally Friendly Ambulances
As your partner, we will transition to Sprinters or equivalent eco-friendly ambulances for
replacement ambulances as the existing fleet reaches its maximum service life. The transition
to environmentally-friendly ambulances will benefit our partnership by greatly decreasing
exhaust, nearly doubling our miles per gallon with reduced costs in the service department.
Safety Features
Hundreds of EMS providers are injured and killed each year because of traffic accidents. We understand the importance of
safe vehicles and has taken numerous steps to ensure our units are the safest on the road. The County can rest assured that
we will amend our safety specifications as federal safety requirements evolve. In addition to the minimum requirements, all of
our ambulances include the following best-in-class safety features:
The only modular body on the market that has been double- impact crash tested and certified. These are listed in the
table on the following page.
Modular body has been certified to more than 200% of minimum load test requirement
All seat belts and anchorages bolted through metal
Attendant seat provided with 3-point seat belt
Squad bench seating provided with 6-point restraint system
A detachable aviation quality restraint net installed at the head of the squad bench
Antimicrobial grab handles
Seamless upholstery to minimize contamination
Emergency Start System with failsafe vehicle starting circuitry switch and dual reserve batteries
High-conspicuity reflective exterior graphics
Aggressive LED warning package
Drive Cam or equivalent
Additional to primary fleet, we will maintain back-up that will remain available from large regional and national fleet as needed
to supplement disaster response or special events in the County. Our selected fleet for the County not only will support green
initiatives through improved fuel efficiency and pollution reduction technology but also will be outfitted with various safety-
and industry-leading features, as highlighted in the table on the following page.
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Ambulance Modifications for County Units
Independent emergency starting system Safety net at the head of the squad bench
Electrical circuits controlled by a circuit board system of 15-
20 independent and interchangeable circuit boards
Limiting straps on cab doors designed to eliminate over-extending
doors that damage door posts and hinder door-latch catching
mechanisms
Recessed overhead grab rails in patient compartment,
eliminating potential head strike hazards
High-performance, high-visibility, interior and exterior LED lighting
packages with 75 percent less electrical power demand
AC systems ducted into the body of the vehicle and intake
equipped with HEPA filters
Automatic 5-minute battery disconnect switch that turns off
battery power when the vehicle is turned off, ensuring batteries do
not discharge while idle
Power inverters with built-in battery conditioners
Yellow caution flags to help prevent head strike when entering and
exiting the rear of the vehicle
Anti-lock Brake System (ABS)
Acceleration Slip Regulation (ASR) traction control that avoids tire
slippage by monitoring and stopping spinning wheels
Brake Assist System (BAS) that monitors driver’s speed and
applies pressure to the brake when needed – applies full
brake boost during panic situations
Load Adaptive Control (LAC) algorithm that calculates the vehicle
mass and center of gravity using various parameters such as
acceleration, speed, accelerator position, etc., improves braking
characteristics and helps reduce the risk of rollover
Rollover Mitigation to improve handling. Detects critical
lateral accelerations and reduces the risk of rollover by
reducing engine torque and by applying controlled braking
pressure to the relevant wheels. Supported by the vehicle
mass-sensing system LAC
Roll Movement Intervention improves roll-over stability even
further by engine and braking intervention during extremely
dynamic maneuvers
Under Steering Control to provide enhanced stability
under heavy under steer
Active Restraint System, a safety feature to keep personnel safe
while attending to the patients
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a) Minimum Requirements—Equipment
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section V.B.3.a.
We will continue to comply with all equipment and supply requirements as listed in the RFP. We understand that we will
remain responsible for all costs of maintenance including parts, supplies, spare parts and costs of extended maintenance
agreements, and that LEMSA may inspect our ambulances at any time, without prior notice. Also, we will maintain all specific
pediatric equipment requirements as specified. In addition, we agree to all penalty provisions outlined in this RFP.
A History of Compliant Equipment
As a public safety provider in the County, we offer a long-lasting history of compliant
equipment. Long before LEMSA requirements, the original founding Fire Departments that
currently make up our organization provided all of the equipment necessary to deliver
emergency care. In 1922, the Fire Chief of the Martinez Fire Department, Chief Briones,
purchased the first resuscitator after a drowning in the Alhambra Creek. It was called a Lung Motor. Over the years, this
proactive commitment to EMS has continued. In 1997, we moved forward to deliver the best available service by leveraging
its Measure H allocation to fund First Response Advanced Life Support. This effort has kept the County in line with the most
progressive EMS systems in the Country.
As your partner, we pledge to continue to meet your needs and always equip our personnel with the appropriate resources to
provide exceptional service and quality care. In addition, we will remain committed to actively seeking innovative equipment
that is specially designed to improve patient outcomes.
b) Higher Levels of Commitment— Equipment
Seamless Equipment Integration
To ensure full integration, as well as a reliable service, the Alliance will utilize all of the same
equipment and software platforms, which includes, but is not limited to our MEDS ePCR and Tri-
Tech CAD system. This strategy will ensure personnel operate as a cohesive unit, allowing us to
provide consistent and dependable pathway management of patient care from the time a call is
received to the time the patient is transported to the hospital.
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Multi-EMS Data System (MEDS) Electronic Patient Care Recording (ePCR)
Through the Alliance, we will utilize the Multi-EMS Data System (MEDS) electronic patient care
reporting (ePCR) system. A current and proven tool to efficiently and accurately capture clinical
and demographic data, the MEDS ePCR system has been tested strenuously over the past several
years and we have developed considerable expertise organization-wide in its upkeep and
maintenance. Thus, our operations are secure in the fact that the system is well-understood and
supported by national resources, and that troubleshooting assistance is available with one phone
call if needed.
We will provide state-of-the-art ruggedized laptops to crews using MEDS. We currently deploy Panasonic tablet FZ-G1. These
ruggedized notebooks meet military and International Electrotechnical Commission standards for vibration, dust, and water-
resistance. The data collected by MEDS software is used by our leaders and our EMS Agency partners to make fact-based
decisions regarding operation performance, clinical protocols, and patient treatments. MEDS is more than an ePCR product; it
is a solution that interconnects multiple systems, including:
ePCR
Clinical data
Billing information
NEMSIS reporting
CAD reconciliation
Data mapping
Reporting and analysis
MEDS ePCR is the largest deployment of pre-hospital care data collection in the United
States. Presently, no other commercially developed ePCR system surpasses the number
of implemented sites as MEDS ePCR solution. The MEDS ePCR system provides a
comprehensive approach to improving patient care through data sharing and patient care
systems integration. Unique characteristics of the MEDS ePCR system include the
following:
Local control of screen changes to meet local requirements and real-time administrator changes to field devices
Ability to deliver expanded communication and reference material to caregivers in the field, including electronic “quick
references” for clinical protocols, medication dosage calculators, and other training material, which is accessible
during down time
Front and back-end business rule configuration to increase accuracy of PCR documentation
Compilation of clinical data into a data warehouse that facilitates research and study of millions of annual patient care
encounters
Mapping of data points to the NHTSA data set (NEMSIS) for compliance with federal recommendations for clinical and
demographic reporting, allowing for data comparison with other EMS systems
The ability to auto-populate fields by pulling data from our billing system for transported patients
The elimination of redundant entry of PCR data into a billing application
Ability to integrate data from our cardiac monitor/defibrillators into the PCR
Ability to perform Clinical Quality Improvement functions through immediate access to PCRs, Ad-Hoc reports, and
MEDS alerts
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Fire MEDS
Our San Mateo operation is in the implementation stages of a new, innovative ePCR data collection
software called “Fire MEDS.” The program software was designed by recognized external software
development companies, supported by our development team and most importantly guided by a
team of local fire paramedic first responders. The goal of this program was to create first responder-
specific ePCR data collection software that enables the ability to document and share data with the
transporting agency’s MEDS ePCR platform. Additionally, this software operates on Apple iPad
hardware, enhances user experience, and supports clinical reporting.
Fire MEDS will benefit first responders in the following ways:
User friendly design
Fast - PCR completion flows logically with the care provided
Photo integration into the ePCR of trailing documents such as the ECG
Data reporting for clinical improvement functions and electronic viewing of the ePCR
Capability if desired to complete ePCR on-scene and transmit
Capability to facsimile transmit ePCR to hospital
Meets NEMSIS 3 GOLD standard of data collection
If awarded the contract, we are willing to implement a similar program with all Contra Costa County fire agencies operating in
the EOA. Below we have provided a screenshot of this software.
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Innovative Equipment
We provide a wide array of innovative equipment and technology for our County personnel,
patients, and partners. This includes, but is not limited to, the following:
LifePak 15
An assistance to firefighters grant, combined with Measure H funds and
the purchasing power of the Alliance, we were able to procure Physio
Control LifePak 15 Cardiac Monitors and defibrillators for all First Response Advanced Life Support
agencies in the County. In addition, the Alliance recently purchased 55 new Physio Control LifePak 15 for
our EMS transport units. This monitor/defibrillator is a state-of-the-art, comprehensive patient monitoring system
incorporating multiple new physiologic parameters and algorithms to help support decision-making in the field or in
consultation with the receiving hospital emergency department. Pre-hospital care providers have the ability to transmit a 12–
lead EKG (critical cardiac diagnostic data), to the receiving emergency department as well as designated physicians.
This transmission capability has a dramatic effect on time-dependent management and coordination of care for an acute heart
attack patient, improving a patient’s probability of surviving these types of emergencies.
EBRCS Portable Radio
We will equip all of our County units with EBRCS Portable Radios. The EBRCS system provides secure,
robust, resilient, and redundant communications to all public safety agencies in Contra Costa and
Alameda County.
Stryker Stair-PRO
Following a recent evaluation, we have decided to equip all of our County units with the Stryker Stair-PRO
(Model 6252) stair chairs. These stair chairs include a stair tread to allow for safe and comfortable
movement of patients.
Stryker Power-Pro
Following a study done by us and Western Michigan University in spring 2010 that
showed a 62 percent reduction in back-injury claims, we are committed to the
installation of Stryker’s Power-PRO XT powered ambulance cots in our County units.
Mobile CAD
Our supervisor unit will be equipped with a mobile CAD unit. This software will enable the supervisor to monitor all EMS
system activity, as well as take care of scheduling in Telestaff, page field personnel, and communicate with on-duty units.
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Vacuum Spine Boards
We will continue to equip all of our County units with Evac-U-Splint. These devices provide
spinal motion restriction more effectively and with greater comfort for the patient.
Compression Devices and other Medical Devices
We routinely evaluates the efficacy of new medical devices to determine which new technology developments positively affect
patient outcomes. Given the recent controversial discussion and lack of evidence supporting any benefit of automated
compression over appropriately performed manual compression, we commit to biannual skills refresher and resuscitation for
all system providers. We will also provide ongoing monitoring of compression density during every resuscitation attempt. In
the future, should the scientific medical evidence determine efficacy of external cardiac compression devices or other medical
devices, we will reevaluate the potential deployment of this equipment in the County EMS system.
a) Minimum Requirements— Vehicle and Equipment Maintenance
Attestation:
We understands and agrees to comply without qualification to provisions, requirements, and commitments
contained in Section V.B.4.a.
High-quality vehicles and on-going fleet maintenance will continue to play a critical role in the success of the County’s EMS
system. Rather than simply performing scheduled routine maintenance to keep our vehicles in superior condition, we will
utilize our comprehensive preventive maintenance program, unrivaled in our industry, to ensure the reliability and safety of
our vehicles. We are pleased to offer a proven program that ensures consistent, safe, local fleet maintenance services for the
County.
Each ambulance would be defined in the system, along with level data.
o The ability to link “secondary” components (i.e., serialized medical equipment in back) with “parent”
ambulances
“Secondary” components can have their own inspections
All scheduled inspections and services are user-defined, customized to the ensure safety of patients.
o Customized inspection checklists
o User-defined services and service intervals
A, B, C, D, etc. level services, each with escalating levels of service and inspection items
Scheduled by date, mileage, and operating hours (whichever comes first)
Integrated work order system captures detailed, job-level data
o Date/time in, first labor, finished, closed, back in service
o Mileage and engine hours at time of job
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o Task-level detail per job (using VMRS industry standard repair task codes)
Labor, by individual technician, to the 1/10th hour
Parts cost, per task
Historical data maintained for life
o Data can be accessed via “canned” reports and custom reports
Fleet Maintenance program
At our operations, we staff four (4) full-time Automobile Service Excellence (ASE) accredited mechanics, who oversee our fleet
maintenance facility’s daily operations. This facility provides services to a fleet of nearly 60 vehicles, which includes the
following:
48 Type III state-of-the-art ambulances designed and equipped to provide Advanced Life Support, and specialized
Bariatric transport units (for patients in excess of 500 lbs)
Five (5) Supervisor vehicles
Three (3) support vehicles
One (1) Disaster unit
Each day, our field crew EMTs and Paramedics stock, check, inspect, clean, test all equipment, and add their personal
equipment before the vehicle is deemed ready for service. Staff members also clean each vehicle at the start of each shift and
inspect it for any damage at the end of the shift. If there is any damage, they report this immediately and remove the vehicle
from service as soon as possible. All units are inventoried daily using an inventory checklist. If any repairs are needed, an
Equipment Failure Problem Report Form is completed. All costs of repairs and maintenance, including extended warranties,
will fall under the expense of the Alliance.
Every 5,000 miles, our in-house mechanics will perform a systematic bumper-to-bumper inspection of our vehicles examining
more than 190 parts, using a preventive maintenance inspection form. Our mechanics will review each preventive maintenance
inspection form to ensure satisfactory completion of the required maintenance. The completed form becomes a permanent
record providing a comprehensive vehicle maintenance history and serving as an example of our accountability. Our inspection
process is based on research involving thousands of vehicles, enabling our company to determine the most effective interval
for part replacement. This has allowed us to maximize the in-service time of our ambulances and reduce the risk of road failure.
Maintenance is performed at the 15,000, 30,000 and 60,000 mile mark as well. Please see the table below for an overview of
this maintenance schedule.
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Preventive Maintenance At-A-Glance
Services
Every 5,000 Miles
Additional Services
Every 15,000 Miles
Additional Services
Every 30,000 Miles
Additional Services
Every 60,000 Miles
•Lubrication •Repeat 5,000-mile service and
add items below
•Repeat 5,000- and 15,000-mile
services and add items below
•Repeat 5,000-, 15,000- and
30,000-mile services and add
items below
•194-point safety and
mechanical Inspection
•Replacement of fuel filter •Rear differential service •Replace belts
•Change oil and filter •Transmission service •Replace idler pulleys and
tensioner
•Replace air filter ●Replace vacuum pump
Batteries – Test and inspect every service interval. Replace in sets of two if required.
Shocks – Inspect every service interval and replace as necessary.
Universal Joints – Inspect every service interval and replace as needed.
Maintenance Recordkeeping
For our operations, we utilize the Ron Turley Associates (RTA) Program, a commercial fleet maintenance software package to
track maintenance and to evaluate our performance in both the ambulance and fire apparatus fleet. RTA documents service
and repairs, tracks mileage, and generates a full range of reports, including vehicle service schedules. As the preventive
maintenance and repair work is performed and the data is posted, the system updates the vehicle maintenance history,
documents equipment failures, deducts the parts used from inventory, and tracks maintenance costs.
As a result, our technicians have at their fingertips the entire maintenance history of the ambulance and fire apparatus– from
the last oil change to any other repair performed – enabling them to be thorough, precise, and fully accountable in all future
situations. Based on compiled data, our technicians can also predict part failures or end of useful life and provide the
appropriate preventive maintenance specific to each ambulance. When ambulances and fire apparatus come into the shop for
maintenance, technicians document every action they take on the preventive maintenance inspection form. These records
help us prioritize ambulances by repair and maintenance needs, and reduce the amount of time our ambulances are out of
service.
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b) Higher Levels of Commitment— Vehicle and Equipment Maintenance
Manufacturer’s Maintenance Standards
Below is our fleet maintenance procedures, from our Fleet Policy Manual. These procedures are in compliance and/or exceed
the California Highway Patrol’s standard for ambulances.
Rotate tires during each PMI, or every 5,000 miles
Replace front and rear tires when they measure 4/32 of an inch at the thinnest point of their tread
Tires across an axle, under normal operating conditions, must be of the same model and tread design
Tire tread depth across an axle will not measure or vary greater than 4/32 of tread height
All tires/rims will have full steel valve stems. When original tires require replacement, valve stems will be converted
as needed to 100 percent full steel valve
Additional procedures regarding inspection and documentation include, but are not limited to, the following:
To conduct a proper brake inspection, all wheels must be removed during the PMI inspection. All brake components,
hoses, lines, pads, rotors, fluids, must be inspected during a PMI interval
To ensure brake wear is documented properly, all measurements will be recorded on Inspection Form CO-0021F-00
Brake pads will be pulled and replaced when they measure 5/32 of an inch
Bio-Medical Equipment Maintenance
Through the Alliance, we will utilize a customized equipment maintenance program to closely
monitor inventory levels and maintain the quality of critical biomedical equipment. This program
allows us to identify when a specific piece of equipment is scheduled for its next maintenance
based on manufacturer specifications and our policies and procedures. By following the
manufacturer’s recommended time schedule for PM, such as with Cardiac Monitors, we minimize
the potential for equipment failure at a critical time.
We seek vendors that offer maintenance guarantees and maintenance agreements. Using our national economies of scale, we
are typically able to purchase agreements for the majority of our equipment. Any equipment not covered by a maintenance
agreement is paid for on a fee-for-service schedule.
In the rare event a biomedical device experiences a mechanical failure, our crews immediately complete an Equipment Failure
Report and take the piece of equipment out of service. The EMS Operations Manager will immediately provide the unit with
an identical replacement from our equipment storage cache, placing the ambulance back in service as rapidly as possible. The
EMS Operations Manager then coordinates with the designated vendor to repair the equipment. Once repaired, the item is
returned to the Alliance and placed in storage as reserve equipment.
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We track all equipment failures through incident reports, which are sent to the EMS Operations Manager. This tracking allows
us to identify trends indicating a manufacturer defect or unusual use by field personnel. Corrective action may include working
with the manufacturer to mitigate manufacturing defects, or using the information to provide needed education to field
personnel on proper care and use of biomedical equipment.
Driver Training
Following the classroom component, Emergency Vehicle Operating Course (EVOC) students move into eight (8) hours of
behind-the-wheel instruction in which they drive an ambulance under close observation. The hands-on field-training
component gives students the opportunity to practice the techniques taught in the classroom on a controlled course, under
the direct supervision of EVOC instructors. Students experience the forces involved in actual maneuvers and learn the
characteristics of the vehicles. The EVOC instructors provide feedback on their performance, begin to incorporate real
experience lessons, and give students ample time to practice their new skills.
Training objectives for this part of the module include the following:
Collision Avoidance – Split-second decision-making drills and simulations of potential accident conditions
Controlled Speed – Line-of-entry, hand positions on the steering wheel, apexing, vehicle dynamics, and braking
techniques
Precision Maneuvering – Parallel parking, off-set lanes, three-point turnaround, backing in and out of parking stalls,
and serpentines
Our EVOC program is designed to instill in personnel the internal motivation to continually learn and seek to improve their
abilities as professional emergency vehicle operators, thereby reducing the likelihood that an EVOC- trained driver will become
involved in a traffic collision. Injuries and even death can be averted by teaching true defensive driving and due regard for the
safety of others.
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Safety Features
Hundreds of EMS providers are injured and killed each year because of traffic accidents. We understand the importance of
safe vehicles and has taken numerous steps to ensure our units are the safest on the road. The County can rest assured that
we will amend our safety specifications as federal safety requirements evolve. In addition to the minimum requirements, all of
our ambulances include the following best-in-class safety features:
The only modular body on the market that has been double- impact crash tested and certified. These are listed in the
table on the following page.
Modular body has been certified to more than 200% of minimum load test requirement
All seat belts and anchorages bolted through metal
Attendant seat provided with 3-point seat belt
Squad bench seating provided with 6-point restraint system
A detachable aviation quality restraint net installed at the head of the squad bench
Antimicrobial grab handles
Seamless upholstery to minimize contamination
Emergency Start System with failsafe vehicle starting circuitry switch and dual reserve batteries
High-conspicuity reflective exterior graphics
Aggressive LED warning package
Drive Cam or equivalent
Commission on the Accreditation of Ambulance Services (CAAS)
We agree to continue to meet and exceed maintenance standard as outlined in in the
Standards – Accreditation of Ambulance services published by the Commission on
Accreditation of Ambulance services (CAAS). CAAS is an independent commission that
promotes quality patient care in America's medical transportation system by establishing and
maintaining comprehensive standards for the ambulance service industry.
CAAS accreditation is the “gold standard” in the ambulance industry, with standards that often exceed local and state
regulations. To become accredited, ambulance providers must complete a comprehensive self-assessment and pass an outside
review conducted by CAAS.
We have held CAAS accreditation for nearly eight (8) years in the County. Nationally, we have more operations accredited by
CAAS than any other provider, with a total of 22 CAAS-accredited operations.
For a list of our CAAS accredited operations please visit http://www.caas.org/caas-accredited-agencies.
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a) Minimum Requirements— Deployment Planning
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section V.B.5.a.
EMS System Design Considerations & Deployment
Through the Alliance, we will continue to offer a deployment plan built on our proven experience in meeting and exceeding
response-time requirements, as we have done consistently over the years in both urban and rural settings. Our operational
experience is supported by our use of evolving technology, techniques and tools in our drive to continually improve our system
coverage to meet changing needs. We will continue to ensure a close collaboration with LEMSA and allied agencies to monitor
and adjust our deployment to exceed the response-time requirements for the County.
In addition, the Alliance will further benefit the County by the achieving the following operational synergies:
Enhanced deployment planning
Effective utilization of resources
Enhanced interoperable communication efficiencies
Enhanced data collection and analysis capabilities
All deployment planning assumptions for the future contract have been based both on the historic information available and
on our own research in the County. This section outlines our proposed contractual commitments to the County system and
offers an overview of our deployment planning methodology.
Deployment Plan
Our deployment plan for the County will ensure the closest ambulance will be sent to the call every time. Based on our
experience, we are able to intimately understand the needs of County and develop a comprehensive deployment plan that will
meet and exceed the expectations of the response time requirements. We will deploy 12-hour shift schedules for our initial
deployment plan. This deployment allows us to more effectively match resources to the demands of the system and also
provides flexibility along with a variety of schedules/work hours for our crews to choose from.
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Our initial deployment plan for this contract includes 4,788 deployed ambulance unit hours per week. This is equivalent to the
provision of at least 248,976 ambulance unit hours annually. Core (lowest) deployment will be 18 units, with a peak of 39
ambulances during the highest demand. As this is a performance-based contract and call demand is dynamic, we are committed
to increasing units to match volume and contractual requirements. Analyzing the County call volume and hot spots, we will
strategically deploy 12-hour units, with the ability of backfill, if needed.
Below and on the following pages, we have provided maps that display historical data from our responses during the day and
night.
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Below and on the following pages, we have provided maps that display historical data from our level four posting coverage for
day and night.
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Events that require an unplanned surge include MCI, unexpected high-call volume, and requested mutual aid into neighboring
counties, such as Alameda, Solano, Marin, Napa, Sacramento, just to name a few. Additionally, we provide backup support for
Moraga Orinda Fire Department.
Rather than wait for the industry-norm twenty week period to elapse to conduct a new demand analysis, we will immediately
begin using our deployment modeling tools upon contract start. With these advanced tools, we do not have to wait the
standard twenty weeks before re-analyzing demand and adjusting accordingly.
Our proposed SSM plan allows us to match our supply of available ambulances to County’s demand for patient care requests,
as outlined here, maximizing our UHU:
Geographical Coverage – We place the correct number of on-duty units in the right location, flexibly relocating them
to ensure optimum system coverage.
Demand Coverage– The demand for services varies by hour-of-day and day-of-week. For example, weekdays may be
busier than the same time of day on the weekend, due to traffic and employment patterns.
Building the plan through analysis
An important step in the deployment modeling process is to ensure that current ambulance request data provides an accurate
reflection of true historical EMS System performance. This goes far beyond simply looking at system response times. Our
organization is at the forefront of SSM planning and has developed a proprietary process that incorporates the traditional
methods of completing a demand analysis and much more. This process is used to determine the number of ambulances
necessary to staff the system for each hour of the day. We strongly focus on the workload of all ambulance crews in the system.
We define workload as all time spent on a call, beginning at time dispatched and ending when the crew is clear from the call.
By evaluating each one-hour period and determining the number of active calls in each time period, each call and its real time
to complete is represented very accurately, often across multiple hours of coverage.
Through the Alliance, we will utilize our web-based application Operations Planning and Analytics Platform (OPAP), which
contains a number of data analysis and reporting tools that allows our management team to quickly and easily evaluate
performance and changing demand, in a close to real time environment. We evaluate response time compliance for each hour
of day and day of week and adjust staffing to fill any identified gaps. Because the target is response time compliance, not how
many calls we run, we do not use the typical demand analysis to determine staffing. Rather, we identify the times of day and/or
days of week that have experienced lower thresholds of response time compliance, and then adjust staffing to bring them up.
Likewise, we analyze response time compliance by geographic sub areas to ensure that no area is underserved. By analyzing
response times and deployment in this fashion, we ensure that no time of day, day of week, or area of the County receives
inequitable service.
Once appropriately tuned to the system, our program produces very clear guidance to make sure we consistently have the
appropriate resources to meet the demand and the performance targets. The more call data brought into the program, the
better it gets.
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Deployment Plan Refinements
Upon analyzing our historical incident data, we engage our Regional and National expert resources to assist us in fine-tuning
our deployment plan. These resources, in conjunction with our local operations management staff (with more in-depth local
system knowledge), review this data and evaluate how our plan is working every day. Traditional approaches would generally
dictate that new demand analysis studies be performed at least twice per year. We know from experience that season al
variances and changes in system growth occur all of the time so our process is always working. This means that a new and
slightly adjusted plan can become active, allowing us to make more frequent, small adjustments to our plan instead of big
changes every six months. Other areas we look at to determine if our deployment plan needs modification are:
Trending of late responses in any zone
Month over month decreases to overall and zone compliance
Feedback from caregivers and system partners
Long term road construction that may be occurring
Ambulance Locations/Posts
Our current posting plans were developed by our team using historical EMS data as the incumbent. As discussed above,
collection and analysis of response time data will begin on the first day of the new contract. For any future posting refinements,
CAD data will be collected and utilized to drive modeling tools and methods to ensure the optimum location of our units for all
service levels.
Our team uses GPS technology in each vehicle to help identify and prioritize the post locations that best ensure our ability to
exceed response-time requirements. To model posting plans, we define a particular service zone, map the historical calls,
identify proposed post locations for unit deployment, and then analyze how many calls our units are capable of reaching from
that post within the contracted response time. We then prioritize the posts based on the ability to capture calls in relation to
other post locations in the system.
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Deployment Plan by Hour-of-Day and Day-of-Week
The table below represents our initial deployment plan for the County’s system, by hour-of-day and day-of-week.
ALLIANCE UNITS DEPLOYED
Contra Costa County
Day & Time
SUN
MON
TUES
WED
THURS
FRI
SAT
12:00 AM 23 23 23 23 23 23 23
1:00 AM 20 20 20 20 20 20 20
2:00 AM 20 20 20 20 20 20 20
3:00 AM 20 20 20 20 20 20 20
4:00 AM 18 18 18 18 18 18 18
5:00 AM 18 18 18 18 18 18 18
6:00 AM 22 22 22 22 22 22 22
7:00 AM 22 22 22 22 22 22 22
8:00 AM 25 25 25 25 25 25 25
9:00 AM 29 29 29 29 29 29 29
10:00 AM 32 32 32 32 32 32 32
11:00 AM 33 33 33 33 33 33 33
12:00 PM 34 34 34 34 34 34 34
1:00 PM 37 37 37 37 37 37 37
2:00 PM 37 37 37 37 37 37 37
3:00 PM 37 37 37 37 37 37 37
4:00 PM 39 39 39 39 39 39 39
5:00 PM 39 39 39 39 39 39 39
6:00 PM 35 35 35 35 35 35 35
7:00 PM 35 35 35 35 35 35 35
8:00 PM 32 32 32 32 32 32 32
9:00 PM 28 28 28 28 28 28 28
10:00 PM 25 25 25 25 25 25 25
11:00 PM 24 24 24 24 24 24 24
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b) Higher Levels of Commitment— Deployment Planning
As a benefit to the County and to improve call processing times, the Alliance will operate through
a consolidated dispatch center that will encompass fire and ambulance dispatch services. Utilizing
this integrated approach, ambulance dispatch personnel will be co-located at CCRFCC, providing
improved situational awareness and instantaneous communication as well as enhanced
coordination of resources and responses. Additionally, this approach will allow us to proactively
identify potential issues in both systems, EMS and fire, enabling decision makers and dispatchers
to distribute resources to improve gap management in times of peak demand.
Operations Planning and Analytics Platform
We have experience and knowledge of systems with potential problem areas. We are
able to pinpoint causes and develop mitigation solutions using our quality improvement
processes and technologies. Our newly developed web based Operations Planning and
Analytics Platform (OPAP) was built for this purpose as well as to ensure we meet and
exceed response time commitments even as population and call volume evolves.
The OPAP platform was built after over a year of extensive
review of deployment best practices and with the
involvement of a third party consulting firm. It is
supported by a team of experienced CAD data managers,
information technology programmers and reporting
analysts. The platform imports data directly from the
local CAD systems and is customized to local community
response time criteria through the development of
business rules.
The OPAP platform enables our operators to produce up to date system demand charting at
the press of a button, any time, any day. Utilizing this data, we will adjust schedules, resources
or posting as needed to ensure excellence in response time performance. We have produced
positive results with OPAP demand charting system. One example involved a system suffering
from poor on-time performance. Through the usage of OPAP demand charting and analysis,
the system was able to identify that crew workloads were too high which was impeding our
ability to be at adequate posting locations when being dispatched on the call. We made the appropriate adjustments which
included a revised posting plan, schedule adjustments to improve responses in the late afternoon, and increased unit hours.
These actions resulted in a decrease in crew workload, a better distribution of the workload throughout the day, fewer late
calls, and much needed improvement in on time performance.
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Daily reviews & Demand Analysis
As part of our ongoing system response time improvement process, late calls are reviewed daily by our operations with an eye
to identifying the performance gap, its ‘root cause’ and providing rapid correction and feedback. Our Supervisors and
Supervisors have the authority to quickly make changes and adjust the ambulance coverage plan as needed to eliminate or
minimize the changes of additional late calls.
To assist our staff with their daily reviews, the OPAP platform provides a mechanism for detailed retrospective investigation of
any call that does not meet specific and customizable criteria or response times. These calls are captured for review to ensure
proper handling of response deployment, posting, routing, etc. Within the same system, the user can quickly research any call
data, routing and response details to investigate delays for quick system adjustments or actions to ensure ongoing improved
response time performance.
Below, we have provided a screenshot of OPAP.
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Below and on the following pages, we have provided screenshots of server viewer app and mapping from our geographic
information system.
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Resolving a problem
If a problem is identified in the system, the team evaluates the situation to determine if it is short-, medium- or long-term in
nature and plans accordingly. Solutions may include the following:
Trend analysis and process improvement
Adjust posting plans
Adjust coverage plans
Adjust employee work schedules
Adding new resources to the system
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Criteria for Change
Compliance with response-time standards is just one of the criteria we use to decide if the coverage plan needs modification.
With the data from our OPAP system we also look at:
Trending of individual late responses in any response zone
Road construction zones
Month-over-month decreases to overall and zone compliance
Special events demand
Effect of adverse weather events and local MCI responses
Feedback from caregivers and system partners
When system changes are identified, our OPAP platform enables users to build custom schedules. A key feature of the OPAP
schedule building software is the ability to graphically overlay new schedules with recent demand trends. This software allows
us to accurately match the right amount of resources to the right times of day and day of week to ensure proper response time
performance. For example, with the recent closure of Doctor’s Medical Center, we strategically identified a trend in call
demand through OPAP, which allowed us to shift unit hours to sufficiently meet our patient’s needs.
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C. PERSONNEL
a) Minimum Requirements— Field Supervision
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section V.C.1.a.
We agree to provide an on-duty supervisor 24-hours per day, seven (7) days per week, within each geographic zone as required
in the RFP.
In order for an EMS system to function effectively and maintain the highest level of clinical care and customer service possible,
it must have consistent and competent field supervision at all times. We intimately understands this need and will continue to
take pride in the fact that our County team will operate at all times under the direction of a highly-experienced and extensively-
trained team of supervisors and captains.
Through the Alliance, we will provide nine (9) EMS Field Supervisors, who are credentialed as County Paramedics and staffed
24/7. These individuals will continue to carry full medical equipment and provide first response and patient care as needed.
Additionally, these EMS Field Supervisors are provided with the training and tools to monitor, evaluate, and improve the clinical
care provided by paramedic and EMT personnel. Upon hire and consistently throughout employment, our supervisory team
members are provided with local professional development opportunities, often in collaboration with regional leadership
teams in neighboring counties. This provides them with both initial and ongoing education to our approach to field supervision
and reinforces the key role our EMS Field Supervisors play within the hierarchy of our management team.
Also, our EMS Field Supervisors will attend monthly leadership team meetings and will remain in direct contact with the EMS
Operations Managers. These individuals serves as an ongoing professional network 24/7.
To ensure our team is continuously prepared for any unforeseen event, our field supervisory personnel must successfully
complete the Federal Emergency Management Institute Incident Command System (ICS) series 100, 200, 300 and 400, NIMS
700 and 800b.
Observation & Evaluation
EMS Field Supervisors are selected for their leadership roles based on performance and spend a majority of their time in the
field, where they directly observe their colleagues caring for patients and interacting with the public. The EMS Field Supervisors
respond on calls with field crews to observe, evaluate, and provide support. Any additional refreshment training is provided
as necessary, at no cost to our team members.
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Exemplary Performance Standards
Below are some additional examples of the knowledge and skill qualifications held by our EMS Field Supervisors.
The ability to effectively communicate organizational goals and objectives that drive outstanding clinical and
operational performance
The ability to evaluate, coach and remediate field personnel. Our dedicated EMS Field Supervisors ensure all field
personnel maintain all State, County, and LEMSA-required certifications and accreditations (managed and tracked
through a web-based platform)
The provision of on-scene assistance for crews, as needed
The ability to act as a coach, teacher or evaluator on multi-casualty incidents with the goal of reviewing each call
for continuous improvement and compliance with existing policies
The ability to assist in driving performance management
Compliance with all employment laws and support of affirmative action/equal opportunity and diversity goals
Participation as part of the unified command structure under the direction of the Fire officer during multi-casualty
incidents and greater alarm fires.
b) Higher Levels of Commitment— Field Supervision
We understand the importance of field supervision as it relates to the success of our operations. In this section, we have
outlined our higher levels of commitment for Field Supervision.
Robust Unified Command Structure
The Alliance offers the County a robust unified command structure that includes the following:
Fire Chief
One (1) Deputy Fire Chief
Two (2) Assistant Fire Chiefs
Four (4) shift Battalion Chiefs 24/7, 365 days per year
One (1) EMS Chief
One (1) General Manager
One (1) EMS Operations Manager
One (1) Training Chief
One (1) Shift Safety Officer (Captain) 24/7, 365 days per year
Four (4) Chief Officers are on call, within a 30 minute response time, each day in addition to the shift Battalion Chiefs
on duty within the District
Fire Prevention Bureau, including one (1) Fire Marshal, four (4) Captains, three (3) Fire Investigators, and sixteen (16)
Fire Inspectors (all sworn peace officers).
o Five (5) personnel trained to serve as Public Information Officers
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Each fire engine and ladder truck company is staffed with a Fire Captain for supervision
Nine (9) EMS Field Supervisors
One (1) Clinical Education Services Manager
Two (2) EMS Quality Improvement and Education Team Coordinators
One (1) Data Analyst / Epidemiologist
One (1) Community Outreach Coordinator
We will continue to have a dedicated EMS Field Supervisor on duty in each section of the county, as well as an on-call response
ready Chief 24/7. If necessary to supplement increased future operations, supervisory, and management staff will be added.
For example, during holidays, three-day weekends, and other periods of increased call volume, we will add supervisory staff
accordingly. We understand the importance of ensuring that our field supervisory team has the right tools to do its job
effectively.
In this regard, the team is provided with supervisory vehicles, as well as a variety of other tools, including the following:
MDTs with broad functions to monitor unit availability, status and current assignments
Full spectrum/interoperable communication equipment for day-to-day supervision as well as disaster management
In-City and out-of-area resource lists for personnel, vehicles, and equipment
A wide array of MCI equipment, training manuals, and supplies
An iPad with the Telestaff scheduling application to make schedule/staffing adjustments quickly
Participation in Regional Strike Teams & Disaster Medical Support Unit Deployment
Our Contra Costa County Field Supervisory team will participate in Regional Strike Teams and Disaster Medical Support Unit
Deployment as well as be highly knowledgeable and competent in the Contra Costa County MCI plan. Through continuous
training, we will continue to offer the County a sophisticated approach to disaster management. We have an extensive network
of local resources in this region, so we will continue to offer County the security of knowing that in the event of a major multi-
casualty incident, our surge capacity from nearby areas can also be activated. All Alliance supervisory staff members will
participate in Strike Team response and have been extensively trained at the Ambulance Strike Team Leader level for
ambulances.
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a) Minimum Requirements— Work Schedules
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section V.C.2.a
We are committed to providing the optimal working conditions for all personnel. In this regard, we will meet and exceed all
requirements related to work schedules and conditions. We will develop practical work schedules and shift assignments to
provide reasonable working conditions for our ambulance personnel. Work schedules are designed to meet both system
requirements and personal needs of everyday life.
We recognize that maintaining a safe work environment is a key component of an ongoing safety program. Studies by federal
and private agencies have shown that fatigue in the workplace is often a contributing factor to increased accidents and
employee injuries. We strive to create and maintain an environment free of hazards and to establish methods for the ongoing
identification of threats to employee health and safety.
Policy Regarding Fatigue Prevention
It is the responsibility of a company officer to continually monitor the status of their crew. Our personnel are provided exercise
time and rest periods throughout their shifts. During down time and the hours of darkness, beds are provided for sleep.
Additionally, a field employee who feels that he or she is no longer able to perform the basic job responsibilities due to fatigue
must immediately notify their supervisor. Once the on-duty supervisor is notified, the unit is immediately taken out of service
and a replacement is identified. We also require the employee to document the following items so we may identify any
contributing factors to the fatigue and resolve those issues.
Time employee reported for duty
Time the unit was placed out of service
Number of calls completed during the shift
Estimated number of hours spent in the ambulance during the shift
Estimated number of hours of sleep obtained during the shift and prior to on duty time
Other factors contributing to the fatigue to include outside employment
Our leadership will relieve any crew member that in the opinion of management is fatigued or presents a risk to the
safety and well-being of our crewmembers, patients or the general public. In the event that it is deemed necessary to
send an employee home it will be considered administrative leave for the remainder of their shift
No transport ambulance personnel will work a regularly scheduled shift of more than 12 hours.
Personnel are discouraged from performing work at outside employers and directly reporting for shifts without
adequate rest time
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b) Higher Levels of Commitment— Work Schedules
We understand that fatigue poses significant safety risks to both our personnel and the patients under their care. Our work
schedules are designed based on analysis of call demand patterns in the community and the desires of personnel, taking into
account human resource policies, labor laws, and the need to minimize on-duty fatigue.
In addition, we have an on-duty fatigue policy; personnel have the ability and obligation to report when feeling fatigued and
unable to safely perform their duties. In this situation, crew members will be removed from service until they are sufficiently
rested.
We will continue to utilize Telestaff, an innovative scheduling system that acts as a tool to
reduce unnecessary overtime, preventing our personnel from working beyond the maximum
allowed shifts. Also, this scheduling system allows our personnel to manage their time off.
We have seen repeated success in reducing employee fatigue through the use of this system.
a) Minimum Requirements—Risk Management
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section V.C.3.a.
Through the experience of the Alliance, we have implemented and maintained an aggressive health, safety, and loss mitigation
program that meets all requirements of this RFP. We currently engage in all LEMSA-required safety and risk mitigation activities
and will continue to do so for this contract if awarded.
Health & Safety Program
It is for the benefit of everyone in the County’s EMS system that our personnel are healthy and work in a safe and effective
way, and that we maintain and introduce ever-higher standards of safety compliance. We have worked rigorously to develop
a safety program that exhibits our commitment to the safety of our personnel, our patients, and the communities we serve
and we are fully compliant with Federal and State OSHAs and other regulatory agencies. We are supported in these efforts by
our local, regional and national safety leadership teams, and we work closely with our partners to address safety concerns that
we can solve together. Our mission in safety and risk management is to understand both systems and behaviors that contribute
to the risk in any given incident or situation; instead of simply reviewing and investigating, our ultimate goal is to eliminate the
potential for a future occurrence.
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Our safety program demonstrates our commitment to the safety of our personnel, our patients, and the communities we serve.
Fully embedded in our CQI process, the program includes the following five (5) objectives and strategies for achieving safety:
Objective 1: The Selection of Highly Qualified Personnel
Objective 2: Loss Control through Exemplary Safety Policies and Programs
Objective 3: Effective Personnel Education and Training
Objective 4: Management and Employee Safety Accountability
Objective 5: Continuous Review / Improvement and New Safety Initiatives
Highly-Qualified Personnel
We are the only provider that offers the County a tenured, well-known workforce of highly qualified personnel. Because most
of our personnel live and work in the communities we serve, they are passionate about providing professional, courteous
service at all times.
The first leg of our safety program is to make sure we hire the best people and ensure their ability to provide the quality of care
we expect. In addition to assessing their clinical skills, our pre-screening also includes drug testing, with a zero tolerance policy
in place as well as a stringent physical agility test specifically developed and validated for Paramedics and EMTs before being
accepted for a position.
Our Physical Agility Test (PAT) is used as a standardized screening tool for pre-employment in EMS. It assesses various physical
abilities required to perform the paramedic and emergency medical technician job duties. The weights and equipment used in
the test are designed to simulate the physical abilities needed to lift and transport patients and equipment in the field. It is
also used for current personnel returning from a leave of absence. The PAT has two (2) main purposes, which are the following:
To measure the ability to perform the essential functions of the job
To reduce health and injury risks for both personnel and patients
Health, Safety, and Risk Management Program Manual
We will utilize a comprehensive set of injury and illness prevention policies, identified in our Health, Safety, and Risk
Management Program Manual. This manual covers our Injury and Illness Prevention Program, Infection Control Program as
well as our Risk Management Program. These programs have consistently reduced employee injuries and workers’
compensation costs year after year.
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Injury and Illness Prevention Program
Our Injury and Illness Prevention Program consists of a set of guidelines and processes to ensure employee and patient safety
at every level, and includes the following central elements:
Injury and Illness Prevention Policy: Provides a structured approach to identification, evaluation and control of
occupational safety and health hazards; summarizes our approach to basic safety and health management issues; and
complies with applicable regulations
Safety Incident Reporting Policy: Provides a structured approach to communications to ensure appropriate resources
are engaged subsequent to a safety incident occurring in the workplace
Safety Inspection Policy: Effectively assists personnel in identifying workplace or equipment hazards so that
corrective actions can be taken. Safety inspections ensure that we are aware of and address all safety, health, risk
management and regulatory concerns during the course of providing medical care and transportation services
Patient Handling Policy: Addresses safe patient handling through the use of transfer assistance devices and safe lifting
practices, helping to reduce the risk of personal or patient injury in the field
Gurney Safety Policy: Addresses the key safety, health, risk management and regulatory issues relating to the use of
gurneys in the field
Vehicle Safety Policy: Communicates how our personnel comply with applicable vehicle safety laws and regulations.
In some cases, the provisions of this policy require our personnel to meet higher performance standards than may be
established by federal or state regulation, providing an enhanced margin of safety for our personnel, our patients, and
the communities we serve
Hazardous Materials and Emergency Response Program: Delivers a structured approach to exposure prevention and
control that maximizes protection against HazMat-related injury and illness for all personnel and covers all aspects of
our responsibilities at a HazMat scene and the medical treatment of properly decontaminated victims
o The program is compatible with national and state standards, and includes annual employee training to meet
the curriculum requirements for First Responder Awareness for EMS, including additional decontamination
and medical management information
Hazardous Communication Program (HazCom): A comprehensive hazard communication system to help personnel
reduce the risk of harmful exposure to hazardous substances in the work environment. The program outlines specific
responsibilities for personnel who may handle potentially hazardous chemicals in the workplace and procedures to
follow in the event of a spill, including first-aid or medical treatment indications. Personnel are trained annually in the
need to clearly label containers filled with hazardous chemicals, how to interpret the markings on the labels and what
to do in the event of a spill or an exposure in accordance with GHS standards
o The program meets guidelines for each employee’s “Right to Know” about the hazardous properties of
chemicals provided for their use, including disinfectants, automotive fluids, degreasers and solvents
Workplace Violence Policy: Outlines a comprehensive prevention and response system to reduce the likelihood of
workplace violence. We do not tolerate acts of workplace violence or abusive behavior, either from our workforce or
out in the field. This policy clearly defines what constitutes workplace violence or abusive behavior and trains
personnel who believe they have been victims of such behavior on the notification steps to follow after an abusive
event. The policy also clearly states that personnel who come forward with such complaints will not be subject to
retaliation that would threaten their employment status
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Compressed Gas Safety Policy: Assists personnel and managers in reducing the risk of compressed gas-related injuries
and complying with regulatory requirements
Fire Prevention Policy: Provides a basic set of procedures to reduce the likelihood of fire in our facilities, vehicles and
other work areas. In the County, we use the policy as a foundation and augment it as needed to comply with our local
requirements, risks and employee circumstances
Emergency Action Plan: Outlines a basic set of procedures to reduce the likelihood of employee injury in the event
of a workplace emergency
Infection Control Policy: Provides a comprehensive infection control system that maximizes protection against
communicable diseases for our personnel and patients
Employee Vaccination and Titer Policy: Provides personnel with the policies and procedures needed to help reduce
the risk of acquiring or spreading infectious disease through a robust vaccination program
Infection Control Training Policy: Provides procedures needed to ensure reduction of occupational exposure to
infectious disease
Infection Control Cleaning and Disinfection Policy: Procedures designed to help reduce occupational exposure to
infectious pathogens through the proper cleaning and disinfection of our buildings, ambulances, equipment and other
environments where contact with infectious agents may occur
Sharps Exposure Prevention Policy: Provides personnel with appropriates policies and procedures to help reduce the
risk of contaminated sharps exposures
PPE for Infection Control Policy: Policies and procedures designed to help reduce occupational exposure to infectious
pathogens and decrease the likelihood of employee injuries caused by motor vehicles, construction vehicles and
equipment while working near a roadway through the use of Personal Protective Equipment
Respiratory Protection Policy: Policies and procedures that provide a structured approach to compliance with
regulations designed to prevent occupational exposure to TB and other airborne transmissible pathogens
Post-Exposure Management Policy: Processes the assist with reducing the risk of occupationally acquired infectious
disease through the use of timely post-exposure evaluation and treatment procedures
Incident Reporting, Investigation, & Corrective Actions
Our success in safety is partially due to our recognition that each incident provides an opportunity to learn more about how to
reduce employee, patient, and organizational risk. In line with our overall approach to improvement, and our goal of
introducing Just Culture as a natural evolution to our current system, we focus on identifying issues in an overall system setting
and putting into place the required education and processes to provide solutions. By developing this culture, in which caregivers
are taught how to recognize that mistakes are made, and feel able to report these mistakes – and have the issue remedied –
in a non-punitive setting, we have been able to create a system in which people feel comfortable reporting incidents.
For an effective safety incident reporting system, it is essential that we gather information on every incident, no matter how
small, that occurs within the organization. In 2010, we developed and implemented our Near Miss Reporting System, which is
a voluntary, anonymous reporting capability that encourages field staff to report potential patient and employee safety events.
Our goal with the near-miss reporting system is to capture the reports that have the biggest potential threat to the safety of
our patients and caregivers and identify reasons and solutions, taking an analytical, non-punitive, system-based approach. Our
near-miss reporting system is based on the 300/29/1 theory, in that for every 1 bad outcome there were 29 near-misses and
300 events that had the potential to be a near miss or bad outcome.
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Through this system, combined with our robust data management system, STARS, we are able to collect data on every clinical
and risk management incident, and we have additional channels – such as Equipment Failure Reports, to gather operational
data. Through these channels, we gather all safety incident data, exceeding legal and OSHA requirements.
Our strict incident reporting standards allow our management team to respond immediately to adverse events, initiate a
thorough investigation, implement mitigation measures, and carry out corrective actions in a timely fashion. In most cases, the
process is handled by the local Operations Manager, who benefits from specialized training, job aids, form tools, and guidance
provided by our Regional Safety and Risk Management staff, who are readily available for consultation 24 hours a day, seven
days a week.
In addition, management and supervisory personnel discuss each incident during monthly meetings to ensure that sound
incident investigation, management, and corrective action processes are used and properly documented. All information
becomes part of our regular CQI program to allow for ongoing monitoring and corrective action as required. We are pleased to
provide the following brief summaries of some of the many practices that support our safety and risk management mission:
Incident reviews: This performance improvement program has been highly successful in reducing risks and improving
workplace safety for our patients, personnel, and stakeholders
Investigation and documentation: We have established strict incident reporting standards that allow our team to
respond immediately to adverse events, initiate a thorough investigation, implement mitigation measures, and carry
out corrective training in a timely matter. Our County operation (as well as several other cities) will utilize STARS, an
electronic safety reporting system that provides daily, monthly, and annual tracking of collisions and workers’
compensation claims. Users can categorize incidents by date, location, and type, body parts affected, equipment in
use, and other parameters. Once entered, this data can be reviewed at local, regional, or national levels, allowing
supervisory staff to recognize trends and improve safety measures and equipment accordingly. All information is
made available to LEMSA and other applicable County personnel on a continuous basis
Ethics and compliance program: Focusing on employee education and company compliance with all federal, state,
and local payor regulations, our compliance program tracks changes in federal laws and regulations, as well as
government enforcement that affects us and our customers, ensuring that we are always in full compliance with all
laws and regulations, something that is essential for the peace of mind of all the communities we serve. Our
compliance program has been in effect since 1998 and contains and exceeds the guidance issued by the Office of
Inspector General (OIG) in 2001
Health and safety programs: Through the Alliance, we will utilize a comprehensive set of injury and illness prevention
policies, known as our Health, Safety and Risk Management Program Manual. This manual includes our Injury and
Illness Prevention Program, Infection Control Program, and Risk Management Program
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b) Higher Levels of Commitment— Risk Management
We have several advanced safety procedures and programs in place that demonstrate our higher-
level commitment to the well-being of our personnel, patients, and partners. Janice Nath-Studzinski
is our Designated Safety Coordinator for the County, providing oversight of safety policies and
procedures. She is supported by a Regional Safety and Risk Manager, 24/7.
In addition, a 24/7 Shift Training Captain (STC) is assigned to each shift. These individuals respond to
all working fires, greater alarm incidents, MCIs, and other incidents when requested to fill the position of incident safety officer.
In the Incident Command System, the safety officer is charged with the responsibility for assuring personnel safety, and to
monitor and/or anticipate hazardous and unsafe situations. The safety officer is also responsible for assuring that exposure
and injury reports are completed, assisting the District’s Safety Officer with accident investigations, recommending policy
changes related to improving safe operations, and for providing ongoing safety training of personnel.
Below, we have highlighted our Risk Management initiatives that will benefit the County.
Rehabilitation Unit
Our fleet of staffed resources includes a Breathing Support Unit, also identified as BS-7. BS-7 also functions as an incident
rehabilitation unit and is equipped with multiple shade canopies, large cool misting fans, chairs, ice chest with cold beverages,
and a full advanced life support cache. This unit is staffed by an engine company with a minimum of one (1) paramedic and
two (2) EMT’s.
Just Culture
It is incumbent on us to create a culture that ensures mistakes are rectified and lessons learned for the benefit of the patient
and our caregivers. All too often in healthcare, mistakes are blamed on the individual when it is often the system that is at fault.
Through the Alliance, we model based on the principles of a Just Culture model, whereby caregivers are taught how to recognize
that mistakes are made and feel able to report these mistakes – and have them remedied – in a non-punitive setting. Our
approach to improvement clearly focuses on identifying issues in an overall system setting and putting into place the required
education and processes to provide solutions. Just Culture is a natural building block to this approach and will become integral
to the improvement model in all elements of our operation.
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Video Event Recorder
To ensure a higher level of safety for our teams and to assist in ongoing driver training, we will install a Video Event Recorder
(VER) on all newly purchased ambulances. This device continuously monitors and captures risky driver behavior in real-time,
providing an objective insight into how our drivers are complying with company policies and federal laws, while also providing
a record of their driving behavior. With the use of this technology, we will improve our ability to reduce unsafe driving habits
and implement corrective measures – before a collision occurs. Additional benefits on Video include:
Reduced Agency Liability
Improved Safety
Useful In-Service Training (Post-Incident)
Heightened Performance and Professionalism
Simplified Incident Review & Reporting
The data being measured will be shared with the LEMSA further attesting to our commitment to a collaborative relationship.
Recent Safety Changes
As a result of the work conducted by our national Safety Leadership Group, we have made a
number of changes to our workplace guidelines and equipment to improve safety for our
crews and patients. The following are a few of the recently refreshed programs:
Effective Personnel Education and Training
Ongoing, stringent, and consistent education and training are keys to the success of our safety program. We begin developing
and maintaining a safety culture for personnel from when they first arrive in orientation and continue the emphasis throughout
their careers. This includes our safety training, including our extensive Emergency Vehicle Operations Course (EVOC).
Initial & Ongoing Driver Training
On an average of 150 times a day, the Alliance’s resources respond to calls for aid. The integrated dispatch center and response
vehicles will have the ability to identify the locations of responding resources, potentially reducing the risk of responder
collisions. To this end, we promote education as a key to safety. This initiative is particularly evident in our driver-training
program, which includes 16 hours of employee training and four hours of refresher training every two (2) years.
Our comprehensive EVOC program presents the necessary classroom instruction, competency field training, and testing for
new and existing drivers, and meets all EVOC goals and objectives. The program verifies proficiency in the understanding of
emergency vehicle driving, as well as the practical application of that knowledge. It covers all applicable laws and regulations,
as well as our local policies governing vehicle operations.
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Topics covered during the eight-hour classroom portion of our driver-training program include the following:
California State vehicle codes pertaining to emergency vehicle operation
Case studies of emergency vehicle collisions and litigation
Vehicle characteristics
Defensive driving
Placement of vehicles at emergency incidents
Driving policies and procedures
Once personnel successfully complete the classroom component, they must complete a practical driving course behind the
wheel of an ambulance. The practical phase covers low-forces maneuvering exercises that include backing, braking, and
cornering in a controlled environment. The program focuses on emergency vehicle dimensions, operating dynamics, and an
enhanced level of awareness of an emergency vehicle's influence on the behaviors of other motorists.
Our personnel learn strategies that allow them to drive defensively and protect themselves, their patients, and anyone else on
the road. This hands-on experience also allows our field personnel to practice their driving skills, enhancing their ability to
understand local traffic patterns, road and weather conditions, and the reaction of local drivers to emergency vehicles. This
technique cannot be accomplished in a simple didactic setting, but must be accomplished through classroom and hands-on
instruction.
Personnel are required to successfully complete the driver-training program before being assigned to work onboard an
ambulance. Once initial training is completed, personnel continue to hone their driving skills as part of their FTEP.
National Safety Initiative
To build a culture of safety, it is essential to communicate expectations clearly and often to all personnel, using a variety of
communication techniques. Our National Safety Initiative a variety of tools to promote safety and safe practices among our
personnel on an ongoing basis.
Every month, our national Safety Leadership Group selects a different subject or safety point to present as a targeted message
to personnel. The subjects are chosen following the Group’s evaluation of trends such as injuries, motor vehicle contacts and
general/professional liability issues, as well as immediate impact issues such as intersection collision, specific lifting injuries and
patient safety issues. Following the messaging, the group continues to evaluate and monitor results over the long term to
determine whether the messaging and any related policy changes are having the intended effect on our safety trends.
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Designed to be engaging and intuitive, we utilize the following tools to spread a safety initiative:
Framed posters and pictures posted at all stations in a conspicuous location
Online training courses or “Safety Nuggets” t focus on specific safety messages in short visually stimulating videos
Interactive safety games on our Learning site to review or deliver safety messages
Safety topics are selected at the national level and are supported with a wide range of tools. Examples of recent safety topics
include:
Ergonomics
Healthy lifestyles
Blood borne pathogens
Intersection safety
Lifting techniques
Stretching while on post
Following distances
Hazardous materials to reduce the risk of harmful
exposure
Compressed gas safety
Fire prevention
Emergency action
Safe Practices
This structured approach improves the quality and quantity of ongoing communications. In addition, personnel all over the
country receive the same information at the same time, ensuring widespread awareness of safety issues.
PAT
In 2013, we released a new Physical Agility Test (PAT) to be used as a standardized screening tool for pre-employment in EMS.
It assesses various physical abilities required to perform the paramedic and emergency medical technician job duties. The
weights and equipment used in the test are designed to simulate the physical abilities needed to lift and transport patient and
equipment in the field. It is also used for current personnel returning from a leave of absence. The PAT has two main purposes,
1) To ensure both new candidates and personnel returning to work can perform the essential functions of the job, and 2) To
reduce health and injury risks for both personnel and patients.
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Continuous Review / Improvement and New Safety Initiatives
Safety is a key performance indicator for the Alliance and is embedded in our CQI program. Strict incident reporting standards
allow our team to respond immediately to adverse events, initiate a thorough investigation, implement mitigation measures
and carry out corrective actions in a timely manner. Central to these standards is our incident review program, which has been
highly successful in reducing risks and improving workplace safety for our patients, personnel and stakeholders.
a) Minimum Requirements— Workforce Engagement
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section V.C.4.a.
We continually strive to effectively communicate with our personnel and encourage behavior that reflects our mission, goals
and values. This improved level of communication has proven to enhance job satisfaction and productivity, both at the
employee and leadership levels.
Annual Review Meetings
The Alliance sits down with each employee individually to conduct an annual review. This review highlights the areas in which
each employee excels as well as the areas where improvement can be realized. Areas subject to review include, but are not
limited to, EMS systems knowledge, customer service, and professionalism. This review also give the employee a venue to put
forth his or her ideas for system and policy improvements.
Labor/Management Meetings
Meetings between the management and labor teams occur no less than a quarterly basis. In this forum, the management team
gives a briefing of facets that are going well with the operation, areas that need improvement, and the direction of the
operation in the foreseeable future. Additionally, the labor team brings forth its areas of concern with the system, and
discussions ensue on possible methods for system improvement.
System Status Meetings
System Status Meetings occur monthly between the leadership, EMS Field Supervisors, EMS Epidemiologist, and
representatives from the Labor force. The purpose of these meetings is to discuss the effectiveness current deployment models
and posting locations. Previous response data is brought to the meeting, areas of concern are noted, and both field personnel
and representatives from management discuss avenues for improvement in the deployment plan.
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Health and Safety Committee
The Health and Safety Committee is comprised of operations management, CES management, logistics management, fleet
management, and field employee representatives. This committee meets to discuss safety concerns noticed by any member
of the organization plans for how to minimize the risk associated with these issues.
Mandatory Trainings
In between two (2) and four (4) times a year we bring in every single front line employee for four (4) to six (6) hours of
mandatory training. This training covers topics including annual protocol changes, general operational updates, as well as
clinical feedback. In these trainings we are able to give direct accountable clinical feedback to our front line personnel. These
data points include “Things That Matter”, and other various clinical metrics including intubation and IV success rates and AMA
rates.
Credentialing Support
Our personnel are required to fulfill all County and State credentialing requirements and to maintain them at all times to be
eligible to work. We currently help personnel maintain their required licenses and certifications by providing ongoing training
as well as certification and licensure tracking and reminders through our web-based data management platform.
Credentials Maintenance Tracking
Our Quality Improvement and Education Team retains copies of current training and documentation of valid certifications for
our Paramedics and EMTs through a web-based data management program on a cloud-based platform. We use an application
to track upcoming certification expirations so we can notify personnel well in advance of the need to update their certifications
and ensure that our field personnel hold all required certifications. We also track course completion and compliance with
annual refresher training requirements. It gives us the ability to scan copies of credentials to provide archival evidence of
certification and training.
In addition, the online solution helps communicate us with our personnel, as it automatically generates and sends electronic
reminders to our management and the employee. This feature ensures that no one works when they have an expired
certification or license. For example, individuals receive automatic email alerts regarding certification expirations, as well as
reminders regarding upcoming courses that they need to complete or other actions to maintain their required licensure or
certification.
Our leadership team follows up with personnel to ensure they maintain all licensing and certification requirements. In addition
to credentials tracking, our web-based data management platform supports training and education, quality management,
complaint and incident tracking, safety, OSHA compliance, and other vital processes.
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Currently we utilize this online software solution for the following:
Track work-related employee health issues and compliance with safety requirements
Provide high quality online education to help personnel maintain clinical credentials
Centralize management of incidents, complaints, and unusual occurrences
Create a performance dashboard to monitor critical data on education and immunizations
Analyze and report on a variety of vital processes involved in running an EMS system
Communicate vital and time-sensitive information to personnel
Track certifications and licenses against continuing education requirements
Upload customized training programs including text, image, audio, video, and Power Point, that front line personnel
can access and complete anytime 24/7
Create, administer and track online tests for post education retention
Print certificates of completion for online continuing education courses
Monitor participation and status with training records, and run reports on course activity, course evaluations, course
rosters, and mandatory training compliance
Notify personnel, supervisors, and administrators of pending and expired certifications/licenses with automated alerts
Create custom reports
Required Credentials
EMS Field Supervisors must have a valid and up-to-date California Driver’s License, DMV issued Ambulance Driver’s
License and DL-51 Medical Examiner’s Card, Healthcare Provider CPR Card Paramedic certification from the California
Department of EMS, a Pediatric Advanced Life Support (PALS) or Pediatric Education for Prehospital Providers (PEPP)
certification, an Advanced Care Life Support certification (ACLS), an International Trauma Life Support (ITLS) or Pre-
hospital Trauma Life Support (PHTLS) certification, as well as have completed all LEMSA-required certifications. EMTs
and paramedics also must complete The County EMS orientation and our New Hire Academy orientation and training
program before they are eligible for work. In addition, EMS Field Supervisors are trained in accordance with the
Incident Command System, MCI response, Strike Team leader, and hazmat operations. We will provide ICS Medical
Command Levels 300 and 400 training to all of our County Field Supervisors. All supervisors will attend one (1) disaster
exercise and two (2) hours of disaster training per year
Alliance Emergency Medical Technician must have a valid and up-to-date California Driver’s License, DMV issued
Ambulance Driver’s License and DL-51 Medical Examiner’s Certificate, Healthcare Provider BLS CPR Card, and EMT
certification from the California Department of EMS
Alliance Paramedics must have a valid and up-to-date California Driver’s License, DMV issued Ambulance Driver’s
License and DL-51 Medical Examiner’s Card, Healthcare Provider CPR Card Paramedic certification from the California
Department of EMS, a Pediatric Advanced Life Support (PALS) or Pediatric Education for Prehospital Providers (PEPP)
certification, an Advanced Care Life Support certification (ACLS), an International Trauma Life Support (ITLS) or Pre-
hospital Trauma Life Support (PHTLS) certification, as well as have completed all LEMSA-required certifications. EMTs
and paramedics also must complete The County EMS orientation and our New Hire Academy orientation and training
program before they are eligible for work
Dispatchers must have a valid and up-to-date Emergency Medical Dispatcher certification
Fire Prevention Staff must maintain current First Aid, CPR, AED certification
Fire Investigators have a valid and up-to-date CPR, First Aid
Mechanics have a valid and up-to-date Automotive Service Excellence Certification, CPR, First Aid
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Supporting Employee Skills
FTOs, EMS Field Supervisors, and our Quality Improvement and Education team coordinate the assessment, development, and
maintenance of new skills for personnel in the workforce under the direction of the LEMSA Medical Director, and our Medical
Directors. Methods of assessment include direct observation and patient care report audits. Methods of development include
formal training and one-on-one coaching utilizing our patient simulation technology.
Developing and maintaining new skills is aided by practical application and ongoing performance feedback through a variety of
mechanisms. These include system performance feedback on clinical composite scores, such as the Airway Checklist, and other
relevant KPIs and individual performance feedback as appropriate.
Diverse Workforce
Communities everywhere are increasingly rich in ethnicity. Society is filled with people of a variety of ethnic traits, backgrounds,
cultures, groups, customs, and language. Being part of a culturally diverse workforce helps provide for the specific needs of
every population served. Quality of care is something we believe in – the recruitment of personnel who represent a wide
spectrum of cultures only enhances this.
Culture, race, and national origin are not the only factors that should be considered by companies creating diversity work plans.
Through the Alliance, we have eagerly supported workforce diversity that includes gender, age, religion, and disability.
Responding to challenges posed by a low number of minority applicants, we engage in minority recruitment activities at both
local and national levels that include, but are not limited to, the following:
A formal diversity plan
Legislative lobbying to make more financial resources available for minorities seeking to enter the medical
transportation industry
Continued presence at cultural events that celebrate diversity
Presentations to inner-city schools on the merits of the EMS profession
Participation in career day events
Annual diversity training
We pledge to meet the federal and state equal opportunity requirements during our hiring practices. These requirements
specifically include:
All advertising identifies the Alliance as an equal opportunity employer
Annual training on sexual harassment, sensitivity and awareness; our vision statement that personnel pledge to abide
by; and our Code of Business Conduct, all contribute to a desirable workplace, free of discrimination by age, gender,
religion, race, disability, national origin, sexual orientation, or marital status
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Job-Posting Process
As a public safety leader in the County, we seek to recruit and retain the best personnel in the nation. Because most of our
personnel live and work in the communities we serve, they are passionate about providing professional, courteous service at
all times. As a corporation, we are dedicated to providing our personnel with a work environment built on respect, integrity,
and service. This is evident by our high retention rates.
Employee retention begins with recruiting the most highly qualified individuals to fill the roles required. In most of our
communities, we have waiting lists of potential personnel. People want to work for our company because of our reputation in
the industry, our employee-centered programs, a competitive wage and benefit package, and management’s commitment to
providing a quality place to work-no matter where or when they work.
Recruitment/Employee Screening
Our experience allowed us to build a program designed to support local recruiting efforts by developing the largest possible
pool of qualified candidates. Our goal is to identify and attract the best pre-hospital medical professionals for long-term
employment. We also seek to recruit a diverse workforce that reflects the communities we serve. All of our recruitment and
screening practices are culturally sensitive and are an integral component of our hiring process. Our recruitment strategies
include the following:
A recruitment tool kit that includes a realistic preview of what our caregivers experience on the job with a focus on
attracting individuals who understand and emphasize customer and patient satisfaction
Employee referrals
Relationships with local and national EMS training programs
Partnerships with state employment offices and diversity organizations
Internet advertisement on our website and industry websites
Attachment booths at industry conferences and symposiums
Participation in local job fairs
Attendance at career fairs held at local educational institutions
Workers’ Rights
We have developed internal policies and procedures to protect our company’s greatest assets, our personnel. These policies
include an internal grievance procedure, as well as a Suggestions and Issue Resolution policy that allows for a review of
personnel actions. These policies are captured in a variety of company publications, including the following:
National Employee Handbook
National Health and Safety Manual
Local Standard Operating Procedures
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Workforce Harmony
We have a zero tolerance policy for discrimination. Our company policy is provided to every employee in the Employee
Handbook and prohibits discrimination and harassment based on based on age, national origin, gender, race, sexual
orientation, religion, physical or mental ability, color, religion, medical condition, pregnancy, sexual orientation, marital status,
retaliation, and any other protected status in accordance with all applicable Federal, State, and local laws. Additionally, we
maintain strict practices to guard against bias as well as offer programs to help increase cultural and diversity awareness and
competence. Workforce harmony is essential to our ability to provide care to our patients.
We promote workforce harmony and prevent discrimination based on these and other characteristics through mandatory
cultural competence training, biannual harassment training, recruiting from traditionally underrepresented groups, and
ensuring our employee interview panel remains diverse. An online legal seminar takes place semiannually and includes
competency-based testing to ensure knowledge transfer. Our cultural competence training is driven by a core understanding
that valuing and leveraging diversity is an organizational imperative that directly and positively impacts morale, retention,
productivity, and organizational culture.
Minimizing Risks from Impairment
We are committed to a workplace that is free from alcohol and controlled substances. A drug-free workplace helps ensure a
safe and healthy environment for personnel, patients and the overall community. We ensure the following for all personnel
working in the County:
We will issue a published statement notifying personnel that the unlawful manufacture, distribution, dispensing,
possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken
against personnel for violations of such prohibition
We will inform all personnel about the dangers of drug abuse in the workplace, the company’s policy of maintaining a
drug-free workplace, any available drug counseling, rehabilitation, employee assistance programs and the penalties
that may be imposed upon the personnel for drug abuse violations
We will require satisfactory participation in a drug assistance or rehabilitation program, by any employee determined
to be in violation of the contractor’s drug and alcohol control policy
We will impose a drug testing program that addresses both pre-employment drug screening and for-cause testing of
personnel
Our personnel are prohibited from unlawful use, possession, manufacture, distribution, dispersion, or sale of controlled
substances or illicit drug paraphernalia. Personnel are not to take prescription drugs unless they are issued to them by a
physician. Therefore, any prescribed drugs taken while on duty must be in the original container and be clearly marked with
the employee’s name on the prescription label. Personnel are not to knowingly misuse or abuse over-the-counter or
prescription medications. Personnel must notify their leadership staff immediately if they are convicted under any criminal
statute associated with drugs or alcohol.
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Drug Test Failure Criteria & Consequences
Any detectable presence of illegal or non-prescribed controlled substances, controlled substance metabolites, or controlled
substance test adulterants will result in corrective action up to and including termination of employment.
Employee Assistance Program
We understand the importance of providing intervention and treatment for personnel who need assistance or face life-
threatening challenges. To support our personnel, we offer an Employee Assistance Program (EAP). In fact, we have recently
re-designed our EAP to be more specific to public safety and issues one may face. For instance, our EAP provides the necessary
resources for an individual who may experience post-traumatic stress syndrome. Also, our EAP is designed to help personnel
with alcohol or other substance abuse problems, providing up to five (5) free outpatient counseling sessions each calendar
year. If extended time is needed, personnel are referred to a care provider in their health benefits program.
Confidential EAP counseling includes early intervention and treatment support regarding alcohol and substance abuse issues,
complementing our company’s drug-free awareness program that educates personnel about alcohol and substance abuse
issues.
Self-Disclosure of a Drug / Alcohol Problem
Personnel are strongly encouraged to proactively inform their supervisor or a Human Resources representative if they have an
alcohol or controlled substance abuse problem. If notified, we will conduct a review into the matter. The investigation may
include requiring the employee to take an alcohol and/or controlled substances test. If the investigation shows that the
employee’s disclosure was made proactively (i.e. before being requested by the Alliance to submit to drug or alcohol testing
and before an incident occurs that could reasonably lead to such request), the employee may be permitted, in lieu of
termination, to enter into a written “Last-chance Agreement” between the employee and our organization.
Personnel may be required to take a leave of absence in order to complete appropriate treatment for alcohol and/or controlled
substance abuse. Before becoming eligible to return to duty, personnel participating in a last-chance agreement must agree
and fully comply with all requirements established by the Alliance, LEMSA, and the LEMSA Medical Director.
Allied Agency Training
We will continue to partner with other public safety agencies annually for drills that exercise the LEMSA’s Multiple Casualty
Incident Plan. The Division also participates with the County EMSA’s Triage and Tracking Program. This program is designed
to exercise various facets of a Mass Casualty Incident to include triaging high quantities of patients and tracking these patients
as they “travel” through the county’s EMS system. The ultimate goal of the program is to successfully reunite patients with
their families in the aftermath of an actual large-scale casualty incident.
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b) Higher Levels of Commitment— Workforce Engagement
We are a paramilitary organization with a clearly defined organizational structure and chain of command. In terms of
emergency operations, leadership and discipline, it is essential that these established lines are followed. However, Senior Staff,
including the Fire Chief, maintain an open door policy that gives value to the voice of every member of the organization. From
the formal chain of command to the Fire Chief’s station meetings, daily opportunities exist for face-to-face, real time, open
communication. Below and on the following pages, are a descriptions of programs we have in place to ensure workforce
engagement.
Career Paths
In accordance with all labor agreements and state law, it is the Alliance’s intent to create a program
in which employees of either division (CCCFPD or AMR) will have preferential standing with regards
to employment at CCCFPD or AMR. Employees meeting specific requirements, training and other
qualifying criteria will be provided with advanced standing within each companies hiring procedures
in an effort to enhance available opportunities, both full and part time, to all employees within the
Alliance.
Critical Incident Stress Management
Through the Alliance, we maintain a group of peer counselors with specialized training in Critical Incident Stress Management
(CISM) to be available for personnel who need help following stressful and/or traumatic events. EMS Field Supervisors and/or
Fire Captains will remain as the first point of contact for any issues. CISM is initiated by call-type in our computer-aided dispatch
system, or by request of employee. Immediately following notification of an incident where they may be needed, a CISM team
member and/or Supervisor responds to the scene or the hospital to hold a defusing session with the crew involved.
Approximately two days after the event, they also hold debriefings in a group setting to refresh coping skills and identify any
additional help that may be available. Personnel also receive one-on-one confidential aid from peers if they wish. The CISM
program provides stress education sessions for all EMS providers and will interface with other existing public safety and health
care CISM programs for additional resource support.
Peer Support Committee
We have performed a comprehensive assessment of our peer support program and resources and had determined that it
needed to be updated. As a result, we have sent four (4) individuals to peer support counselling training and are rewriting our
policy and procedures to address peer support.
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EMS committee
The EMS Committee is made up of six (6) members and is chaired by the EMS Battalion Chief. The group provides support and
advisement, regarding EMS in the Alliance, to the Fire Chief through the chain of command. The primary goal is to improve
patient care by way of improved work flow, organization, policy, and equipment.
There are two (2) distinct areas of focus: First Response and transport. An area of high concentration will be the workflow
between these two (2) areas focusing on providing a better patient experience and a higher quality of care.
EMS Field Supervisors Directive for Field Employee Acknowledgement
The EMS Field Supervisors are measured annually by how well and often they acknowledge field personnel for exceptional
performance. The acknowledgement must be sincere and a result of specific acts; however, the form of acknowledgement can
be innovative. A letter for the personnel file, a nominally valued gift card, the EMS Field Supervisor washing the ambulance for
the employee, etc. are all past examples of acknowledgements of field employee excellence by the Division Captains.
Trauma Bag Committee
This committee is a focus group that consists of both field representatives and management and is tasked with setting the
standard for the equipment that each unit will carry in their Trauma/Med Bag. This group is driven mostly by the field with
management oversight. The committee makes a determination for quantities and types of equipment that should be carried
in the bag, which type of bag is most functional, and how the equipment will be stored for uniformity and functionality.
Alternate Supervisor Program
We are committed to empowering field personnel that are interested becoming leaders in their own organization. The
Lieutenant Program is an opportunity to take first steps towards leadership by filling the traditional “Supervisor” shift on days
that the full time EMS Field Supervisors are not available. The Alternate EMS Field Supervisors undergo the LEAD U training
program as well as ICS 100, 200, and 700. They meet with the EMS Field Supervisors quarterly to discuss pros and cons to the
status quo, and to provide input on the direction of the company in the foreseeable future. The Lieutenants also meet quarterly
in a separate format to discuss similar changes.
Building a Higher Level of Interoperability
We believe that proactivity is one of the keys to being a seamlessly interoperable partner with the County’s various fire and
law enforcement agencies. We have recently brought in personnel from other Operations who specialize in forming this type
of partnerships. Specifically, we have enlisted the help of Subject Matter Expertise that mitigated large scale disasters like the
San Bruno Pipeline Explosion and the Asiana Plane Crash at the San Francisco International Airport.
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Our Special Operations Unit for the Alliance proactively organized and conducted and active shooter drill at St. Mary’s College
on December 17th 2014 with various fire agencies in the County. We have donated its Regional Ebola Response Team to
multiple training drills in 2014 local the county EMSA and various hospitals in the wake of the heightened Ebola precautions
that same year. We are currently building a Tactical EMS subdivision of the Special Operations Unit that will be fit for
implementation during the new contract.
We have also partnered with the County LEMSA to provide equipment and training to the local law enforcement agencies for
rapid first aid treatment of officers shot or otherwise seriously wounded in the line of duty.
Communication and Unity
We truly believe that the hallmark of a unified operation is effective, closed-loop, two way communication. To that end, the
Alliance is constantly seeking ways new and innovative methods for establishing communication conduits. The forefront of our
efforts are focused on structured quarterly discussions with a true cross-section of our workforce and management team. The
work force’s seniority list is broken into four equal groups, and five personnel from each group are chosen at random to attend
the monthly meeting. The purpose of the discussion is to hear from a distinct yet complete cross-section of the workforce
concerning what they feel is going well, what needs improvement, and what suggestions can be provided to implement positive
change where needed. This group is also afforded the opportunity to hear directly from management about the direction of
the division for the foreseeable future. The people selected for the monthly meeting change constantly so that no employee
is invited for consecutive meetings, and field participation in the discussion is completely optional.
Field Training Officer (FTO) Program
We strive to set a culture of peer-driven accountability within our organization. In order for this to happen we need a dedicated,
passionate, clinically and ethically sound group of individuals to carry out this mission. Our high-functioning Field Training
Officers (FTOs) fulfill this goal. We use our FTOs to teach our yearly clinical update classes, CPR courses, and other courses
needed for EMT and Paramedic recertification. In their monthly FTO meetings they are dealt new equipment for testing, review
of new procedures and general brain-storming about field operations. By receiving their expertise and gaining their buy-in we
engage our workforce on a whole new level and gain the peer-driven accountability that is so valuable.
Field/Base Communication Review
Field/Base Communication Review is a monthly course that is offered to front line staff and other allied agencies in the area
(Fire and local hospitals). This course is currently taught by a FTO. This course reviews telephone calls that were made from the
front line staff to the local base hospital (John Muir Walnut Creek). Through the review of these telephone calls that deal mostly
with high level trauma injuries we are able to reflect on the clinical and operational aspects and engage all agencies county-
wide to ensure excellence.
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Employee Feedback Surveys
Constructive feedback is crucial to make effectual and long-lasting change in any organization Bi-quarterly we send out
electronic surveys to our front line staff on various topics relating to operational efficiency to gain their opinion and feedback.
These surveys have been extremely valuable to our division for two reasons. One, they show the front line staff that we value
their opinions and that we care about their workplace satisfaction. Two, it allows us to get a real picture of what we need to
improve overall as an organization. The more people we are able to reach will help us maximize our ability to make lasting
change.
Just Culture
It is incumbent on us to create a culture that ensures mistakes are rectified and lessons learned for the benefit of the patient
and our caregivers. All too often in healthcare, mistakes are blamed on the individual when it is often the system that is at fault.
We are proposing to continue to utilize the Just Culture model, whereby caregivers are taught how to recognize that mistakes
are made and feel able to report these mistakes – and have them remedied – in a non-punitive setting. Our approach to
improvement clearly focuses on identifying issues in an overall system setting and putting into place the required education
and processes to provide solutions. Just Culture is a natural building block to this approach and will become integral to the
improvement model in all elements of our operation.
Professional Growth Opportunities
As a leader in EMS services, we are uniquely and exceptionally qualified to provide professional growth opportunities to all
personnel, in all areas. We will provide these opportunities to the current and future workforce in the County.
Developing the next generation of leaders is critical for the long-term success of any organization, especially one such as the
Alliance, which is labor-driven and strives to promote within whenever possible. The practice of developing our own leaders
has many benefits, which includes providing a career path for our personnel by using our internal bench strength (locally and
nationally) and eliminating the steep learning curve experienced by outside hires. Additionally, understanding the line job in
conjunction with superior leadership skills provides field staff with the critical support and guidance they need to perform at
their best.
We recognize that transitioning into a leadership role requires augmented skills and tools as well as ongoing training to support
specific organizational/County needs. We have developed and tailored several unique programs that are available in a variety
of platforms and learning environments including Leadership, Education and Development University (LEAD U).
We will offer courses to the County staff in leadership positions to ensure that they have the fundamental tools to be successful.
These offerings are for both proposed personnel and newly promoted leaders. Our Leadership Succession Planning Program
encompasses these positional educational requirements. This program is tiered learning specific to each leadership level —
Supervisor, Manager, Director, General Manager, and Regional CEO.
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Leadership Educational Elements
Supervisor Level
o Interdepartmental/cross-program exposure
o Local leadership/professional development seminars
o Leadership Development Program (LEAD U)
o SOAR Program
o Continuing education courses
Manager Level
o Seminars
o Continuing education courses
o Community college courses (such as finance for non-financial professionals
o LEAD U (including didactic modules/sessions)
o SOAR Program
o Fitch and Associates Ambulance Service Manager Program
Director Level
o Industry-wide conferences
o Continuing education courses
o Seminars
o Business development/sales/negotiation training
o Finance for non-finance professionals
o LEAD U (including didactic modules/sessions)
o SOAR Program
General Manager
o Executive education programs at business schools/colleges
o Industry-wide conferences
o Continuing education courses
o LEAD U (including didactic modules/sessions)
o SOAR Program
Regional CEO Level
o Executive education programs at business schools/colleges
o Personal development and advancement seminars
o Continuing education courses
o LEAD U (including didactic modules/sessions)
o SOAR Program
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Continuing Education (CE) Opportunities
Finally, we encourage all personnel to continually enhance their skills and give themselves the foundation to achieve greater
job satisfaction and opportunities. We offer a broad range of CE classes designed to enhance their experience.
Advanced Airway Assessment
Capnography
12 Lead EKG Interpretation
Pit Crew Resuscitation
Continuous Positive Airway Pressure Devices
High Performance CPR
Hazardous Materials
START Triage
Recognizing ACS
EZ-IO
Cascade’s Pre-Hospital Education & Evaluation Readiness Solutions (PEERS) Program
Cascade Healthcare Services is an organization of healthcare professionals providing real time, cost effective and patient care
focused solutions for the staffing, training and health needs of our community.
For the County, we will utilized Cascade’s PEERS Program which is a training management solution that integrates required
continuing education training with quality improvement customized to our personnel and community served. Cascade hires
local prehospital and clinical based instructors who represent all phases in the continuum of patient care. PEERS is a turn-key
solution that immediately reduces liability; while simultaneously improving the quality of EMS education provided. The PEERS
Programs include the following: EMS Training Program Management, Infection Control, Paramedic Preceptor & Field Training
Officer Workshops, Policy Updates and Continuous Quality Improvement.
In addition, for the Alliance, we will be implementing a Mobile Simulation program that focuses
on providers working together as a crew in a structured "real-time" environment with the
emphasis on improving patient outcomes and enhancing providers current skill sets. We utilize
state-of-the-art equipment that provides high fidelity feedback on critical skills including CPR and
airway management and conclude the simulation drill with an extensive debrief of the simulation
utilizing standard evaluation techniques and video documentation.
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Leadership Succession Planning Program
The Leadership Succession Planning Program details specific educational requirements and provides the necessary courses for
all leadership positions to ensure that proposed leaders and newly promoted individuals have the tools they need to be
successful. Ongoing education is essential if our leaders are to stay on top of workforce challenges and solutions. We work
closely with several organizations to provide the educational resources our leaders need.
Article Share Program
On a regular basis, our leadership distributes recent and relevant articles from trade journals, websites and general
business/management sources in an effort to provide thought provoking and forward-thinking material to Alliance managers
and supervisors. These articles focus on topics such as personnel management, financial strategies, trends in EMS and medical
care delivery, personal well-being, critical incident stress management and career development. Topics shared are also
discussed during meetings and other gatherings of staff members.
Reward and Recognition Programs
We take every opportunity possible to recognize and reward our personnel. One key component is our Employee Anniversary
Program, which recognizes personnel for their years of service with our organization and acknowledges their contributions.
This formal program includes the presentation of pins for years of service, as well as gift certificates and other items for key
employment milestones. The following is a list of other reward and recognition programs offered through the Alliance:
Points Program (Points for Swag)
Annual holiday banquet and awards ceremony
EMS Week celebrations
Posting and filing of commendations in personnel files
Nomination of outstanding personnel for local, state, and national EMS awards
Posting of customer feedback cards and letters
Stars of Life, sponsored by the American Ambulance Association
National Employee Recognition Program for personnel to recognize their peers in relationship to our mission and
values
Focus Groups & Other Feedback Mechanisms
We perform several “quality checks” regarding employee satisfaction, including polling our personnel on their experiences and
needs. Our goal is to show personnel that their input is valuable and will receive a response. We have also created focus
groups where interested personnel help make positive changes in their work environment.
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Fast Facts Newsletter
We have developed a monthly newsletter entitled “Fast Facts”. This newsletter aids us in the engagement of the front line staff
through general operational announcements, quick clinical tips, and recognition of a job well done for certain calls where
personnel went above and beyond with their care. These newsletters maintain important communication between all levels of
the organization.
Envision Healthcare Charitable Foundation
The Envision Healthcare Charitable Foundation was founded in the wake of Hurricane Katrina in 2005. At that time, personnel
from across our companies demonstrated an unwavering commitment to co-workers who were affected, donating generously
to help those in severe need.
Since then, the Charitable Foundation has been able to provide financial assistance to hundreds of our co-workers following
catastrophic events. In 2013, the Foundation assisted more than 87 personnel, including co-workers who experienced property
losses from fires or floods, suffered the death of an employee or family member, or who were unable to work due to
catastrophic illness. The Foundation depends almost entirely on the generosity of our co-workers for its funding and employee
participation increases year over year.
How is “Severe Need” Defined?
Personnel may be eligible for a grant up to $10,000 for the following types of potential qualifying events:
Death of employee or relative
Uncontrollable loss of income resulting in potential loss of home
Non-insured traumatic medical expenses
Hospitalization or incapacitation of employee or relative, resulting in employee’s inability to work for more than seven
days
Complete home loss due to fire or other natural cause
Any combination of the above
Where Does the Foundation Get its Funding?
The EVHC Charitable Foundation relies almost entirely on the generosity of its personnel and affiliated physicians for funding.
The Foundation incurs virtually no administrative expenses, as these are largely donated by the Corporation. Nearly 100% of
the dollars donated by personnel are used to help fellow personnel in times of severe need. There are several ways to donate
to Foundation. Personnel may make an ongoing commitment to helping our colleagues through a recurring or one-time payroll
deduction. Personnel may also donate PTO/vacation time, which the Foundation will convert to cash at their regular hourly
rate. Direct contributions by check to the Foundation are also accepted from personnel and private donors. Since the EVHC
Charitable Foundation’s inception in 2005, we have assisted over 700 personnel with grants totaling over $1,200,000.
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D. MANAGEMENT
a) Minimum Requirements—Key Personnel
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section V.D.1 .a.
The Alliance considers key personnel individuals who are directly responsible for ensuring the provision of services provided
required by the contract.
For this contract, our key personnel will provide the County continuous operational and medical oversight for entire EMS
system. Our proposed command structure will consist of a group of highly-qualified, dedicated individuals with decades of
experience who stand ready to serve County at a moment’s notice. Our leadership members have extensive experience in
some of the most diverse and sophisticated EMS and public safety systems in the country—both geographically and
demographically—uniquely qualifying them to execute the County’s service requirements. Most of our key personnel have
operated in the County for years, furthering ensuring our ability to seamlessly provide the requested services.
On the following pages, we have provided tables that illustrates our key personnel as well as out-state support. Additionally,
we have attached resumes/CVs for our key personnel as Exhibit No. 9.
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Key Personnel
NAME TITLE RESPONSIBILITIES
YEARS OF SERVICE
IN THE COUNTY
JEFF CARMAN Fire Chief Oversight and leadership of the organization Nearly Two
(1.5)
LON GOETSCH
Assistant Fire
Chief, Operations
Chief
Oversight, management, and leadership of the
Operations Division, including EMS and Training Fifteen (15)
LEWIS
BROSCHARD
Assistant Fire
Chief, Support
Services Division
Oversight, management, and leadership of the Contra
Costa Regional Fire Communications Center
Radio and telecommunications, Fire Department (FD)
facilities, FD fleet services, FD logistics and supply
Eight (8)
JACKIE
LORREKOVICH
Chief of
Administrative
Services
Administration, budgeting, and financial oversight;
billing services Seventeen (17)
MIKE JOHNSON General Manager
Ensures operational needs and performance objectives
are met and are in compliance with this contract as well
as EMS regulations at all levels.
First year as he
transferred
from San
Bernardino
County
DR. BENSON
Chief Medical
Director
Ensures medical direction aligns with LEMSA, while
providing medical oversight for entire EMS system Ten (10)
DR. HERN
Associate
Medical Director
Working in coordination with Chief Medical Director
Additional medical oversight and support for entire
EMS system
Eight (8)
MIKE MARSH
EMS Operations
Manager
Oversees the day-to-day county-wide operations and
delivery of EMS services to the county Fourteen (14)
JOANNY ALL
Quality
Improvement
and Education
Coordinator
Oversight of our Clinical Quality Improvement Program Fifteen (15)
DINO CRUZI Data Analyst
Monitors, trends and predicts in relation to our system
status readiness plan. Compiles all planning reports,
clinical reports and trending
Four (4)
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Out-of-State Support
b) Higher Levels of Commitment—Key Personnel
In-County Support Personnel
As a higher level of commitment, the Alliance offers additional key personnel to ensure we meet the
County’s needs. These individuals are located in-county and will provide support for our system, as
needed.
NAME TITLE RESPONSIBILITIES
SHANNON MARSHALL Regional Director of
Clinical Services
Regional oversight of clinical services
JENNIFER BALES
Regional Safety &
Risk Manager
Regional oversight of safety and risk
KERI LIMPKIN Regional Human
Resource Manager
Regional oversight of human resources
RANDY HARRELL Regional Fleet Manager Regional oversight of fleet resources
NAME TITLE RESPONSIBILITIES
YEARS OF SERVICE
IN THE COUNTY
TOM WAGNER Regional Chief
Executive Officer
Regional oversight to support the local management
team in all aspects of ambulance services execution
and contract compliance
Nine (9)
BEN SMITH EMS Battalion
Leadership, administration, and management of the
EMS Division Twenty three
(23)
GREG KENNEDY
Quality
Improvement
and Education
Coordinator
Oversight of our Clinical Quality Improvement
Program Nine (9)
SUSAN
FITZGERALD
Regional
Financial Officer Regional oversight of finances Eight (8)
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Northern California 9-1-1 Network
Through the Alliance, our family of companies is unique in its ability to provide support to its local managers, thereby leveraging
the strength of the organization as a whole and its individual talent. General Managers have the responsibility to guide
execution of performance improvement initiatives. General Managers are supported by quality improvement staff, educators,
managers and supervisors as well as the entire operations team. One of the most valuable aspects of our network, however, is
in the counterbalancing of similarities in services and challenges and diversity between communities, which provides a fantastic
laboratory for innovation, combined with a company culture of collaboration and an unparalleled network in Northern
California EMS, with adaptability being a key advantage for our customers.
A great example of how this collaborative environment works is in the Northern California 9-1-1 EOAs that we serve. Our eight
(8) General Managers meet regularly to discuss topics of both local and regional importance. In- person meetings are
augmented by telephone, WebEx, email and cutting edge data sharing and information presentation tools. All of these
executives are familiar with the inner workings and performance of their neighboring EMS systems. Problem solving is
enhanced and the experience of the team members is amplified because of the diversity of EMS systems this management
network serves. Customers have directly benefited from and commented on this strength. Not only do the West General
Managers share a collaborative bond with one another, but also with EMS leaders in the LEMSA and other agencies. Everyone
in the EMS system benefits from our professional network.
Forum with other Fire Executives
We participate in a monthly forum with other fire executives to review operational practices and standards. This forum,
which includes fire chiefs and operation chiefs, provides an opportunity to create standardizations that target issues or
concerns that a specific operation(s) may be experiencing.
Approach to Leadership Development
Through the Alliance and in collaboration with the County and LESMA, we will utilized a learning curriculum designed to prepare
our key personnel for leadership positions and enhance their development as they progress within the organization. We are
truly honored to play a part in grooming future EMS leaders, and believe a collaborative approach will benefit our partnership.
Once we have jointly established our learning curriculum, we will make our leadership development available to our personnel
in a variety of platforms and environments. We will provide a core curriculum for each leadership level within the organization.
The intent is to ensure a baseline level of knowledge and competency at each level and to provide a foundation to build upon
for future growth. In addition, we regularly encourage our leadership team to participate in outreach to elected officials. We
also encourage our personnel to participate in our recruiting efforts such as career fairs at community colleges and our
community education campaigns.
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Our leadership development program is continuously evolving in response to identified new challenges facing our leaders and
our front-line personnel. Today’s workforce is as diverse as it has ever been, and our goal is to ensure our leaders have—and
build upon—the skills necessary to effectively coach, communicate, and recognize employee efforts. A few examples are the
following:
We will continue to send two (2) personnel annually to Ambulance Service Managers program conducted by Fitch and
Associates
We will continue to send personnel to local classes sponsored by Fred Pryor Seminars on leadership, finance and a
variety of topics are attended by leadership
We will continue to constantly distribute peer reviewed articles and books for continuing education purposes
Also, we offer various programs aimed at career growth such as, but not limited to the following:
LEAD U
Senior Leadership Internship Program
o We have recognized the need to create a robust succession planning and leadership internship program to
help ensure the continued success of the company. While still in its infancy, the company intends to continue
development of this program quickly. The program seeks to identify employees who possess the will, skill
sets and potential to advance within the company. The most important part of the program is providing
these individuals with exposure, training and hands on experience within different disciplines throughout the
organization. By doing this, the employee gets a feel for what it is like to work in these positions, and the
company gets a brief glimpse at the employee’s talents and abilities in this new setting. The goal is to create
a pool of talented and motivated employees who are ready and willing to assume new leadership positions
as they come available, and without any serious interruptions to our operations
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E. EMS SYSTEM AND COMMUNITY
a) Minimum Requirements—First Response System
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section V.E.1.a.
We share LEMSA’s desire to increase collaboration with First Responders and ambulance services and we will continue to
commit to the minimum requirements toward this aim. In fact, we are 60 percent of the first responders in the County and
agree to provide the other 40 percent with the continued education opportunities listed in the RFP. Many of the listed RFP
requirements are currently in place through the Alliance. Also, we have also extended invitations to multiple Law Enforcement
agencies within the County to participate in quarterly EMS training for continued education and in support of their Tactical
Programs. A few of our other examples of supporting the first response system include the following:
We work in partnership with Los Medanos Community College to provide environments for EMT student ride-along
opportunities. This partnership has been in place for over two (2) years and will continue into the future.
We provide ride-along opportunities for the US Marshals Service to provide observation time for the Air Marshal
Service.
Positive Working Relationships with all Responders
We understand the importance of a strong, supporting partnership between our personnel and local First Responders in the
County. Should a problem arise on a call, EMS Field Supervisors are available 24/7 as the first line for problem resolution. The
Supervisor is responsible for listening and documenting the situation in order to achieve the best possible resolution. We
review all incident reports submitted by field or supervisory personnel, as well as any report coming in from a customer or
allied agency. Incident reports are divided into two categories: clinical and operational. Our Operations Managers and
Supervisory staff handle all operational incidents, coordinating the investigation and follow-up activities. When necessary, the
General Manager is consulted or will assume control of highly sensitive or serious investigations. Clinical incidents are reviewed
and investigated by our Quality Improvement and Education Team, Medical Directors and/or our regional and national clinical
leadership staff if needed.
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Continuing EMS Education Services for all Responders
We will provide a collaborative, integrated, state-of-the-art, County-wide continuing education program to serve First
Responders and ambulance personnel. We will collaborate with all parties to jointly explore the best location to hold training,
the topics to be covered, and how each agency plays a role in providing instructors. The methodology to the program is as
follows:
Meet with all Responder agencies and identify key system participants
Collaboratively perform a needs assessment for near and long term training needs. Our unique data collection process
and performance metric monitoring allow us to identify specific targeted areas of emphasis. That data is then used
on a prospective basis to measure the impact of the educational intervention.
Establish an immediate orientation to our resources and equipment
Establish a schedule to be provided to all First Responders meeting training needs based on needs assessment
information
We look forward to continuing to build relationships with local agencies to determine specialized proficiencies they believe to
be essential for efficient and competent field operations, and developing continuing education courses to address those
proficiencies. We strive to create educational programs that are engaging, reflect the current state of the science and are
professionally rewarding and practical in their approach. We will execute an agreement with any First Responder agencies who
desire to participate in a collaborative continuing education program.
This program will be at no cost for Responder agencies and may include, but is not limited to the following:
Emergency Medical Responder (formerly first responder) course
Access to our Infection Control and Exposure Programs
Partnership in advanced training with local flight services
Mass Casualty Incident (MCI) drills and after-action reporting and reviews
Ambulance operations orientation
Respiratory, stroke and cardiac care awareness
Community flu prevention
CISM joint training
Restocking of Supplies for First Responders
We will continue to provide the local agencies with one-for-one restocking of disposable medical supplies after each call, at no
cost to the fire agency. Depending on the desires of the agency, we deliver supplies to a central location or to individual fire
stations. Our experience with inventory systems allows us to thoroughly manage this process to ensure providers have the
supplies they need to care for patients while controlling inventory costs.
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Internship Opportunities
A unique strength of the Alliance is our ability to provide internship opportunities for Paramedics, and EMT students at
numerous operational locations. As always, we will give space available preference to students from training programs located
in the County.
We will invite and encourage County EMT and Paramedic students who will be interns in the local EMS system to attend our
classroom orientation program. With this approach, they can gain an understanding of EMS system requirements in the
classroom. Then, during their field internship, they can focus primarily on their clinical skills. This will allow EMS interns to
maximize their time spent onboard one of our units on clinical skills coaching and assessment. We are eager to provide time
on ambulances to fulfill all training and internship requirements for our First Responder partners as well as other physician,
EMT, and paramedic training programs. Our policy is that we will schedule ride-along time for any local First Responder who
requests it. This policy also applies to all other EMS system participants.
b) Higher Levels of Commitment—First Response System
Collaborative Alliance
Our desire to best meet the needs the County and actively support the first response system is
apparent through the collaborative Alliance with your current EMS provider. Through the
Alliance, our organizations will benefit the County in the following ways:
Unified Command Structure
Enhanced Interoperable Communications
Equipment Utilization
Shared Training Opportunities
Expanded Services
Improved Data Collection and Analysis
Again, we are confident that the Alliance will lead to best patient outcomes as the result of an integrated system that works
well together to care for patients. Our personnel will always follow NIMS/ICS standards for scene management. Additionally,
our proposal includes a range of collaborative programs, including but not limited to, joint continuing education opportunities
and efficient restocking of supplies for the County First Responders.
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Investments in First Response System
We are excited to propose new innovative and forward-thinking relationships with
governmental agencies and other private entities within County, designed to provide both cost-
efficiencies to the system and service enhancements for patient care. A summary of the
proposed offerings are included below.
First Responder Continuing Education and Skills Check-off: We are willing to provide check-off services to local First
Responders or skills competency testing at no cost
Consolidated Dispatcher Center: To improve call process time, the Alliance will operate through a consolidated
dispatch center that will encompass fire and ambulance dispatch services. Utilizing this collaborative approach,
ambulance dispatch personnel will be co-located at CCRFCC in Pleasant Hill, providing improved situational awareness
and instantaneous communication as well as enhanced coordination of resources and responses. Additionally, this
approach will allow us to proactively identify potential issues in both systems, fire and EMS, enabling decision makers
and dispatchers to distribute resources to improve gap management in times of peak demand
Shared Computer Charting and Data Platform: We intend to both work from the MEDS platform for pre-hospital care
reporting. This software will allow streamlined access for chart review, comparative analysis and one stop data mining
and analysis by concerned parties
Advancing BLS First Responders Capabilities: If approved by the LEMSA and involved entities, we are willing to
develop, train and assist with the implementation of enhanced BLS provider care. This would include the deployment
of Epi-Pens for allergic reactions, Albuterol for respiratory care and aspirin for cardiac patients
Shared Purchasing Power: Through the Alliance, we maintain national purchasing contracts with Ford, Leader,
American Emergency Vehicles, McKesson and Physio-Control as well as other selected vendors to supply our vehicles
and equipment. As your partner, we will lend our purchasing power to all system participants to offset the cost of
investing in new equipment and technology, such as cardiac monitors, AEDs, and respiratory equipment. These
national relationships also assist us while repairing and identifying issues in our everyday equipment. In fact, we are
currently in the process of standardizing our equipment across all operations, which will streamline this process. If
we notice a trend of issues with a certain piece of equipment, it is recorded and stored on an electronic Equipment
Failure/Replacement Form. Our large-scale purchasing power allows us to submit these identified trending failures
directly to the manufacturer. Often times, the manufacturer will dispatch a team of equipment technicians to every
operation and resolve the problem at its source. While other organizations may have some type of group purchasing
arrangements, no other EMS organization is afforded discount pricing at the level of ours. An example of this is when
we used our national contract for LP-15s and saved more than $350,000, representing significant savings for the
system. Additionally, we possess government contracts that can be levied as a system cost savings
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Collaborative Strategies for Disaster and Mass Casualty Events: We will commit to working collaboratively with
County, LEMSA, police chiefs, sheriff’s office, local hospitals and other system partners to develop strategies for
responses to Mass Casualty Incidents (MCIs) and other disaster events What differentiates us from other
organizations is that we have the resources and proven capabilities to help our local team maintain local service levels,
even during large-scale deployments in response to disasters. In addition to our County resources, we can move
resources from our surrounding operations to assist our County operations. We are in an extremely unique situation
to bring as many resources as needed to support the County during times of a declared disaster. Our proven track
record of handling large volumes of responses during and after major catastrophes is unmatched in the industry, not
just in Northern California, but throughout the United States. We are one of the only EMS organizations in the world
that has the resources to provide massive disaster response while continuing to provide full services in our local
communities
Catastrophic Disasters Responses: For major Federal declared disasters, we are also well prepared and will work
collaboratively with County and all system partners to perform hazard recognition, symptom surveillance and
reporting, on-scene medical stand-by, and transport and redistribution of patients to free-up receiving hospital and
bed space. We have additional assets that may be used for a variety of secondary functions including distributing
immunizations, staffing shelters and emergency departments, and setting up mobile medical units
Tactical Operations: The demand for EMS responders to have an increased role in tactical Law Enforcement Tactical
Operations is increasing. The Alliance has 19 personnel who have completed an 80 hour tactical paramedic course
delivered by the International School of Tactical Medicine. This is the only program recognized by the California EMS
Authority
Public Health Emergencies: We will actively support the functions of the Health Officer by providing EMTs, paramedics
and CCT nurses as additional staff at community care and vaccination centers. Our experienced team members will
remain available to assist with County and regional health incidents, as well as provide training to the County First
Responders and other applicable agencies for the proper handling of local emergencies, disasters, and other
unforeseen events affecting the County public
Fire Executives Forums: We participate in a monthly forum with other fire executives to review operational practices
and standards. This forum, which includes fire chiefs and operation chiefs, allows an opportunity to create
standardizations that eliminate future issues or concerns
First Responder Billing Services Program: If an agency opts to perform first responder services, we will bill their first
responder fees on their behalf, which will ultimately reduce their administration burden and reduce costs
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a) Minimum Requirements—Community Education
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section V.E.2.a.
We commit to continue to exceed the minimum requirements outlined for Community Education. As your partner, we will
continue to provide health initiatives and outreach programs that go beyond the services required as an EMS provider.
To display our commitment to the community, we will allocate $300,000 under Plan A, exceeding the RFP requirement, and
$300,000 under Plan B, as required by the RFP.
Commitment to the Community
We take pride in its focus on capturing and analyzing local health and safety data and collaborating with local stakeholders to
develop community education programs targeted at identified local needs. Thus, while we will implement specific programs
with our new contract, we will also develop targeted community outreach campaigns. In the years ahead, we will continuously
evaluate public health data, as well as the effectiveness of our outreach campaigns, and based on that analysis, will work to
improve and update our community education programs.
In response to our data analysis and collaboration with local stakeholders, we will implement community outreach initiatives
and participate in existing local community education campaigns.
Some examples of these campaigns in the County’s region may include the following:
Compression-Only CPR: One recent community outreach campaign launched in the fall of 2012 was an effort to teach
Compression-Only CPR to community residents. This simple CPR technique takes only 60 seconds to teach and
eliminates mouth-to-mouth resuscitation, allowing a wider audience to learn this life-saving skill
Pool Safety Day: is a drowning prevention event that occurs during the beginning of the summer at two locations,
Pruitt Ranch Waterpark Antioch and YMCA in Pleasant Hill
Is Your Number Up Campaign: reminding residents that their address should be clearly visible so responders can find
them, and providing education regarding turning on exterior lights after calling 9-1-1
Make the Right Call, 9-1-1 Campaign: helping residents recognize the signs and symptoms of heart attacks, strokes,
and other life threatening emergencies, so they are better prepared to promptly call 9-1-1
Blood Pressure Checks: offering free checks at community events
School-based Programs: discussions regarding how the local EMS system functions, what constitutes an emergency,
how to use 9-1-1 to access emergency services, and what to expect from First Responders and ambulance personnel,
along with ambulance tours and demonstrations of medical procedures such as splinting, taking vital signs, and
immobilization of a person on a backboard
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Seasonal Events: participating in local community education events, for example: National Heart Month in February,
National EMS Week each May, Disaster Preparedness Month in September, and Memory Walk and National Breast
Cancer Awareness Month in October, as well as Safe Halloween campaigns
Disaster Preparedness: raising awareness regarding how to be ready for a disaster and how to create a readiness
checklist on topics such as having printed phone numbers to call for help, knowing where your exits are located, and
knowing what resources to keep on site
EMS and Healthcare Career Exploration: focused on introducing young people to this exciting career opportunity
through schools, community forums and networking
Youth Cardiac Health Screening: The purpose of this program is to detect potential abnormalities of the heart and
possibly prevent an unexpected death within our community. The EKG machine scans the hearts of adolescents ages
14-24, the cardiologist reviews and the student is sent away with life changing information. The screening process is
quick, painless, non-invasive and free
Community Wellness Fairs: A free resource fair to educate the community on a variety of health issues and concerns.
Flu Shot Clinic: Utilizing our local operations and our partnership with Rite Aid, we will provide free flu shot clinics
prior flu season
Raising Community Awareness
A key part of any successful community education campaign is awareness. In addition to the strategies described above, we
will raise community awareness regarding health and safety topics through targeted communication strategies. Our goal is to
enhance understanding of how to prepare for and prevent health and safety issues, as well as how LEMSA and other
stakeholders play a vital role in community education.
Print Materials
We will work with the LEMSA Medical Director to create and distribute materials regarding injury and disease prevention as
well as chronic disease self-care information. (Drowning Prevention, Injury Prevention, Bicycle Safety etc.) We will also create
and distribute information regarding career opportunities in EMS through the high schools, colleges and other venues. Through
our participation in community events, we will have ongoing opportunities to distribute these materials to County residents.
Reports to EMS Agency
We recognize that a key part of our community education initiatives is providing regular reports to LEMSA regarding our
programs, and the value they add to our citizens and their outcomes. We commit to providing regular reports to the LEMSA.
The LEMSA can use portions of these reports to raise awareness regarding the many ways it is involved in overseeing community
education initiatives.
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Local Pride in Education
We have long-standing relationships in the communities we currently serve. This is not only because we work in these areas,
but also because we are residents of these communities, the communities are home to us. We have always placed an emphasis
on community involvement. Although we strive to improve the health and safety of the community, community involvement
does not always focus on these areas. Here are just a few of the activities that we have sponsored and/or supported over the
past few years.
School Ambulance Demonstrations consist of a hands-on tour of an ambulance. This not only alleviates the possible
fear of the ambulance for children but also spurs interest in possible careers in healthcare
Every 15 Minutes is a program designed to teach teenagers the dangers of drunk driving given based on the concept
that every 15 minutes someone is killed due to a drunk driver. Annually we have provided multiple ambulances and
an Operations Supervisor to support this valuable learning experience totaling 12 hours of time for the day of the
event. Additionally, the our Management team provides many hours of planning in the process of assisting with
coordinating multiple agencies such as local law enforcement, fire agencies, high school groups, and volunteers
National Night Out activities are quite popular in the Contra Costa County community. One night each year we will
participate with local law enforcement and community groups to take back the night. Multiple convoys of patrol cars,
fire engines, and our ambulances will visit local communities to highlight the resources that are there to protect the
health and safety of the community
Local Health Fairs. We will participate in local annual health fairs providing a variety of health related information.
This information includes prevention of prominent health issues such as diabetes, heart disease, and stroke. Also local
parades and festivals, such as Seafood Festival, Pleasant Hill Fourth of July Parade, Brentwood Corn Festival, Lafayette
Art And Wine Festival, San Pablo Cinco De Mayo Parade, Memorial Day Boat Patrol, and many more
Fire Station Open House. We will actively participate in Fire Station Open Houses. These open houses provide an
opportunity for our EMTs and Paramedics to interact with the community with a hands-on demonstration of the
ambulance and its equipment
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Educational Programs for Contra Costa County Caregivers
We offer a range of educational programs to Contra Costa County’ healthcare partners as well. Many of these programs focus
on the educational needs of personnel who work at skilled nursing and assisted living facilities. They include the following:
Civic Group Talks: We will provide speakers to various community groups. Topics covered will include, but not be
limited to: when and how to call EMS, what to do before EMS arrives, billing/insurance reimbursement issues, Do Not
Resuscitate (DNR) education and first aid/accident prevention
CPR Certification: Instruction includes Adult, Child, and Infant CPR, as well as AED use and Foreign Body Airway
Obstruction treatment
First Aid Refresher Classes: This class covers signs and symptoms of a heart attack, stroke, and diabetic emergencies.
Also included in this class are basic assessments (head to toe), bleeding control, respiratory emergencies, and splinting
of extremities
Fall Prevention/First Aid for the Fall Victim: Instruction includes prevention of falls and treatment for a victim
Respiratory Distress: This in-service covers the signs, symptoms, and initial treatment of patients with acute
respiratory distress
Cardiac Distress: Instruction includes signs, symptoms, and initial treatment of patients with acute cardiac distress
Disaster Preparedness: We work with residents and facility managers to help them prepare their facility for a disaster
Culture Diversity Awareness Program: We will develop together with our Public Health partners targeting clinical
trends, focus group knowledge bases and feedback opportunities for caregivers. This training would be incorporated
for all field and administrative personnel
Introduction to EMS: This in-service is designed to educate personnel regarding the difference between 9-1-1 EMS
and Basic Life Support transportation services, when to call 9-1-1 and what to expect
Hospitals play a significant role in the EMS system and it is important to us that we maintain strong working relationships with
the acute care hospitals in the County. We want the hospitals within County to weigh in on clinical initiatives, our overall
performance and specific areas of the EMS system that are most important to them. We enthusiastically commit to invite and
encourage participation of local area hospital leadership to attend quality steering meetings and participate in other initiatives
aimed to improve EMS clinical sophistication and patient outcomes.
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b) Higher Levels of Commitment—Health Status Improvement and Community
Education
Community Outreach Coordinator
As a higher level of commitment, we will provide a Community Outreach Coordinator. This full-
time staff member will lead our health status improvement and community education in the
County. Additionally, they will coordinate and oversee all County community outreach programs
that we participate in.
Navigator
As your partner, we offer our Navigator program provides a perfect fit for ensuring that the most vulnerable in the community
do not fall through the cracks of an evolving local healthcare environment and is frequently thought of as reducing high-user
9-1-1 calls. By working with local care providers—hospitals, community health clinics, primary physicians, mental health teams,
and addiction management specialists—we apply specific program modalities that respond to the priorities identified by the
community itself and by the healthcare teams that serve it.
Navigator staff participate in both a standardized national MIH Foundations education program and in locally defined, site-
specific training that bonds us to each new community we serve and to the local providers we will work with. We have no “one
way” of providing MIH services, but rather a process for allowing the local environment to shape and redefine the optimal mix
of navigation, direct care, referral, and patient education to achieve the community’s goals.
SAVE Program
We participate in the SAVE program through California Fire Foundation. Through the SAVE program, the California Fire
Foundation aims to provide immediate short-term support in the aftermath of a fire or other natural disaster to displaced
victims. Working together with the California Fire Foundation, the fire service in California is distributing gift cards, in the
amount of $100, to eligible victims of fires or other natural disasters so they may purchase basic necessities such as food,
clothing or medicine. SAVE cards are carried by all Battalion Chiefs.
Resource Packets
We are offered a unique opportunity to meet customers in their own environment, many times that is the home. It is during
these interactions where we get a genuine sense of the needs of individuals or families. Each Unit is equipped with a Resource
Packet that includes information of vital services offered throughout the County. For example, literature that is provided by
Aging and Adult Services, Fall Prevention, Poison Control to name a few are included. In the event that our personnel identifies
a potential need, they will provide the household with valuable information and may assist in “connecting the dots” to facilitate
the appropriate help.
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Health Status Improvement & Community Education
As a higher level of commitment, we will reach out to the Public Health Division and actively participate on various committees
and forums they deem appropriate. This involvement could bring significant new information for the management of acute
and chronic diseases, as well as provide timely data reports for bio-terrorism monitoring.
Data-Driven Health Status Improvement Initiatives & Community Education
Data and community trends drive our community education efforts. The decisions we make regarding community education
are based on data from our own operations, as well as information shared with us by other EMS and public health stakeholders.
We examine trends regarding the types of calls we respond to, and the geographic location of those calls. This allows us to
target our campaigns to identified local needs. As an example, in California, we analyzed data regarding falls, including th e
gender and age of the victims, and the time of year and nature of the fall. We identified a significant increase in falls by men
over age 60 during winter months. Through a closer look at this data, we found that many of those falls were a result of men
cleaning out rain gutters and hanging holiday lights. We then developed a fall prevention campaign targeted at this audience.
This campaign included distributing information to seniors groups, asking if the Fall Prevention Coalition would like us to make
a presentation regarding fall prevention. Many presentations were made to diverse audiences from seniors to home health
caregivers and political forums. The presentation is available upon request.
We also asked them to partner with us in distributing information to seniors regarding common causes for falls and prevention
tips. A year after we initiated our fall prevention health improvement campaign, we analyzed data to determine if there had
been a decrease in falls, and we included this data in our annual Health Initiative Project for a report to the local EMS Agency
and County Board of Supervisor in partnership with the Fall Prevention Coalition.
Local Community Needs
We bring our experience delivering community education programs to numerous communities across the nation, yet we
understand the importance of developing programs that are targeted at identified local needs and delivered in partnership
with other EMS system stakeholders. We look forward to working with LEMSA and other EMS system stakeholders to deliver
community education programs that we can monitor and measure, and thus demonstrate that they make a real difference in
the community’s health and wellness. Further, we are eager to provide ambulance demonstrations during health fairs, career
fairs, Public Safety Awareness Day, school ‘read-in” programs and senior awareness programs.
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Compression-Only CPR
In honor of Emergency Medical Services Week, 140 operations in nearly 40 states and two international operations in India and
Trinidad and Tobago hosted the first-annual World CPR Challenge. Our teams trained more than 54,000 people, including 570
in the County on how to save lives using compression-only CPR, a new technique that does not require mouth-to-mouth
resuscitation. During the second-annual World CPR Challenge, we hosted 175 events across 28 states, training an astounding
61,883 people, including 1,000 individuals in the County.
Participants in the event were trained in compression- only CPR by our paramedics, EMT’s and other caregivers. More than 175
separate training events were held around the country.
Safety Jam
We are interested in bringing our successful Safety Jam™ event to the County. Safety Jam is a free to the public event offered
and coordinated by our personnel and conducted in a fun, festival-like environment. Safety Jam was started in 2013 with the
goal of the event is to minimize traumatic brain injuries from riding and boarding. The event ultimately improves the health
and wellbeing of the communities we serve. The event offered free bicycle and skateboard helmets on a first come first serve
basis to children in the community. The helmets were sized and properly fit along with education on proper use. The first
event had contests, free hot dogs, as well as several bicycles and skateboards given away through drawings. This event
accomplished with the help of partners such as local hospitals and area businesses. The 2013 event impacted nearly 300 area
youth with a total attendance of over 500 people.
The second annual event attendance was over 2,000 people. At this event, 627 bicycle and skateboard helmets were sized and
given away, a bicycle rodeo was held, fire safety education offered by local fire departments, water safety education offered
by the local dive rescue team, electrical safety education and much more. The event gave away 53 bicycles, 28 skateboards and
fed hot dogs to over 1100 people all free of charge. 38 sponsors and 22 exhibitors came together in the hope of increasing child
and family safety in our community.
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Additional Community Partnerships
Enlist our hospital partners to participate in Cardiac Arrest Registry to Enhance Survival (CARES) to measure
community OHCA survival rates
Analyzing the data we collect through our MEDS ePCR system and identifying trends regarding the types of calls we
respond to and the geographic locations of those calls
Designated talented and passionate caregivers who will focus on designing and delivering programs in County in
response to identified local clinical and safety trends
Ongoing collaboration with local stakeholders to share data and assessments, and partner in developing and delivering
targeted community education campaigns
Continuous monitoring of our campaigns, using outcome data to drive future programs
Involving our field personnel in community outreach campaigns to expand their impact
Immediate implementation of proven initiatives, such as citizen CPR, Public Access Defibrillator (PAD) programs, and
medical coverage for large events
Engage our the County community in “HEART Safe Community” initiatives
Development of targeted campaigns, such as recognizing and responding to life threatening emergencies and disaster
preparedness
Offering in-services on prevention and wellness topics to personnel at local health care facilities
EMS caregiver appreciation forums for “Saves”, delivering babies, STEMI and Stroke quality outcomes, in addition to
recognizing our teams during National EMS week, Dispatcher and Nurse appreciation celebrations
Tracking, responding and publishing consumer feedback regarding our services
Ensuring that the LEMSA receives regular updates regarding our community education campaigns and system
outcomes
Access to Grant Opportunities
Due to our governmental structure, we have the ability to search and review various grant opportunities. We will continue to
seek grants that will aid in our ability to provide exceptional services in the County.
Standby at Special Events
We commit to providing standby coverage for special events in Contra Costa County, including free coverage for public safety
events. Through our experience serving numerous communities, we have found that by partnering with organizers of large
community events, we can develop a plan to manage medical emergencies, as well as non-emergency first aid needs – without
compromising the EMS system’s ability to respond to other calls. We will meet with event organizers to evaluate their needs,
and then deploy resources during their event, such as Paramedics on foot, at a first aid booth, or deployed with an ambulance.
We look forward to continuing to work with the local Chambers of Commerce, Contra Costa County Fairs, Contra Costa County
high schools, parades and other event organizers.
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F. INTEGRATION WITH HEALTHCARE PROVIDERS
a) Minimum Requirements—Collaboration with Healthcare Providers
Attestation:
We understand and agree to comply without qualification to provisions, requirements, and commitments
contained in Section V.F.1.a.
We are committed to further collaborating and enhancing our relationships with local healthcare providers within the EOA and
the County. Through the Alliance, we have established and maintained relationships with all hospitals in the County. For
example, a few of these are, but not limited to the following:
John Muir (we currently hold a contract for non-emergency transport)
Contra Costa County Medical Center
Contra Costa County Health Department
Kaiser Hospital
Sutter Delta Medical Center
And other hospitals/facilities requested by patient.
b) Higher Levels of Commitment— Collaboration with Healthcare Providers
Below we have outlined a few of our higher levels of commitment for this section.
Out-of-Hospital Electronic Healthcare Record - MEDS
As your partner, we will utilize the Multi-EMS Data System (MEDS) electronic patient care
reporting (ePCR) system, which will operate as out-of-hospital electronic healthcare record. A
current and proven tool to efficiently and accurately capture clinical and demographic data,
the MEDS ePCR system has been tested strenuously over the past several years and we have
developed considerable expertise organization-wide in its upkeep and maintenance. Thus, our
operations are secure in the fact that the system is well-understood and supported by national
resources, and that troubleshooting assistance is available with one phone call if needed.
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We will provide state-of-the-art ruggedized laptops to crews using MEDS. We currently deploy Panasonic tablet FZ-G1. These
ruggedized notebooks meet military and International Electrotechnical Commission standards for vibration, dust, and water-
resistance. The data collected by MEDS software is used by our leaders and our EMS Agency partners to make fact-based
decisions regarding operation performance, clinical protocols, and patient treatments. MEDS is more than an ePCR product; it
is a solution that interconnects multiple systems, including:
ePCR
Clinical data
Billing information
NEMSIS reporting
CAD reconciliation
Data mapping
Reporting and analysis
MEDS ePCR is the largest deployment of pre-hospital care data collection in the United States. Presently, no other commercially
developed ePCR system surpasses the number of implemented sites as our MEDS ePCR solution. The MEDS ePCR system
provides a comprehensive approach to improving patient care through data sharing and patient care systems integration.
Unique characteristics of the MEDS ePCR system include the following:
Local control of screen changes to meet local requirements and real-time administrator changes to field devices
Ability to deliver expanded communication and reference material to caregivers in the field, including electronic “quick
references” for clinical protocols, medication dosage calculators, and other training material, which is accessible
during down time
Front and back-end business rule configuration to increase accuracy of PCR documentation
Compilation of clinical data into a data warehouse that facilitates research and study of millions of annual patient care
encounters
Mapping of data points to the NHTSA data set (NEMSIS) for compliance with federal recommendations for clinical and
demographic reporting, allowing for data comparison with other EMS systems
The ability to auto-populate fields by pulling data from our billing system for transported patients
The elimination of redundant entry of PCR data into a billing application
Ability to integrate data from our cardiac monitor/defibrillators into the PCR
Ability to perform Clinical Quality Improvement functions through immediate access to PCRs, Ad-Hoc reports, and
MEDS alerts
EPIC language
Working collaboratively with LEMSA, we have recently partnered with Contra Costa County
Medical Center to offer future integration with the EPIC software. While it is important to
capture and analyze a broad range of data, it is also important to striate the data to determine
if any segment of our patient population receives different levels or types of service.
With MEDS, CAD, and future integration with the EPIC healthcare software program being used by some local hospitals, we
can measure key indicators and striate by gender, ethnicity, age and any number of geographic, demographic and socio-
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economic layers to determine if any group statistically varies from the norm of the overall population. Our approach to
“community equity” goes beyond ambulance response times, and dives into the question of whether any population segments
receive different levels of care, present with different clinical challenges, or any number of variations.
Commitment to Healthcare Providers
We are committed to our local healthcare providers and supporting their medical transportation needs. We are willing to meet
with healthcare providers in County and discuss solutions that our organization can provide. In addition to providing medical
transportation, there may be opportunities to establish unique programs that will help with the healthcare providers’
throughput efficiencies. For example, we have a program in place with Kaiser Hospital that if we transport a Kaiser patient to a
non-Kaiser facility due to medical condition or necessity, we permit Kaiser’s medical staff access to our MEDS ePCR to facilitate
and process the patient.
Feasibility Study
For the last year, Dr. Benson, our Chief Medical Director, has been performing a feasibility study that has looked at alternative
models of care to our elderly (Rossmoor) population. The results of his project suggest that an alternative model of urgent
outpatient based midlevel (PA or NP) or physician care, can successfully prevent visits to the ED, or even EMS calls from
occurring in the first place. He has met with the hospital on several occasions and there is significant interest on their end. We
have applied previously for a CMS grant to fund a community paramedicine project, and are preparing to pursue additional
community paramedicine projects.
Other collaborative efforts involving cardiology, neurology and trauma services, that are currently being considered include
potential for physician field response in an advanced ground unit with advanced capabilities such as blood transfusion, chemical
extrication, RSI, trauma care (resuscitative endovascular balloon occlusion of the aorta (REBOA), transfusion, field amputation)
and innovative emergency care upon ED arrival, such as PCI for refractory cardiac arrest, or ED ECMO. Potential partnerships
include but are not limited to: Fall Prevention, Asthma Awareness, Public Health, Pre Season Athletic screening and others.
We are confident that together we can improve the patient experience of care (including quality and satisfaction) in many
ways. With the recent introduction of above initiatives, advancements in technology, and a 24-hour professional workforce,
we are poised to take advantage of all of these components to deliver care in alternate environments.
We have earned the trust of the public by taking care of their needs in their homes for decades. By addressing a systematic
approach to change where consistency and continuity of care is provided through the Alliance, critical gaps in patient
information will be eliminated and the goals of healthcare information exchange will be addressed.
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Expanded Mobile Integrated Healthcare Services
One of the current hot topics in EMS system design is the Community Paramedic Program. Several
EMS organizations have begun to experiment with the concept of expanded scope Community
Paramedic Programs that can mitigate gaps in current system resources. We have embarked on
similar pilot programs in many locations with great success for improving care, while reducing
healthcare costs. Once approved in California, the program will offer service lines focused on
difficult-to-serve patients with a high risk of repeat episodic care events. The following is a brief
description of the services we propose based upon identified needs:
Ambassador
Ambassador provides experience-focused transition-to-home services. These services can include transport to residence,
prescription fulfillment and delivery, medication reconciliation, re-connecting the patient with family and social supports, and
communicating with the patient’s primary physician to reestablish routine surveillance and care. Where a patient has ongoing
needs before traditional home care commences, Ambassador can provide follow-up visits or call center telephone contacts to
ensure successful reintegration in the home, identify patient experience gaps, etc.
Continuum
Continuum provides longitudinal inter-professional medical care at home. Continuum is a family of multi-provider inter-
professional in-home medical care programs most often focused upon reduction of avoidable readmission and unrecognized
patient deterioration. While not all readmissions are avoidable, they are a disappointment to patients and providers alike. Our
experience is that simple interventions immediately after discharge and in the days following resolve key issues leading to an
unexpected return to the emergency department or to in-patient care. Continuum programs can reduce cost in post-discharge
patients through patient-specific care plans designed to prevent relapse, avoidable emergency department visits, and
preventable readmission.
Sentinel
Sentinel provides support services to home hospice programs 24 hours a day, seven days a week. Additionally, Sentinel offers
program-specific niche intervention services for home hospice patients, their families, and caregivers when changes in patient
condition occur or when unexpected needs arise. By rapidly placing a Sentinel specialist provider at the patient’s side, we
provide rapid event assessment and immediate communication with the patient’s normal hospice team member to enhance
on-scene support and allow an informed decision by the hospice team as to whether an off-hours or unplanned visit is needed.
Sentinel interventions would depend on the scope of the program and could range from remaining with the patient until the
hospice team can reach the scene, assisting family in understanding the patient’s condition, adjustment of supportive care
measures, and more.
Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
KEY PERSONNEL
Jeff A. Carman
jcarm@cccfpd.org
Professional Profile
CONTRA COSTA COUNTY FIRE PROTECTION DISTRICT
FIRE CHIEF (2013-present)
Organizational Leadership |Innovation |Planning
Duties include leading the largest all-hazard fire district in the second most industrialized county in California. The
district consists of app. 300 uniformed fire personnel and support staff working within a budget of over $100 million and
answering over 45,000 annual requests for service in nine different cities and a daytime population of over 1 million
people.
ROSEVILLE FIRE DEPARTMENT
ASSISTANT FIRE CHIEF/ OPERATIONS (2010-2013)
Emergency Incident Command & Control| Public Information Officer| Operational Program Manager
Manage the Operations Division of the Roseville Fire Department including eight fire stations, 2 Battalions, 10
companies, and 100+ uniformed personal. Administer several critical programs including EMS, Hazmat, Technical
Rescue, and Fire Training. Manage internal and external communications including intranet, internet, custome r
service, and the public and media relations programs.
BATTALION CHIEF (1994-2010)
Emergency Incident Command & Control | Battalion Management| Special Operations Manager| Customer
Service Program Manager
Charged with managing a Battalion consisting of 4 fire stations, 5 companies and 16 personnel. Also tasked with
administering the department’s Special Operations program including a Type II Rescue and a Type I Hazmat team.
DIVISION CHIEF/ FIRE MARSHAL (1993-1994)
Fire Prevention | Fire Code Administration | Specific Planning for Development |Public Education
Managed the department’s Fire Prevention Bureau as the Fire Marshal during period of rapid growth. Worked
cooperatively with developers and prevention staff to insure community safety was maintained and/ or improved.
FIRE CAPTAIN (1989 – 1993)
Company Supervision | Program Manager | Apparatus Design and Acquisition
Supervised both Engine and Truck companies in various neighborhoods throughout the city. Added value to the
organization through program development and implementation.
Education and Skills
Bachelor of Science, Occupational Studies & Vocational Arts, emphasis in Public Safety
CSU Long Beach, 2006
Associate of Arts, Liberal Arts and Fire Technology
Sierra Community College, Rocklin, CA. 2003
Certified Chief Officer, California State Fire Marshal’s Office, CA. 2000
Extensive fire command and management studies not listed.
Lon Goetsch
E-Mail: LGoet@cccfpd.org
Experience
Assistant Chief, Operations Division July 2014 – March 2015 (Interim)
March 2015 – Present (Perm. Appt.)
Provide leadership and management of the Operations Division. Maintained close working
relationships with eleven direct report Battalion Chiefs and stayed in coordination with the fellow
Members of Senior Staff. Developed, expanded, and maintained relationships with cooperating
agencies to improve Fire/Rescue/EMS services throughout the county. Actively developed new
cooperative relationships with the Contra Costa Sheriff’s Department and Contra Costa Hazardous
Materials Team. Improved Battalion Chief command training and mentored four probationary chief
officers. Provided presentations for County and local political bodies on the status of the Fire District.
Staff Assignments- Vice-Chair XCC Operations Chiefs Committee, Wildland Program Manager,
Member- CCCFPD Sub-Jac, Operations Lead- EBRCS Transition Team, Member- East Bay Incident
Management Team, and CCCFPD Representative- West County Joint Operations Committee.
Battalion Chief, Operations Division April 2010 to July 2014
Provided leadership and management in one of the most dynamic Operational Battalions in the Fire
District. Developed, expanded, and maintained relationships with cooperating agencies to improve
Fire/Rescue/EMS services in a resource challenged region. Initiated regular multi-agency training drills
to improve safety and operational effectiveness. Provided local political bodies (El Sobrante MAC
and San Pablo City Council) with regular updates on Fire District activities and status.
Staff Assignments- Vice-Chair XCC Operations Chiefs Committee, Wildland Program Manager,
Strategic Planning Group Lead- Standards of Cover, Member- CCCFPD Sub-Jac, Operations Lead-
EBRCS Transition Team, Member- East Bay Incident Management Team, and CCCFPD
Representative- West County Joint Operations Committee.
Captain/Engineer/Firefighter-Paramedic, Operations Division May 2002- April 2010
Engine and Rescue company assignments in all three geographical areas of the Fire District.
Paramedic Evaluator, Wildland Program Functional Supervisor, Member of CATF-4 USAR team, and
Lead Fire Academy Wildland Instructor.
Captain/Engineer/Firefighter-Paramedic, CAL FIRE January 1990- April 2002
Helitack Captain, Helicopter Short-haul Crew Chief/Rescue Supervisor, Acting Battalion Chief, and
various assignments at all ranks in local government contract and state responsibility area Stations.
Overhead Assignments: Strike Team Leader, Division Supervisor, Helicopter Coordinator, Heli-base
Manager, and Operations Section Chief.
Education/Qualifications
CFSTES Chief Officer Series (90 % complete), S-420 Command &General Staff, ICS 100 through 700,
G-775/191EOC Operations/Management/SEMS EOC, CSTI Earthquake Management, CFSTES Fire
Officer Certification, State Fire Training Instructor (Command, Wildland/Structural Firefighting, and
Technical Rescue), 120 Units of Post-Secondary Education, Division/Group Supervisor, and Strike
Team Leader Engine.
Lewis T. Broschard III
Professional Experience
2014 – Present Contra Costa County Fire District Pleasant Hill, CA
Assistant Fire Chief, Support Services Division
Administration, management, fiscal accountability, and leadership of division consisting of Fire
Prevention, Facilities, Fleet and Apparatus Shop, Information Systems, Logistics, and the Contra
Costa County Regional Fire Communications Center.
Assist the Fire Chief in setting the goals and strategic plans, and administering the general
operations of the District
Contract administration and development
Maintaining and strengthening relationships between the Fire District and labor organizations, city
and county government agencies and their staff and departments.
Preparation of the Fire District's program budgets and expenditures of funds, including staffing,
operational, and capital outlay requirements
Evaluate Fire District emergency response and fire prevention operations and recommends
advancements to keep pace with industry standards, practices, and technology
Recommend and oversee the maintenance, operation, and utilization of facilities, apparatus and
equipment
Coordinate long-term planning, location, design, and construction of fire stations and other district
facilities
Coordinate procurement, utilization, and maintenance of equipment
2010 – 2014 Contra Costa County Fire District Pleasant Hill, CA
Fire Marshal/Public Information Officer
Administration and leadership of Fire Prevention Bureau protecting 720,000 residents over 420
square miles in multiple fire districts
Complex contract and local ordinance development, review, and implementation for fire
prevention, general fire district operations, revenue generation and cost recovery
Liaison with County and City staff, elected officials and various agency department heads on a
regular and frequent basis
Development and implementation of Fire Prevention Bureau strategic plan
Created efficiencies and successfully implemented change model processes to increase
revenues to fully offset costs of providing fire prevention services
Collaborated to build consensus with 9 city building officials in adoption and ratification of 2010
Fire Code amendment ordinance
Manage District light vehicle fleet of 83 units, including surplus of equipment and maintenance
agreements with vendors
Public information development and distribution for critical incidents and non-emergency events
using social media, internet, and traditional media outreach methods
PIO for East Bay Incident Management Team (Type III)
2009-2010 Contra Costa County Fire District Pleasant Hill, CA
Fire Prevention Captain
Supervisor of Engineering Unit – plan review, new construction, fire and life safety system
acceptance testing
Supervision of Exterior Hazard Control Unit
Collaborate with other member of FPB, administrative staff, operations, and chief officers on
policy development, standards, and daily FPB operations.
Provide detailed and efficient customer service to internal and external customers.
Train, mentor, and develop Fire Inspectors.
Assist in developing strategic plan.
Coordinate and communicate with contractors, owners, county and city building departments, and
other internal/external customers on a regular basis.
Lewis T. Broschard III
2007–2009 Contra Costa County Fire District Pleasant Hill, CA
Fire Inspector
Conduct plan review, fire code enforcement, and new construction inspections.
Fire alarm and suppression system testing.
Coordinate and communicate with contractors, owners, county and city building departments, and
other internal/external customers on a regular basis.
Drafting standards and forms for use by all members of FPB.
Assist in training delivery for Fire Inspectors and other members of FPB.
2003–2007 Cordelia Fire Protection District Fairfield, CA
Assistant Fire Chief – Fire Marshal
Emergency response, incident command, and member of countywide incident management team
Conduct and supervise plan review, fire code enforcement, and new construction inspections.
Conduct and supervise fire alarm and suppression system acceptance testing.
Manage occupancy and vegetation clearance inspection programs.
Coordinate and communicate with contractors, owners, county staff, and other internal/external
customers on a regular basis.
Collaborate with other fire agencies to develop a standard fire code ordinance throughout the
County, drafting and implementing ordinances, standards, policies and procedures
1999–2003 Cordelia Fire Protection District Fairfield, CA
Fire Chief - Interim
Administration, budgeting, personnel, and fire prevention responsibilities for a combination Fire
District providing 24 hour staffing of two stations with engine based paramedic service.
Emergency response, incident command, and member of countywide incident management team
Implemented improved fire prevention standards and practices.
Developed resident firefighter program to increase 24 hour staffing and ALS capabilities
Regional collaboration and coordination on fire service related issues between counties, cities,
and special districts
1995-1999 Cordelia Fire Protection Dist. Fairfield, CA
Engineer, Lieutenant
1993-1995 UC Davis Fire Department Davis, CA
Firefighter
1991-1993 Cordelia Fire Protection Dist. Fairfield, CA
Firefighter
Education
2005 John F. Kennedy University Pleasant Hill, CA
Master’s Degree, Business Administration
1995 UC Davis Davis, CA
B.S., Managerial Economics; Minor work in Political Science
Certifications
California State Fire Marshal
Fire Officer
Fire Plans Examiner
Fire Protection Specialist
Fire Prevention Officer
International Code Council
Fire Inspector I, II
Lewis T. Broschard III
Memberships and Associations
Contra Costa County Fire Chief’s Association – President (2013-2015)
International Association of Fire Chiefs (IAFC) – Member
National Fire Protection Association (NFPA) – Member
International Fire Marshals Association (IFMA) - Member
International Code Council (ICC) – Voting Member
Professional Education and Coursework
Fire Service Management and Leadership
CSFM Fire Management 1 (Management/Supervision for Company Officers)
CSFM Fire Management 2A (Organizational Development and Human Relations)
CSFM Fire Management 2B (Fire Service Financial Management)
CSFM Fire Management 2C (Personnel and Labor Relations)
CSFM Fire Management 2D (Strategic Planning)
CSFM Fire Management 2E (Ethics and the Challenges of Leadership)
Collaborative Leadership in Homeland Security Program (University of Connecticut/FEMA)
Northwest Leadership Seminar (2013, 2014)
The “Compleat Fire Officer” (Center for Public Safety Excellence)
Various seminars on labor relations, leadership, supervisory principles, personnel investigations
Incident Command
S-420 (Command and General Staff)
S-404 (Safety Officer – All Risk)
I-200, 300, 400 (Incident Command System)
I-700, 800 (NIMS)
S-339 (Division/Group Supervisor)
S-334 (Strike Team Leader)
S-205 (Fire Operations in the Wildland Urban Interface)
S-230 (Crew Boss – Wildland Fire)
CSFM Command 1A (Command Principles for Company Officers)
CSFM Command 1B (Incident Management for Company Officers)
CSFM Command 1C (I-Zone Firefighting for Company Officers)
CSFM Command 2A (Command Tactics at Major Fires)
CSFM Command 2C (High Rise Firefighting Tactics)
CSFM Command 2E (Wildland Firefighting Tactics)
S-190 (Wildland Fire Behavior)
S-290 (Intermediate Wildland Fire Behavior)
S-390 (Wildland Fire Behavior Calculations)
Annual Cal-OES Overhead and Strike Team Leader Refresher Training
Fire Prevention and Training
Fire Training Instructor 1A (Cognitive Lesson Delivery)
Fire Training Instructor 1B (Psychomotor Lesson Delivery)
Fire Investigation 1A (Fire Origin and Cause Determination)
Fire Investigation 1B (Techniques of Fire Investigation)
Fire Prevention 1A (California Fire Code)
Fire Prevention 1B (Fire Protection Systems and Special Hazards)
Fire Prevention 1C (Flammable Liquids and Gases)
Fire Prevention 2A (Fire Protection Systems and Building Components)
Fire Prevention 2B (Interpreting the Building Code and Fire Code)
Fire Prevention 2C (Special Hazard Occupancies)
Fire Prevention 3A (Hydraulic Sprinkler Calculations)
Fire Prevention 3B (Plan Review)
Principles of Fire Protection (National Fire Academy, on-campus)
Public Information
S-403 (Information Officer)
CSTI Crisis Communication and the Media – Level 1
G-290 (Public Information Officer)
J A C K I E L O R R E K O V I C H
(925) 941-3312 Office
jlorr@cccfpd.org
SUMMARY OF QUALIFICATIONS
Over seventeen (17) years of complex managerial and analytical experience in local government finance,
personnel management, and general public administration.
Sensitivity to issues that accompany serving elected public officials.
Knowledgeable in federal and state personnel laws, including current trends and industry best practices.
Ability to manage multiple work projects simultaneously in a dynamic environment with constantly shifting
priorities.
Accustomed to working in highly unionized environment.
Advanced analytical, planning, problem solving, and written communication skills.
WORK EXPERIENCE
Contra Costa County Fire Protection District
Fire District Chief of Administrative Services January 2010 – Present
Job Duties: Serve as chief financial officer for the District and direct and manage all administrative services within
the organization including office management, payroll, personnel, purchasing, capital and construction, contracts
and grants management, accounts payable/receivable, debt service and investments. Prepare and monitor the
District’s general operating budget and other budgets (e.g., restricted capital and debt service funds). Prepare
periodic reports relative to the status of the budget. Develop, prepare, and approve board orders and resolutions
for presentation before the fire board of directors.
Personnel Services Assistant III April 2003 – January 2010
Job Duties: Managed the District’s personnel program. Represented fire chief in labor relations issues and
employee grievances. Prepared documents to effect disciplinary actions when warranted. Acted as liaison to
county counsel on merit board appeals, DFEH/EEOC complaints, and civil litigation matters pertaining to
discrimination in employment and hiring practices. Developed and promulgated personnel policies, standards and
regulations. Interpreted and revised existing policies. Provided guidance to senior staff and other managers on
personnel matters. Analyzed positions and agency structure to determine most effective staffing levels and
classification relationships. Developed justification for position adjustment requests as needed. Reviewed and
approved all employee performance evaluations. Reviewed and cleared all personnel transactions. Ensured
relevant personnel records were retained. Coordinated new hire and promotional processes and job analysis and
exam development efforts. Created new and revised existing job specifications.
Contra Costa County Human Resources Department
Human Resources Analyst III February 2002 – April 2003
Human Resources Analyst II April 2000 – January 2002
Human Resources Analyst I January 1999 – March 2000
Administrative Intern April 1998 – January 1999
Job Duties: Performed generalist technical personnel work within the central human resources department of a large, merit-based public agency. Worked extensively in the following areas: recruitment, examination,
classification/compensation, job analysis, position audits, consideration of departmental requests, interpretation of
County policies and procedures, and consultative support to the labor relations unit.
J. Lorrekovich
Page 2 of 2
CONTINUING EDUCATION
Social Media (October 2014), Public Sector Employment Law Update (September 2014), Disciplinary and
Harassment Investigations (May 2014), Mandated Reporting (April 2014), Preventing Workplace Harassment
(September 2013), Managing the Marginal Employee (September 2013), Negotiating Modifications to
Retirement and Retiree Medical (April 2013), Pension Reform (October 2012), Forecasting Property Tax
Revenue (October 2012), Difficult Conversations (October 2012), Government Accounting (June 2012),
Impact of RDA Dissolutions on Special Districts (April 2012), AB 646 – The Meet and Confer Process (March
2012), Generational Diversity (October 2011), FLSA (March 2011), Privacy Issues in the Workplace (April
2011), Principles for Public Safety Employment (April 2010), Employee Due Process Rights and Skelly (April
2010), Management Rights, Communication, and Discipline (October 2009), The Disability Interactive
Process (September 2009), Public Agency Issues During Lean Economic Times (May 2009), Privacy Issues
in Our Technological World (May 2009), Performance Management: Evaluation, Documents and Discipline
(April 2009), Labor Law and Arbitration Conference (January 2009), Managing Overlapping Leave Laws (May
2008), Firefighter Procedural Bill of Rights Act Training (December 2007), Employees and Driving / Disaster
Service Workers (April 2007), Employment Relations Primer (October 2006), Supervisory Skills (April 2006),
Public Service 101 (February 2006), Legal Issues Regarding Hiring (February 2006), Collective Bargaining
for Public Safety Employees (June 2005), FLSA Update (May 2005), Employment Liability (May 2005),
NIOSH Conference on Long Working Hours, Safety and Health (April 2004), Conducting a Public Sector
Workplace Investigation (January 2004), The Harvard Program on Negotiation (December 2003), Advanced
Classification & Compensation Training (March 2002), IPMA Competency Model (July 2001), Developing &
Using Supplemental Application Forms (March 2000), Developing Interviews (March 2000), Developing &
Using Work Sample & Performance Tests (March 2000), Passpoint Setting (March 2000), Scoring Models
(March 2000), T3 - Train the Trainer (February 2000), Developing & Using Multiple Choice Written Exams
(February 2000), Interpreting Item Analysis Data (February 2000), FLSA Workshop (February 2000), Selection
Planning (January 2000), Job Analysis (December 1999), Employee & Labor Relations (April 1999),
Strategies & Applications for Public Sector Compensation (April 1999), Classification & Compensation
(February 1999), The FLSA in the Public Sector (September 1999), Recruitment & Selection (May 1998)
EDUCATION
Bachelor of Science Degree, Business Administration/Finance, California State University, Chico December 1992
PROFESSIONAL REFERENCES
Available upon request.
Michael Johnson
5151 Port Chicago Hwy Concord, Ca 92336
Office: (888) 267-6597
michael_johnson@amr.net
OBJECTIVE
Committed to patient care with twenty four years experience in the emergency medical service industry, including ten years of
operational management. Expertise in developing business strategies, fueling healthcare awareness and cultivating government
relationships. Motivator and trusted leader with proven track record of building successful teams through diversity, training and
cross functional business support. Ability to solve problems with creative solutions based on a broad understanding of
technology, medical, legal and regulatory issues.
SKILLS
Customer Service & Communication
Leadership & Employee Development
Financial & Budget Management
Strategic Business Planning & Analytics
Risk Management & Safety Awareness
Process Efficiency & Business Continuity
CAREER EXPERIENCE
2015 – Present General Manager, AMR – Contra Costa County
Develop distinctive strategies to achieve competitive advantage; translate broad growth, government
relations, and other relevant strategies into specific objectives and action plans; align the organization to
support strategic priorities.
Demonstrate sound, entrepreneurial risk taking by championing new ideas and initiatives that address
market potential, level of care needs, and customer expectations. Identify financially sound, new
business opportunities and make them a reality in order to create a culture of sustained growth; foster
innovation and risk taking.
Plan, prepare, and utilize financial records (including budgets, forecasts, payroll data, etc.) and key
metrics in order to analyze and make decisions to meet specific strategic and financial goals. Take
timely and appropriate corrective actions when necessary to ensure financial expectations (EBITDA,
ROIC, etc) are met.
Responsible for all facets of the profit and loss of the division which includes top line revenue to
allocations. Understand the nature of the transports provided and responsible for the documentation
provided by crews. This documentation dictates the level of service (CCT/ALS/BLS) and nature (nonemergency/
emergency) which drives the revenue billed.
Responsible for the division’s accounts receivable (AR) and understanding all payer classes (Medicare,
Medicaid, HMO’s, 3rd party insurers, VA, etc). Collaborate with PBS (as well as all support departments)
to ensure AR is promptly addressed.
Provide clear strategic direction regarding the organization’s values and model AMR’ values for all levels
of the division.
Communicate with division regarding local, regional and national strategies and related
initiatives. Encourage input and participation where practical to ensure success related to such efforts.
Regularly foster strong working relationships with local public, private, political and community members,
including but not limited to mayors, boards of supervision, commissioners, officials of fire and police
departments, chambers of commerce, rotaries, and in some cases state officials.
Participate in labor negotiations and other actions to balance employee engagement and the financial
viability of division.
Regularly review and address transport ticket work to ensure timely and appropriate payments.
Ensure customer satisfaction and contract retention, by providing optimal service levels to agencies,
hospitals, and the medical community. Analyze information regarding customer satisfaction, modify
processes, and counsel employees to ensure high levels of customer service.
Review and approve expense reports and invoices in compliance with company policy.
Keep current on industry trends that have potential impact on the division.
Formulate, coordinate and/or lead marketing activities and business development to increase revenues
and decrease costs.
Champion the practice of AMR medicine to improve health outcomes of the general population
Design, implement and maintain processes to maximize quality of operations.
2006 – 2015 Operations Manager, AMR - San Bernardino County
Successfully meets contractual compliance with five San Bernardino County EOAs.
Consistently manages budget to exceed EBITDA; effectively maintaining expenses, labor costs and UHUs.
Manage approximately 200 employees including EMTs, Paramedics, Supervisors, Schedulers, Fleet Services, Pre-Hospital
Billing, Administration and Clinical Education Services.
Experienced in union campaigns and managing both union / non-union work environments.
San Bernardino County DRT Coordinator; county disaster preparedness and FEMA personnel response.
EMSC Operational Performance Audit - Highest overall score awarded for execution of business continuity and operational
process management, including; safety, inventory regulation, controlled substance management, expense reporting, 911
contractual compliance, certification management, etc.
Rooted in community service; coordinate employee charitable events, actively participat e and coordinate community
donations, partner with other organizations such as United Way, District Lions Club and various public agencies to support
charity work.
Contribute to the development of future EMS professionals working with; Cucamonga Unified School District, Chaffey
College, Baldy View OCC. Received Quality of Time Award in 2008 for coordinating ambulance donation and assisting with
the development of educational curriculum.
2001 – 2006 Operations Manager, AMR - Los Angeles County
Successfully managed over 200 employees in a diverse operation, while maintaining a high level of employee satisfaction,
resulting in the top retention rate of Southland Division Operations
Consistently maintained contractual response criteria for LA County Fire Department
Regularly met EBITDA goals leading the only operation in the Southland Division to meet favorable variance in the 2005
stub budget.
Successful in effective cost management; significantly reduced double time costs each pay period.
Effectively maintained positive labor relations, demonstrating reduced grievances and arbitration.
Spearheaded operational projects gaining non-emergent business in the private sector, such as; Cedar Sinai Helipad
Contract, San Fernando CCT, Good Samaritan Hospital AMI, Citrus Valley Medical Center.
Organized community events; participated in the creation of the first EMT school at the San Gabriel Regional Occupation
Center, sponsored the Junior Paramedic Program, coordinated the Camp Afflerbaugh First Responder Training, supported
Junior Diabetes Foundation, committee member of the City of Irwindale Educational Foundation.
Certificate of Appreciation City of LA 2004 – from Michael Antonovich
1996 – 2001 Operations Supervisor, AMR & MedTrans - Los Angeles County
Mentored and trained personnel; observed and coordinated field performance for new emergency responders. Taught safe
driving techniques, and reinforced company policy and procedures.
Accessed daily deployment and equipment needs; assign replacements and schedule service as necessary for contractual
compliance.
Investigated incidents involving field personnel and communicate with operations manager on status of assigned units.
1989 – 1996 EMT / Training Officer, Goodhew Ambulance - Los Angeles County
Performed all duties of an EMT with a high level of proficiency.
ACCOMPLISHMENTS
CEO for a Day Semi Finalist 2011
Safety Recognition Award 2010
Clinical Safety & Education Award 2008
Silver Patron EMSC Charitable Foundation 2008
Business of the Year San Gabriel Valley 2006
Congressional Recognition to Community Service 2005
Community Provider of the Year 2000
City of LA Certificate of Appreciation 1992 –Devotion to
EMS During Civil Unrest
Institute for Healthcare Improvement Open School Certificate
EDUCATION
Los Angeles Harbor College – Los Angeles, Ca 1987 –Business Administration
REFERENCES
Available Upon Request
PETER BENSON MD FACEP
–
Education
1994 B.A., German, UC Berkeley
1998 M.D., Tufts University School of Medicine, Boston
2005 Emergency Medicine Residency, Level I Trauma Center, L.A. County/USC
2006 M.P.H. with focus of EMS & Disaster Medicine, UMass Amherst
Foreign Languages
Spanish (Fluent)
German (Fluent)
Certifications
2006 Board Certified, American Board of Emergency Medicine
2013 Subspecialty Board Certified, American Board of Emergency Medicine-EMS
Medical Licensures, Current
California: A69360
Active Memberships
Emergency Medical Directors Association of California (EMDAC), Secretary 2006-2007
National Association of EMS Physicians (NAEMSP)
Fellow, American College of Emergency Physicians (FACEP)
Related Current Work Experience
2013-present: Fire-EMS Medical Director, Contra Costa County Fire Protection District
Duties: CQI, protocols, communicable diseases (Ebola, Measles, Flu etc), occupational health
and safety, multi-disciplinary committees (preTAC, MAC, Cal Chiefs), teaching/lecturing
Supervisor: Ben Smith, Battalion Chief (925-941-3513)
2008-present: Emergency Physician, John Muir Level II Trauma Center
Duties: Emergency Department physician practice, member of trauma team
Supervisor: Katie Hurt MD, Medical Director (925-939-5800)
2011-present: Medical Director, John Muir Hyperbaric Medicine Department
Duties: CQI, physician oversight, protocols, outreach.
Supervisor: Mandy Mori, Program Director (925-357-5237)
Related Previous Work Experience
2007-2010 Associate ED Medical Director St Joseph’s Medical Center, Stockton
2007-2009: Medical Director, American Medical Response, San Joaquin County
2006-2007: Assistant EMS Medical Director, San Joaquin County EMS Agency
2003-2006: Medical Director, San Andreas Ambulance, Calaveras County
1988-2002: EMT Basic, EMT- Paramedic, Flight Physician, Various Agencies
Academic Appointments
2006-2008: Associate Professor of Emergency Medicine, University of Southern California
Publications
Benson PC, Eckstein M, McClung CD, Henderson SO.
Racial/ethnic differences in bystander CPR in Los Angeles, California.
Ethn Dis. 2009 Autumn;19(4):401-6
Benson P, Eckstein M.
Pulseless electrical activity: a diagnostic challenge for EMS.
Prehosp Emerg Care. 2005 Apr-Jun;9(2):231-5
Benson PC, Swadron SP.
Empiric acyclovir is infrequently initiated in the emergency department to patients ultimately
diagnosed with encephalitis.
Ann Emerg Med. 2006 Jan;47(1):100-5. Epub 2005 Nov 8
Benson P. Rocky Mountain Spotted Fever, another important cause of fever and
rash. J Emerg Med. 2004 Nov;27(4):415-6; author reply 416.
Benson PC
Emergency Resuscitation in the Emergency Medicine Handbook.
Landes Bioscience. Ed: SO Henderson, Apr 2006
CURRICULUM VITAE
Name: Herbert E. “Gene” Hern, JR., M.D., M.S.
Position: Program and Residency Director
Department of Emergency Medicine
Alameda County Medical Center, Highland Hospital Campus
Address: Alameda County Medical Center
Highland Hospital Campus/Emergency Dept.
1411 East 31st Street
Oakland, CA 94602
EDUCATION:
1987-1991 Pomona College, Pomona, CA B.A. Magna cum Laude
Honors Thesis Topic: “Rationing Health Care for the Elderly”
1989 University College, Oxford University
Main Tutorial in Bioethics and the British National Health Service
1991-1994 University of California, Berkeley, M.S. (Bioethics)
School of Public Health, Health and Medical Science
UCB/UCSF Joint Medical Program
1991-1996 University of California, San Francisco M.D.
1996-2000 Highland General Hospital, Oakland, CA Residency Emergency Medicine
1999-2000 Highland General Hospital, Oakland, CA Chief Resident Emergency Medicine
2003-2004 American College of Emergency Physicians Teaching Fellow
LICENSES, CERTIFICATION
2001 American Board of Emergency Medicine Cert No. 200857. Certified Through 2021.
PRINCIPLE POSITIONS HELD
1999-present Kaiser Permanente, Oakland Emergency Physician Emergency Medicine
2000-present Highland General Hospital Attending Physician Emergency Medicine
2008-present University of California, SF Associate Clinical Professor Emergency Medicine
2007-present Highland General Hospital Program/Residency Director Emergency Medicine
2007-present American Medical Response Medical Director Contra Costa County
2011-present Oakland Fire Department Medical Director EMS Division
2012-present Las Positas College Medical Director Paramedic Program
2014-present Berkeley Fire Department Medical Director EMS Division
OTHER POSITIONS RECENTLY HELD
1999-2000 Highland General Hospital Chief Resident Emergency Medicine
1999-present Highland General Hospital Residency Education Committee Emergency Medicine
1999-present Highland General Hospital Grad. Medical Education Committee Emergency Medicine
2001-2008 University of California, SF Assistant Clinical Professor Dept. of Medicine
2001-2007 Highland General Hospital Associate Residency Director Emergency Medicine
2007-2011 American Medical Response Medical Director Alameda County
HONORS AND AWARDS:
1983 Vigil Honor (Order of the Arrow, BSA), Eagle Scout
1991 Phi Beta Kappa
1998 Urgent Care Resident of the Year
1998 Kay Simmons Award, ACMC Department of Emergency Medicine (Humanitarianism)
1999 - 2000 Chief Resident
1999 National CPC Champion
2000 Gary P. Young Award for Excellence in Academic Medicine
2000 Resident of the Year
2007 UCSF Training Award Nominee – Outstanding Foundations of Patient Care Preceptor
2008 UCSF Kaiser Award for Excellence in Teaching by a Volunteer Clinical Faculty Nominee
2008 EMS Hospital Award for Excellence, Alameda County EMS Agency
2009 UCSF Recipient of AOA Induction (Nominated and Voted by Graduating Medical Students, Class
of 2009)
2013 Residency Director of the Year, presented by the Emergency Medicine Residents’ Association
2014 Michael P Wainscott Program Director Award, presented by the EM Council of Residency Directors
KEYWORDS/AREAS OF INTEREST:
Graduate Medical Education, Emergency Medical Services, Ultrasound, Ethics
PROFESSIONAL ACTIVITIES:
American College of Emergency Physicians
American College of Emergency Physicians/California Chapter
Board of Directors, 2006 – 2010
Education Committee, Co-Editor – Lifeline Newsletter, 2002 - 2011
SUMMARY OF CLINICAL ACTIVITIES
Full-time Attending Physician, Department of Emergency Medicine
Alameda County Medical Center, Highland Hospital Campus
PROFESSIONAL ORGANIZAIONS:
Membership
1997-2002, Bioethics Committee Member, ACMC
1998-present, GME Committee, ACMC
1999-2000, 2002–2003, 2007-2008, Society of Academic Emergency Medicine, Ethics Committee
2000-Present, Committee on Inter-Disciplinary Practice
2001-Present, Council of Residency Directors (CORD)
2006-Present, American College of Emergency Physicians/California Chapter
2006-Present, American Academy of Emergency Medicine
2009, Alpha Omega Alpha (Medical Honor Society)
Service to Professional Organizations
2001-present Committee on Inter-Disciplinary Practice
Chairman
2002-present American College of Emergency Physicians/California Chapter
Education Committee
Co-Editor – Lifeline Newsletter 2002-2011
2002-present Council of Residency Directors
Standardized Evaluation Committee
Year End Competency Committee Chair
County Program Directors Caucus, Chair
Task Force on Transitions of Care, Chair
2006-2010 American College of Emergency Physicians/California Chapter
Board of Directors
SERVICES TO PROFESSIONAL PUBLICATIONS:
2007-2010 Editor, Education Section, Western Journal of Emergency Medicine
NATIONAL INVITED PRESENTATIONS
2004 ACEP, 2 Invited Presentations. “ABCs of STDs,” “CTs in Trauma.”
2005 – 2011 CORD AA Research Forum Chair
2007 CORD, Speaker Best Practices
2008 CORD, Panel Discussion
2007- 2015 SAEM, Medical Student Forum
2012 ACEP, 3 Invited Presentations. “Sore Throats,” “Facial Swelling,” “ENT Bleeding.”
2013 ACEP, 3 Invited Presentations. “Sore Throats,” “ENT visual Diagnosis” “Rapid ENT procedures”
2014 ACEP, 3 Invited Presentations. “Sore Throats,” “ENT visual Diagnosis” “Rapid ENT procedures”
REGIONAL AND OTHER INVITED PRESENTATIONS
2003-2010 Western Regional SAEM Conference
2004, 2005 25th Annual Mammoth EM Conference Lecturer
2012 Northwestern University, Dept of EM, Grand Rounds, “Sore Throats that Kill.”
2012 Columbia University, Dept of EM, Grand Rounds, “Sore Throats that Kill” and
“So Now You Have Been Sued.”
CME COURSES ATTENDED
1999 – 2013 Society for Academic Emergency Medicine Annual Meeting
1999 – 2009, 2011 - 2014 American College of Emergency Medicine – Scientific Assembly
2001 – 2012 Council of Residency Directors, Academic Assembly
UNIVERSITY AND PUBLIC SERVICE
UNIVERSITY SERVICE
EM 140.40 Advanced EM Medical Student Teaching
EM 140.41 Intro to EM Medical Student Teaching
EM 140.42 Emergency ULS Medical Student Teaching
FPC precepting Medical Student Teaching
JMP precepting Medical Student Teaching
132C: Transitional Clerkship – Course Director – Procedures
PUBLIC SERVICE
2003-2009 Medical Director Oakland Police Department SWAT Team
2000-2005 Volunteer Clinician, UCB Suitcase Homeless Clinic
TEACHING and MENTORING
2009 ACEP Teaching Fellowship Lecturer
POSTGRADUATE AND OTHER COURSES
1999-2004 Clinical Instructor, Suitcase Homeless Clinic First through third year medical students
1999-present Guest Lecturer, Introduction to Clinical Medicine Second year medical students
1999-present Small Group Co-Leader, Foundation of Patient Care 1st and 2nd year medical students
2000-present Attending Physician, ACMC Individual and bedside teaching
2000-2002 Coordinator/Instructor, Clinical Procedures Course Joint Medical Program
2004 Guest Lecturer, Hospital Consortium Education Network
2004 Guest Lecturer, AMR Hot Topics in EMS Paramedic Training, Syncope
2006-2008, 2010 Lecturer, Splinting Techniques, Basic Procedures in EM First year medical students
2008-2014 Course Director, Procedures, Transitional Clerkship Second year medical students
2009-2014 Course Coordinator, IV and ULS skills Session,
Intersession Clerkship Third year medical students
TEACHING AWARDS AND NOMINATIONS
2007 UCSF Teaching Award Nominee
2008 UCSF Kaiser Award for Excellence
2009 UCSF AoA Faculty Nomination (chosen by graduating seniors)
SUMMARY OF TEACHING HOURS:
2000-2014 EM 140.40 Advanced EM Medical Student Teaching (over 40 UCSF students taught throughout the
academic year)
2009-2014 EM 140.41 Intro to EM Medical Student Teaching
2007-2014 EM 140.42 Emergency ULS Medical Student Teaching
1999-2014 FPC precepting Medical Student Teaching (Over 100 hours per year)
2006-2014 JMP precepting Medical Student Teaching
2008-2014 132C: Transitional Clerkship – Course Director – Procedures (Entire MSII class)
PEER REVIEWED PUBLICATIONS:
1. Hern, HE Jr. Ethics and human values committee survey: (AMI Denver Hospitals: Saint Luke’s,
Presbyterian Denver, Presbyterian Aurora: Summer 1989). A study of physician’s attitudes and perceptions of
a hospital ethics committee. Hec Forum, 1990, 2(2):105-25.
2. Hern, HE Jr.; Rain L; Vrolyk A. Hospital staff perceptions of the ethics committee and the Bioethics Institute:
a multi-disciplinary approach (Northridge Hospital Medical Center, California). Hec Forum, 1991, 3(3):129-
46.
3. Ciesielski-Carlucci C; Hern, HE Jr.; Kushner TK. Avoiding discriminatory medical school admission and
residency interviewing [letter]. Academic Medicine, 1994 Dec, 69(12):975.
4. Ciesielski-Carlucci C; Hern, HE Jr.; Kushner TK. A Rite Gone Wrong… Medical School and Residency
Interviews, the New Physician, Nov. 1995.
5. Hern, HE Jr., Koening BA, Moore LJ, Marshall PA. The difference that culture can make in end-of-life
decision making. Camb Q Health Ethics, 1998:7(1):27-40.
6. Cohen, MA and Hern, HE Jr. Sore throat and weakness in an injection drug user. Academic Emergency
Medicine, 2000, June; 7(6):679-86.
7. Rodriguez, Robert and Hern, HE Jr. “An approach to critically ill patients,” West J Med 2001; 175 392-395.
8. Eric D Katz, Lee Shockley, Lawrence Kass, David Howes, Janis P Tupesis, Christopher Weaver, Osman R
Sayan, Victoria Hogan, Jason Begue, Diamond Vrocher, Jackie Frazer, Timothy Evans, Gene Hern, Ralph
Riviello, Antonio Rivera, Keith Kinoshita, and Edward Ferguson, Identifying inaccuracies on emergency
medicine residency applications, BMC Medical Education 2005, 5:30 doi:10.1186/1472-6920-5-30.
9. Shayne P, Gallahue F, Rinnert S, Anderson CL, Hern G, Katz E; CORD SDOT Study Group. Reliability of a
core competency checklist assessment in the emergency department: the Standardized Direct Observation
Assessment Tool. Academy of Emergency Med. 2006 Jul; 13(7):727-32.
10. Wang R, Snoey ER, Clements RC, Hern HG, Price D. Effect of head rotation on vascular anatomy of the
neck: an ultrasound study. J Emergency Medicine. 2006 Oct; 31(3):283-6.
11. Stone, Micheal B., and Hern, H. Gene, Inadvertent Carotid Artery Cannulation During Ultrasound Guided
Central Venous Catheterization, Annals of Emergency Medicine, 2007 May, 49(5):720. Letter.
12. Wallin TR, Hern HG, Frazee BW. Community-associated methicillin-resistant, Staphylococcus aureus.
Emergency Medical Clinic North America. 2008 May; 26(2):431-55, ix. Review.
13. Catron T, Hern HG. Herpes zoster ophthalmicus. West J Emergency Medicine. 2008, Aug; 9(3):174-6.
14. Yarris L, Fu R, LaMantia J, Linden J, Hern HG, Lefebvre C, Kman N, Tupesis J, Nestler DM, An
Educational Intervention Improves Resident Satisfaction with Real-time Feedback in the Emergency
Department, Acad Emerg Med. 2009 Dec;16 Suppl 2:S76-81.
15. Sadosty A, Goyal D, Hern HG, Kilian B, Beeson M, Alternatives to the Conference Status Quo: Summary
Recommendations from the 2008 CORD Academic Assembly Conference Alternatives Workgroup Acad
Emerg Med. 2009 Dec;16 Suppl 2:S25-31
16. Hern HG Jr., Wills C, Alter H, Bowman SH, Katz E, Shayne P, Vahidnia F, Conference Attendance Does
Not Correlate With Emergency Medicine Residency In-Training Examination Scores, Acad Emerg Med.
2009 Dec;16 Suppl 2:S63-6
17. Jennifer Carnell, Gene Hern, Amandeep Singh, Larry Lambert, Paul Cheung, Bitou Cisse, Charlotte Silver,
Bradley Frazee, Longitudinal nasal methicillin-resistant Staphylococcus aureus colonization among resident
physicians at an urban, public hospital, International Journal of Infection Control. Vol 7, No 3 (2011)
18. Yarris, Lalena; Fu, Rochelle; LaMantia, Joseph; Linden, Judith; Hern, H.; Lefebvre, Cedric; Nestler, David;
Tupesis, Janis, Effect of an Educational Intervention on Faculty and Resident Satisfaction with Real-time
Feedback in the Emergency Department, Acad Emerg Med. 2011 May;18(5):504-12.
19. Andrade, A, Hern, H Gene, Traumatic Hand Injuries: An Evidence- Based Approach In The Emergency
Department, EM Practice, Emerg Med Pract. 2011 Jun;13(6).
20. Love JN, Howell JM, Hegarty CB, McLaughlin SA, Coates WC, Hopson LR, Hern GH, Rosen CL, Fisher J,
Santen S.; Factors that Influence Medical Student Selection of an Emergency Medicine Residency:
Implications for Training Programs, Acad Emerg Med. 2012 Apr;19(4):455-60
21. Young MF, Hern HG, Alter HJ, Barger J, Vahidnia F; Racial Differences in Receiving Morphine among
Prehospital Patients with Blunt Trauma, J Emerg Med. 2013 Mar 8. pii: S0736-4679(12)01420-5.
22. Kessler C, Shakeel F, Hern HG, Jones JS, Comes J, Kulstad C, Gallahue FA, Burns BD, Knapp BJ, Gang M,
Davenport M, Osborne B, Velez LI. An algorithm for transition of care in the emergency department. Acad
Emerg Med. 2013 Jun;20(6):605-10. doi: 10.1111/acem.12153. PubMed PMID: 23758308.
23. Hern HG Jr, Alter HJ, Wills CP, Snoey ER, Simon BC. How Prevalent Are Potentially Illegal Questions
During Residency Interviews? Acad Med. 2013 Aug;88(8):1116-1121. PubMed PMID: 23807097.
24. Riguzzi, Hern, Alter, The July Effect: Is Emergency Department Length of Stay Greater at the Beginning of
the Hospital Academic Year?, Western Journal of Emergency Medicine. 2014 Feb;15(1):88-93. PMID:
24578770
25. Hunter BR, Keim SM, Seupaul RA, Hern G, Are plain radiographs sufficient to exclude cervical spine
injuries in low risk adults, J Emerg Med. 2014 Feb;46(2):257-63.
26. Kiefer, M, Hern, H, Alter, H., Barger, J, Dextrose 10% in the Treatment of Out-of-Hospital Hypoglycemia,
Prehospital and Disaster Medicine, 2014 Apr;29(2):190-4. PMID: 24735872
27. Diab J, Riley S, Downes A, Gaeta T, Hern HG, Hwang E, Kass L, Kelly M, Luber S, Martel M, Minns A,
Pazderka P, Patterson L, Sayan O, Thurman J, Vallee P, Overton D: A Multicenter study of the Family
Education Rights and Privacy Act and the Standardized Letter of Recommendation: Impact on Emergency
Medicine Residency Applicant and Faculty Behaviors. J of Graduate Medical Education. 2014 June 6(2):
292-5. PMID 24949134
28. Kessler C, Shakeel F, Hern HG, Jones JS, Comes J, Kulstad C, Gallahue FA, Burns BD, Knapp BJ, Gang M,
Davenport M, Osborne B, Velez LI. A Survey of Handoff Practices in Emergency Medicine. Am J Med Qual.
2014 Sep-Oct 29(5); 408-414. PMID: 24071713
29. Soares, Sohoni, Hern, Wills, Simon, Comparison of the Multiple-Mini Interview with Traditional Interview
in US Emergency Medicine Residency Applicants: A single-institution experience. Acad Med. 2015
Jan;90(1):76-81. PMID 25319173
30. Hern HG Jr, Wills CP, Johnson B., Change to an informal interview dress code improves residency
applicant perceptions. West J Emerg Med. 2015 Jan;16(1):127-32. PMID: 25671021
31. Wills C, Hern HG Jr, Alter H., Residency applicants prefer online system for scheduling interviews. West J
Emerg Med. 2015 Mar;16(2):352-4. PMID 25434686
32. Hern HG Jr, Johnson B, Alter HJ, Wills CP, Snoey ER, Simon BC., Asking for a Commitment: Violations
during the 2007 Match and the Effect on Applicant Rank Lists. West J Emerg Med. 2015 Mar;16(2):331-5.
PMID 25834683
NON PEER REVIEWED PUBLICATIONS AND OTHER CREATIVE ACTIVIES:
Review Articles
CAL/ACEP Lifeline Journal
H. Gene Hern, Jr., MD, MS, “Sexually Transmitted Disease,” CAL/ACEP Lifeline,
September 2004
H. Gene Hern, Jr., MD, MS, “Tetanus,” CAL/ACEP Lifeline, April 2001
H. Gene Hern, Jr., MD, MS, “Blast Injuries,” CAL/ACEP Lifeline, December 2001
H. Gene Hern, Jr., MD, MS, "Can Families Give Informed Consent for Ethnic Patients?”
SAEM Newsletter Jan/Feb. 2001
H. Gene Hern, Jr., MD, MS, and Eric R. Snoey, MD, “Cardiac Ultrasound Offers Benefits in Emergency
Medicine,” Diagnostic Imaging -- Supplement: Advanced Ultrasound, November 2001: 27-29.
Lonergan Seamus and Hern, H Gene, Refresher Course on STDs, Emergency Medicine, Vol 38(1), January
2006. pp 33-44.
C. Bailey, Hern, H Gene, Hepatic Failure: An Evidence- Based Approach In The Emergency Department,
EM Practice, April 2010.
Books and Chapters
Hern HE Jr, Kent Olson. “Valproate Toxicity,” in Emedicine (An Online Emergency Medicine Text).
Spring 1999. www.emedicine.com. Major Revision 2005.
Hern, HE Jr., “Ear Nose and Throat Emergencies,” in Emergency Medicine: A Comprehensive Study Guide,
Fifth Edition, Tintinalli ed. McGraw-Hill 1999.
Hern, HE Jr., “Tracheostomy Care,” in Emergency Procedures and Techniques, Simon and Brenner eds.,
Lippincott Williams & Wilkins, June 2003.
Hern, HG Jr, Cardiology in Emergency Medicine: A Comprehensive Study Guide, Fifth Edition, Tintinalli
ed... McGraw-Hill 2004.
Hern, Herbert. “Hematuria,” in Harwood-Nuss' Clinical Practice of Emergency Medicine, Wolfson and
Suchard eds., Lippincott Williams & Wilkins, 2005, 2013
Johnson, Colleen and Hern, Herbert, “Syncope,” in Case Studies in Emergency Medicine, Elsevier, 2006.
Hern, H. Gene, Jr., “Ear, Nose and Throat Emergencies,” in Adams’ Textbook of Emergency Medicine,
Elsevier, 2007. 2012
Hern and Kwan, “Wound Management” in Emergency Care, McMillan, 2007.
Hern, Herbert and Pease, Abigail. “Hematuria,” in Harwood-Nuss' Clinical Practice of Emergency
Medicine, Wolfson and Suchard eds., Lippincott Williams & Wilkins, 2007.
Hern, Herbert and Cook, Justin, Sore Throat. Case Files: Emergency Medicine, 2nd edition. Eds. Toy,
Simon et al, Lange, 2009, 2005
Hern, Herbert and Chiles, Kristopher, Case Files: Emergency Medicine, 3nd edition. Eds. Toy, Simon et al,
Lange, 2012
Hern HG, Cardiac Emergencies in Tintinalli’s Emergency Medicine Examination and Board Review; Editor
Promes SB. McGraw Hill 2012.
Simon, Barry and Hern, HE Jr., “Wound management,” in Principles and Practice of Emergency Medicine,
Rosen et al. eds, Mosby, 2015, 2012, 2009, 2004, 2001.
BIO:
Growing up, Michael Marsh always knew he wanted to help people which lead him a career in Emergency Medical
Services (EMS). Over the years, Michael has developed a passion for the industry while learning the tools and skills
needed to be successful in the 911 system. Michael ‘s previous position as a Paramedic Captain for AMR San
Mateo County, and also as the Mass Casualty Incident Committee Chairman led to his involvement with local and
national disasters such as Hurricane’s Gustav, San Bruno natural gas explosion, and the recent crash of flight 214.
Michael shares these experiences and expertise through speaking engagements covering disaster response and
preparation. Other positions include; Disaster Response Coordinator for the Northern California Disaster ground
ambulance contract and also, Special Operations Coordinator for the Regional Tactical Medic Program. Michael
currently holds the position of Assistant Chief for AMR Contra Costa County where he leads a team of 350+
Paramedics, EMTs and office personnel. With more than 18 years of EMS experience, Michael is a passionate and
self-motivated individual.
EXPERIENCE
EMS Assistant Chief, American Medical Response, Contra Costa, Ca. — 2014-Current
Lead and direct a team of 350+ employees ensuring that our 911 system runs seamlessly and is prepared for given
incident that may occur in Contra Costa County or any neighboring counties. His duties include: managing and
implementing incident command plans, preparing EMS reports and charts, ensure compliance with local policies
and procedures, and interact with allied agencies, hospitals and the general public.
Nor-Cal Disaster Response Coordinator, American Medical Response, CA — 2006-Current
Coordination, tracking and deployment of Nor Cal resources, both personnel and assets, from regional ERT
teams through AMR OEP in accordance with AMR’s FEMA contract upon activation for disaster response. Also
ensures and coordinates regional team readiness during periods with no active deployments. Deployments:
Hurricane Katrina, Hurricanes Gustav and Ike, Hurricane Irene, Hurricane Isaac, Super storm Sandy
Assistant Team Commander, San Mateo County AMR Special Operations Team, CA — 2008-2014
Assistant commander of AMR employees who train to a higher level of standards in regards to specialized responses
that evolved from the foundation provided by the AMR ERT concept and local team response to Hurricanes Gustav
and Ike. The team was developed through modification, expansion and evolution of the national framework of AMR
ERT concept to meet regional and local needs. Specialized response training includes but is not limited to law
enforcement interface/SWAT, hazardous material responses, multi-casualty incidents with emphasis on ICS
knowledge and unified command, water rescues, and mutual aide responses. Responses: SF New Years Mutual
Aide, SF Giants Championship Parade 2010 and 2012 Mutual Aide, Santa Cruz Civil Unrest, Oakland Mehserle
Verdict Mutual Aide, San Bruno Gas Pipeline Explosion, and Asiana Flight 214 Crash at SFO.
Member/Representative, Project First Responder, Department of Homeland Security — 2007-Current
Serve as a member and field representative to committee established by the Department of Homeland Security to
discuss and share information on technology, resources, products, programs, standards, testing and evaluation, and
best practices.
Paramedic Captain, American Medical Response, Burlingame, CA — 2006-2014
Supervision of all field crews, system status management and all other operational duties as assigned.
Interagency relations. MCI and Significant Event mitigation. Competency as an accredited
Paramedic within San Mateo County.
Operations Supervisor, American Medical Response, San Francisco, CA — 2005-2006
Supervision of all field crews, system status management and all other operational duties as assigned.
Interagency relations. MCI and Significant Event mitigation. Competency as an accredited
Paramedic within San Francisco County.
Paramedic/Firefighter, Dixon Fire Department, Dixon, CA — 2001-2003
Respond to medical, fire, hazardous material and various other emergencies. Competency as a Firefighter and as
an accredited Paramedic in Solano County.
Operations Manager, METS/LMS, Concord, CA — 1999-2001
Responsible for the coordination, management and overall performance of the operation.
Paramedic, American Medical Response, Concord, CA — 1997-1999
Respond to medical and various other emergencies. Competency as an accredited Paramedic in Contra
Costa County.
Paramedic, Mercy Ambulance, St. Helena, CA — 1997-1999
Respond to medical and various other emergencies. Competency as an accredited Paramedic in Napa
County.
EDUCATION
University of Phoenix, Online Campus — Bachelor of Science in Health Administration, -In Progress
ICS/NIMS Training – FEMA – ICS 100, 200, 300, 400, 700, 701, 703, 704, 706, 800b
Multiple California State Fire Marshal Certifications
M.E.T.S Paramedic School, Concord, CA — Paramedic Training, 1996-1997
Paramedic Field Internship, San Francisco Department of Health, San Francisco, CA 1996-1997
Sacramento City College, Sacramento, CA — General Education, 1994-1996
El Camino College, Torrance, CA — General Education and EMT Training, 1993-1994
SKILLS
In addition to the experience and education enumerated above I am also a member of the San Mateo County
Regional Tactical Medical Team, and the chairperson of the MCI Committee for San Mateo County.
Presentations:
Bay Area Paramedic Journal Club
Boston Urban Shield
National Disaster Life Support Foundation
San Benito Base Station Hospital meeting
EMSAAC-San Diego
SFGH San Mateo County MAC AMR Leadership
River Side EMS
Contra Costa County Dispatch appreciation week
JOANNY M. ALL, RN, E MT-P
SUMMARY OF QUALIFICATIONS
Advanced Cardiac Life Support Certification Expires: 1/2016
Pediatric Advanced Life Support Certification Expires: 3/2015
RN Licensure #790447 Expires: 7/2016
Paramedic Licensure #P17689 Expires: 6/2015
Pediatric Education for Pre-hospital Provider Certification Expires: 8/2016
International Trauma Life Support Certification Expires: 2/2015
BLS Healthcare Provider (CPR) Certification Expires: 8/2015
EMPLOYMENT
Clinical Manager/ Registered Nurse
10/2014- Present- American Medical Response- Contra Costa County Ops
Manage Clinical and Education Services department employees which provide 911
emergency transport providers with Clinical Practice Oversight utilizing a variety
of tools, including quality improvement activities, data collection and analysis, in
an effort to promote and improve clinical excellence.
Provide oversight of annual training and skills testing that provide insight on
caregiver skills, competence, and decision making abilities.
Provide oversight of continuing education course curriculum and trainings
Conduct Clinical Investigations when medical care deviates from established
protocols.
Provide annual TB screenings and Flu vaccinations to employees.
Establish and nurture positive relationships with other agencies such as Contra
Costa County EMS, multiple fire agency personnel, area hospitals and their
representatives while maintaining effective communication.
Conduct screening, hiring, and training of new EMT and Paramedic employees.
CES Specialist/ Registered Nurse
6/2012- Present- American Medical Response- Contra Costa County Ops
Provide 911 emergency transport providers with Clinical Practice Oversight
utilizing a variety of tools, including quality improvement activities, data
collection and analysis, in an effort to promote and improve clinical excellence.
Perform annual training and skills testing that provide insight on caregiver skills,
competence, and decision making abilities.
Participate in Clinical Investigations when medical care deviates from established
protocols.
Provide annual TB screenings and Flu vaccinations to employees.
Established positive relationships with other agencies such as Contra Costa
County EMS, multiple fire agency personnel, area hospitals and their
representatives while maintaining effective communication.
Participate in the screening, hiring, and training of new EMT and Paramedic
employees.
Paramedic
6/2001- 6/2012- American Medical Response- Contra Costa County Ops
Successfully provide critical life support, ambulatory and patient care services
and treat traumatized patients throughout various medical and traumatic
emergencies.
Provide patient care services including intubation, IV insertion and IV fluid
administration, medication administration via all routes (IV, IO, IM, PO, SL, SQ,
and Inhalation), EKG 12-lead interpretation, recognition and treatment, and
emergency childbirth.
Work closely and effectively with other emergency first responders including
police/fire departments and emergency medical technicians.
Paramedic Supervisor
9/2006-1/2009- American Medical Response- Contra Costa County Ops
Provide managed services support for Contra Costa County’s 911 Emergency
Management System for a $75 million operation, i.e. logistical support, customer
service, and inter-agency relations. Perform computer troubleshooting, resolve
technological issues to ensure the 911 system runs smoothly, and provide
response to 911 calls ranging from single patient to mass casualty incidents
(MCIs).
Operate in a leadership role and serve as part of the Incident Command (lar ge
response with multiple patients), including resource management, facilitating
emergency vehicle repairs, and supervision of up to 30 people on a daily basis.
Complete detailed reports; transmit to billing, and follow-up for higher medical
care.
Serve as liaison between field employees and upper management.
Collaborate and establish positive relationships and facilitate communications
with other agencies including the fire/police departments and investigations.
Boosted morale by recognizing field employees for jobs well done.
Main Instructor- Emergency Medical Technician Program
9/2001-1/2009- Los Medanos College- Pittsburg, CA
Provided lecture and manual skills instruction to adult learners in college setting
in accordance with Emergency Medical Technician curriculum.
Worked to develop current course curriculum in accordance with National
Registry of Emergency Medical Technicians guidelines.
Curriculum taught included basic anatomy and physiology, airway management
and oxygen administration, medical and traumatic patient assessment and
management, medical emergencies to include acute cardiac, abdominal,
respiratory emergencies, and medication administration.
EDUCATION
October 2009- December 2010 - Napa Valley College, Napa, Ca
Associate Degree in Nursing
August 1999 - February 2000 - Foothill College, Los Altos Hills, Ca
Emergency Medical Technician Paramedic Licensure
September 1993- December 1995- De Anza College, Cupertino, Ca
Associate Degree in Liberal Arts
Dino Curzi
Professional Experience
American Medical Response, Concord, CA | Senior Data Analyst 9/2013 – Present
Composed advanced business intelligence reports and performance charts.
Developed clinical reports and made recommendations to help improve patient care practices.
Implemented online compliance and reporting tool (FirstWatch) between AMR and Contra Costa County.
Generated a daily forecasting tool used to adjust deployment based on demand and compliance.
Created new employee ID badges and manage building access.
Instituted deployment dashboard and stat sheet for equipment tracking and crew shift start efficiencies.
Trained supervisors in areas of compliance, deployment, technology and system design.
Utilized data to create charts, graphs and report cards of response and patient care performance.
Managed ambulance services reaccreditation (CAAS).
Provided clinical data and reporting metrics to California Department of Public Health related to strokes.
Assisted Stanford graduate students with 9-1-1 related data analysis.
Member of Contra Costa RFP team.
American Medical Response, Concord, CA | Data Analyst 01/2011 – 9/2013
Responsible for ensuring compliance for 9-1-1 county contract exceeding 70,000 annual responses.
Validated and submitted all data-related contract requirements monthly to customers.
Designed a dispatch training binder, paramedic policy guide and office media information center.
Conducted meetings with supervisors and crews to avoid potential delays in patient care.
Assessed demand to create system efficiencies resulting in cost savings.
Fashioned ambulance posting plans based on 9-1-1 response demand.
Established reporting metrics, charts and dashboards for performance updates to team.
Formulated patient demographics reports, charts and graphs for Contra Costa County.
Volunteered reporting expertise for Fall Prevention Coalition (Meals on Wheels) to assist with fund raising.
Education
Skills
California State University, Long Beach
Bachelor of Science, Finance
Concentration in Financial Management
De La Salle High School, Concord, CA
Athletic Spirit Award Winner
Varsity, Junior Varsity Basketball Teams
Data Analytics and Modeling
Budgeting and Forecasting
Financial Planning and Analysis
Project Management
Accounting Principles
Communication
Microsoft Excel: Advanced
Microsoft Word, PowerPoint, Outlook, Visio and Access
Report Building – SQL and Crystal
o MEDS, OPAP, MCIS & Business Objects
Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
OUT-OF-STATE SUPPORT
Shannon Marshall
Director of Clinical Services
Shannon Marshall serves as the Director of Clinical Services for the West Region of AMR
covering our WA, MT, SD, OR, CA and HI Operations. Shannon has held a clinical management
role at AMR for 10 years and her duties include oversight of all employee educational processes
as well as insuring the clinical abilities of all employees meets and exceeds national standards.
In addition to these duties, she is responsible for oversight of tracking, coordinating and
following all clinical complaint and compliance issues to resolution. She provides oversight to
each Operation regarding matters of system, individual performance measures and the tracking
and trending of clinical metrics data.
Ms. Marshall has been employed by AMR and prior companies since 1989, working as an EMT,
Paramedic, Teamster’s Shop Steward, FTO, CES Specialist and CES Manager prior to her current
assignment. She received her Paramedic certification in 1995 and received her BA degree from
University of Washington in 2003. She received Six Sigma-Green Belt in Healthcare from
Villanova University in 2011. In addition to her extensive experience with AMR, she has been
actively involved in her community with service on multiple county and regional committees
and CISM team. She is also an active volunteer paramedic on her local Fire Department.
Education
University of Washington—B.A., Interdisciplinary Arts and Sciences: Ethnic, Gender and Labor
Tacoma Community College—Paramedic Training
Professional Associations
Pierce County EMS Committee Membership
West Region Trauma QIF Member
International Brotherhood of Teamsters Shop Steward
Milton Volunteer Fire Department FFIMSO
JENNIFER L. BALES
SUMMARY OF QUALIFICATIONS
Operations Manager with 25 years of EMT, Paramedic, Supervisor, Safety Coordinator, AMR
Operations Manager, and Regional Safety & Risk Manager experience in California
Manage budget for Sacramento County Operations to include management of KPI and
Strategic Indicators for operational and safety performance
Local Safety Coordinator since 2000 with responsibility for implementation , development and
maintenance of local SRM program
Regional Safety & Risk Manager since 2013 with responsibility for 22 operations
Management of regional MSIP, accident and injury claims management, IIPP, safety training,
MWMP, HMP and OSHA compliance
Oversight of required local operational permits and licenses including: HMP (fleet shop),
MWMP, and LQHE
Manage compliance with mandatory training for NorCal region and Hawaii
Oversee National Safety Initiative Program for NorCal operations
Responsible for support and roll-out of new programs at local operations level including but
not limited to recruitment, transition to Success Factors, SRM programs, MEDS, and
TeleStaff
2003 – AMR Sacramento County ranked 1st place overall for 2002-2003 AMR Corporate
Safety Audit
ICS 100, 200, 300, 400, 700, 800
WORK EXPERIENCE
American Medical Response, Sacramento County 1989 to Present
Position
1989 – 1990 EMT, FTO
1991 – 1999 Paramedic, FTO, Remedial Preceptor
1999 – 2000 Field Operations Supervisor
2000 – 2005 Safety Coordinator/Field Operations Supervisor
2005 – Present Operations Manager/Safety Coordinator
2013 – Present Regional Safety & Risk Manager
EDUCATION
NCTI, Roseville 1990-1991
Paramedic Program
Cosumnes River College 1989
EMT Program
San Jose State University 1983-1984
General Education and Finance Courses
Foothills Community College, Los Altos Hills, CA 1979-1980
Animal Health Technology Program – A.S. Degree Vocational program
San Jose City College 1978
College preparatory Chemistry and Biology
CURRENT COMMITTEES
NCTI - Advisory Board, Private Employer - AMR Representative
American River College Paramedic Advisory Committee Board – private employer representative
Hospital Council of Northern & Central California - Diversion Committee
Hospital Council of Northern & Central California - Emergency Services Task Force Committee
Hospital Council of Northern & Central California – Emergency Preparedness Committee
REFERENCES
Available upon request
Kerri Limpin – Human Resources Manager for AMR’s West Region
Current position:
As Human Resources Manager for AMR’s West Region, Ms. Limpin oversees human resources (HR)
activities for multiple counties. Her responsibilities include employee relations, staff and training
development, union activities relating to grievance/bargaining agreement interpretation, company and
operational policy and procedure implementation and adherence, and ensuring compliance with State
and Federal laws.
Ms. Limpin is celebrating her first year with AMR and brings over 10 years of HR experience in a union
environment to include recruitment and retention, performance management, staff training and
development, labor relations, workers’ compensation, and support of company safety initiatives.
Ms. Limpin will continue to serve the County by ensuring compliance with state and federal regulations
and to partner with AMR management as a resource to support the alignment of HR strategies with
business initiatives and goals.
Prior Employment Experience
Human Resources Administrator 2006-2010 IC&S Wholesale Grocers I Stockton, CA
• Perform recruitment activities, including advertising, attend job fairs, background screening,
interviewing, conduct pre-employment and drug testing, orientation, training and processing
new hire paperwork
• Track, manage and investigate grievance and employee relations issues/complaints to resolve
labor and management, wage, benefit, and work practice disputes for 500+ union and non-union
employees
• Interpret and administer labor contracts with respect to wages, employee welfare,
healthcare, union and management practices and contractual stipulations for multiple
bargaining units
• Maintain proper administration of employee record keeping and data integrity within HRIS
system, prepare employee status reports and management of department budget, assist in
payroll processing, track and manage leave of absence, disability and workers compensation
• Coordinate employee events, recognition programs, company health fairs and volunteer programs
• Oversee job bidding procedures , hiring and separation of all employees . Maintain
seniority listings for multiple collective bargaining agreements
• Ensure the proper administration of all generalist duties and company policies including
LOA/FMLA/CFRA, STD -benefit enrollments, changes, garnishments, State and Federal
employment law compliance
Staffing Manager 2003- 2005 I The Plus Group, Inc. I Gold River, CA
• Recruit, screen and place applicants in technical, administrative and industrial positions
• Coordinate all pre-selection activities, including drug testing, reference checks and background
verifications
• Establish and maintain partnerships with community career centers, resource groups,
colleges and Employment Development Department to recruit potential candidates
• Supervise administrative staff and interns
• Process payroll and manage unemployment and Worker's Compensation claims
RANDY HARRELL
PROFESSIONAL PROFILE
Regional Director / General Manager / Fleet Maintenance Manager
Excellent Knowledge of Heavy Duty Engines ♦ Strict Compliance ♦ Management Training
Motivated, intelligent Regional / Service Manager with an extensive track record of adeptly managing
productive and performance-driven service & fleet maintenance operations, processes and procedures
while constantly creating and implementing methods to increase efficiency and productivity. Proactive
leader also highly skilled in training and supervising teams toward achieving company production goals
while maintaining full compliance with business and government guidelines and regulations. Multi-
talented operations manager with vast experience in operations, project management, problem solving,
new business development and heavy duty industrial and vehicle engine repairs. Competent leader with
willingness and ability to energetically perform multiple responsibilities with a hard-working mentality
which produces results, translating into greater company efficiency, productivity and profits.
______________________________________________________________________________
Selected Career Highlights
Successfully increased new business segment in first year by $3 million. [Stewart & Stevenson]
Grew labor sales from $3 million to $8 million, with a 22% net profit. [Stewart & Stevenson]
Started a new business within the corporate business structure of several companies – which
included marketing, invoicing, hiring, training and creating and implementing internal
procedures. [American Bus Repair, LLC]
Transformed a failing and recently-acquired business into a profitable venture by developing
effective and successful procedures which fit a retail business into an operational business with
little aid from the corporate structure. [American Bus Repair, LLC]
Effectively supervised 60 productive and efficient technicians. [Stewart & Stevenson]
______________________________________________________________________________
Areas of Expertise
Heavy Duty Engine &
Fleet Repairs
Troubleshooting
Compliance Auditing
Staff Hiring/Training
Vehicle Maintenance
OSHA, EPA, CARB Laws
New Business
Development
Employee Safety
Communication
Goal Achievement
Operations
Management
Quality Assurance
______________________________________________________________________________
Professional Job Summary
American Medical Response (Western Region.) Burlingame, CA
Regional Fleet Manager 2011-Present
Manage multiple Ambulance Fleet shops in the San Francisco Bay Area and Southern CA. both union
and non union divisions. Negotiate vendor agreements, conduct shop audits to conform to company
policy, work directly with General Managers and Regional CEO regarding purchases of equipment and
staffing. Conducted start up of new divisions and arrange contracts with suppliers and vendors. Train
shop supervisors and technicians on fleet management and invoicing software. Track expenses for finance
directors regarding budget and non budget items.
American Bus Repair, LLC (Subsidiary of MV Transportation.) Alameda, CA
Director of Retail Sales / General Manager 2007 – 2011
Directed the start-up of this new retail business within an operational business. Oversaw and managed
the following departments: Body Shop, Bus Repairs, DPF Cleaning, and MV Excess Fleet Management.
Research and develop processes for billing and invoicing customers. Collect and review receivables and
invoices from vendors. Schedule and assign work flow, write estimates, oversee billing and payroll work
with vendors, and advise upper management regarding business development. Manage field service
technicians and interact with larger company divisions on necessary repairs. Hire and fire employees.
Attend trade shows to market new business and develop marketing tools, website layout and brochures.
Develop all company protocols and procedures, including marketing and management materials.
Oversee the parent companies excess fleet stored at present location. Store used vehicles and monitor the
usability of vehicles. Aid in the selling of vehicles or scrapping the iron. Successfully passed the DMV
tests for application process and also become a Vehicle Vin Verifier, being bonded to fill out the DMV
paper work for parent company and customers who purchase new vehicles.
MV Public Transportation Fairfield, CA
Northwest Director of Maintenance 2004 – 2007
Supervised 25 company divisions which consisted of a total fleet of over 850 vehicles (including the first
Hybrid fleet in Northern California). Worked with division clients on purchasing new equipment and
then auditing the new vehicle purchases. Aided in planning start ups of new operations business in
various cities, including hiring shop managers and technicians. Performed monthly audits of the facilities
for compliance to OSHA laws and company policies, along with current EPA regulations and Highway
Patrol / DOT inspections. Hired staff members, including maintenance managers and mechanics.
Developed and began four new company locations. Transformed negative client relationships into
positive ones. Improved maintenance department facilities through a successful audit process.
Stewart & Stevenson San Leandro, CA
Largest Detroit Diesel & Allison distributor in the world – with over 3,500 employees, 40 locations and revenues
exceeding $1 billion in sales.
Distributed Energies Systems (DES) Operations Manager 1993 – 2004
Oversaw the operations of five company locations in California. Hired mechanics and staff members.
Implemented EPA rulings and obtained Air Quality Board Permits. Analyzed and troubleshot large
engine failures and site problems.
Fire Apparatus Product Manager (Corporate Position)
Expanded 9 out of 30 branches to include a fire maintenance apparatus. Developed a fire apparatus
training manual and PM inspection forms. Trained sales staff, as well as service and parts personnel, on
the fire apparatus. Represented company at regional and national trade shows.
Western Region General Service Manager
Managed seven service departments located in the Western region. Expanded technicians from 32 to 60
in Northern California. Trained four new service managers on software procedures. Supervised an office
of 12 staff members. Developed a policy and procedure manual for service departments. Oversaw
warranties for dealers of Detroit Diesel & Allison. Negotiated transit contracts for various companies –
including Sam Trans, Wheels and AC Transit. Successfully negotiated three union contracts.
Viking Freight Systems / FedEx Milpitas, CA
Service Manager / Detroit Diesel, Cummins and Allison Dealer 1988 – 1993
Managed the service and machine shop departments. Developed a service code manual and maintained
price lists. Held company meetings regarding P&L statements. Negotiated a contract for San Francisco
Municipal Transit.
______________________________________________________________________________
Education & Professional Development
Ohlone Jr. College ♦ Fremont, CA Associate of Arts ♦ General Arts
Industrial Training: Warranty Processing for Detroit Diesel, Cummins & Allison, CHP B.I.T.
Program, Detroit Diesel Engine Overhaul, Allison Transmission Overhaul, Failure Analysis,
Series 60 EGR 2004, Ricon & Braun ADA Wheelchair Lift Training, Haz Mat & SPPC Certified.
Memberships & Certificates: Board Member Apparatus Maintenance Section, International
Association of Fire Chiefs, Committee Member for NFPA-1071 (Technician Qualifications),
Emergency Vehicle Technician Validation Committee, Detroit Diesel & Allison Guild Member,
Certified Compressed Natural Gas Tank Inspector, Various ASE Certifications, Certified EVT
Aerial Inspector
(Extensive technical and professional education and references list provided upon request.)
Contra Costa County Fire & EMS
Exclusive Operator for Emergency Ambulance Service
IN-COUNTY SUPPORT
Thomas Wagner
Regional Chief Executive Officer
West Region
5151 Port Chicago Hwy
Concord, CA 94520
Mr. Wagner is responsible for the oversight of AMR's West Region, which provides 9‐1‐1 and non‐
emergency services in California, Hawaii, Oregon, Washington, Montana and South Dakota. AMR's West
Region team of clinical and operational professionals handles more than 1,320,000 ambulance
responses a year, making it AMR's largest operating region. Mr. Wagner has more than 27 years of EMS
Operations experience. As a former Malcolm Baldridge Quality Award examiner for the State of
Oklahoma, Mr. Wagner has developed service excellence and performance standards for EMS systems
across the nation. Mr. Wagner is a member of the College of Healthcare Executives and is completing his
credentialing for his Faculty of American College of Healthcare Executives Certificate. He holds an
undergraduate degree in Biology from the University of California, San Diego, and an MBA from the
University of Phoenix.
EXPERIENCE
2006 – Present American Medical Response
West Region Chief Executive Officer (2012–present) Concord, CA
Northern California Division Chief Executive Officer (2006–2012) Concord, CA
1998 – 2006 Paramedics Plus Oklahoma City, OK
Chief Operating Officer, EMSA Oklahoma
1985 – 1998 American Medical Response
Vice President of Operations EMSA Oklahoma (1997–1998) Oklahoma City, OK
Managing Director MedTrans (1995–1997) Dallas, TX
Director of Operations, Baystar Medical Services (1991–1995) Burlingame, CA
Supervisor of Operations, EMT, Hartson Ambulance (1985–1991) San Diego, CA
EDUCATION
University of Phoenix San Diego, CA
M.B.A.
University of California San Diego, CA
B.S., Biology
Miramar College San Diego, CA
Certificate – Emergency Medical Technician
PROFESSIONAL AFFILIATIONS
California Emergency Medical Services Authority
Medical Director Advisory Committee 2010 – Present
American College of Healthcare Executives Member, 2005 – Present
Regional Advisory Committee, American College of Healthcare Executives
Committee Member, 2010 – 2011
American Ambulance Association
Chairman of Professional Standards Committee, 2012 – Present
Chairman of Government Affairs Committee, 2010 – 2012
Member Ethics Committee, 2009 – 2010
Emergency Medical Services Corp. (EMSC) Investment Committee, Committee Member, 2007 – Present
Ben Smith
Battalion Chief, EMS Division
Contra Costa County Fire Protection District
Highlights of Qualifications:
Working and managerial experience in emergency management
Proficient with Cal OSHA, Title 22 and Ca H&S Code Div. 2.5 requirements for emergency medical services
Solid knowledge of Medical Priority Dispatch, Local Protocol and LEMSA requirements
Solid knowledge of EMT and EMT-P education, training, and licensing requirements
Working knowledge of static and dynamic system resource deployment
Working knowledge of national community paramedicine programs
Experience in employee Performance Counseling, Discipline, and workplace investigations
Professional Experience:
Battalion Chief, EMS Division
Contra Costa County Fire Protection District, Pleasant Hill, CA
January 2010 – Present
Responsible for budget and oversight of EMT and EMT-P first response program serving 660k citizens
Develop strategies, policies, plans, and procedures to achieve identified Department objectives and priorities
Attend various educational and conference programs pertaining to emergency medical services
Manage and coordinate recruit academy EMS and quarterly continued education training
Represent the Fire District as the EMS point of contact to officials and organizations
Coordinate investigations of EMS related complaints and unusual occurrences
Multiple ranks
Contra Costa County Fire Protection District, Pleasant Hill, CA
January 1992 – 2010
Firefighter/EMT, trained and performed all disciplines in all risk hazards in rapidly growing system
Firefighter/Paramedic, worked to establish engine based first response advanced life support program in the agency
Captain/Paramedic, provided training, oversight, and mentorship for recruit and probationary employees
Training Captain, developed curriculum and coordinated training at the battalion level
Training:
Safety and Survival, Commanding the Mayday, Rapid Intervention Crew Tactics (Instructor), Commanding the RIC, Tactical
Decision Making Under Stress and the Will to Survive, Rescue Systems I Technician, Swift Water Rescue Technician, Confined
Space Rescue Technician, ISTM Tactical Medic, ICS 100-400, Instructor 1-A, 1-B, Hazardous Materials First Responder
Operations, Hazardous Material Incident Command, Mobile Intensive Care Paramedic, EMS Leadership Academy-Specialist, S-
359 Medical Unit Leader, S-404 All Risk Safety Officer, CAL-EMA Disaster Specialist, Terrorism Liaison Officer
Education:
Stanford Hospital/Foothill College: Menlo Park, CA
EMT-Paramedic Program
Solano Community College: Fairfield, CA
Fire Science studies
Truckee Meadows Community College: Reno, NV
Fire Science studies
Simpson College: San Francisco, CA
Communications studies
GREG KENNEDY
OBJECTIVE: Current Contra Costa County Fire Protection District EMS CQI RN /Clinical Educator/Infection Control Officer
EDUCATION: Graduate of Concordia University MBA/MS Health Sciences, 2008
Graduate of Sacramento State University School of Nursing, 1992
Graduate of Southern Illinois University School of Human Resource Training & Development, 1990
Graduate of U.S. Air Force Air University / Community College of the Air Force, 1987
Graduate of US Air force Air University Medical Specialty School Sheppard AFB, 1984
Graduate of US Air force Basic Training Lackland AFB, 1984
EXPERIENCE:
2013- Present Pinole Fire Department EMS CQI RN
2013-Present Rodeo Hercules Fire District EMS CQI RN
2011- Present Moraga Orinda Fire District EMS/CQI RN
Is the Fire Districts Infection Control Officer
2010 – 2011 Level Three Trauma Center Coordinator
Queen of the Valley, Napa
Ran and updated the trauma program. I assisted in writing the Napa County Trauma Plan.
2009 – 2012 Consultant (Clinical and Outreach)
Reach Air Medical
Consults with Hospitals and Reach partners regarding contracts and clinical practice.
2006 to Present EMS CQI RN Clinical Educator/EMS Coordinator/Infection Control Officer
Contra Costa County Fire, Contra Costa County
Lead Instructor, develop and create advanced training classes, write EMS policy and procedure.
Provide Incident Command (ICS) leadership for MCI’s and major medical events. Lead EMS Academy Instructor
2002 to 2012 Quality Assurance RN/EMS Coordinator (part time)
Benicia Fire Department, Benicia California
Audit PCR reports/charts, focused call audits, training, meetings.
2001 to 2006 Staff R.N. Emergency room (full time)/Charge RN Emergency Room (full time)
Sutter Delta Medical Center, Antioch, California
All levels of care related to Emergency Room patients, Charge Nurse.
1999 to 2003 Flight Nurse/Crew Chief
Reach Helicopter, (Redwood Empire Air Care Helicopter)
Santa Rosa, California
Advanced Flight Nursing care for injured patients/Critical transport of critical ICU and CCU patients
1996 to 2000 Paid Reserve Fire Fighter and EMS Instructor
Moraga/Orinda Fire Department, Moraga California
Trained Fire Fighters advanced airway and Paramedic skills.
1993 to 2002 Staff Nurse/Mobile intensive Care Nurse/Relief Charge Nurse
John Muir Medical Center, Walnut Creek, California
Responsible for the assessment, planning, implementation and evaluation of care to emergency
department patients in a level II trauma center. Making sure the emergency room runs smoothly.
Monitor and oversee MICN Base Station
1993 to 2000 Flight Nurse Full Time
Calstar/California Shock Trauma Air Rescue, Hayward, California
Responsible for providing advanced ALS care. Emergency care and transportation of patients in
the helicopter and pre-hospital setting.
1990 to 1994 Staff Nurse II/Mobile Intensive Care Nurse
Queen of the Valley Hospital, Napa, California
Responsible for the assessment, planning, implementation and evaluation of care to emergency
department patients in a level III trauma center.
1986 - 1989 Emergency Medical Paramedic/ USAF Cooperative
Allied Ambulance Company, Oakland, California
Emergency care and transportation of patients in the pre-hospital setting.
1984 - 1991 United States Air Force
1990 - 1991 Training Non Commissioned Officer In Charge (NCO)
Combat Medical Readiness/Prehospital Medical Readiness, David Grant Medical Center, Travis AFB
Preparation of all military personnel for participation in the "Gulf War" conflict.
Deployed for Desert Shield and Desert Storm War 12th Contingency Hospital/Air Evacuation Squadron
1986 - 1990 Emergency Air Evacuation Critical Care Transport Team
David Grant Medical Center, Travis AFB
Routine and emergency patient care duties while aboard aero medical evacuation aircraft
(C-130 and C141) 65th Evacuation squadron.
1985 - 1990 Emergency Department
David Grant Medical Center, Travis AFB
General patient care duties in a busy military hospital emergency department and provided ALS ambulance service
CREDENTIALS:
Contra Costa County Medical Advisory Committee Member
Contra Costa County Prehospital Trauma Advisory Committee Member
Contra Costa County Helicopter Advisory Committee Member
Contra Costa County STEMI Advisory Committee Member
Contra Costa County STROKE Advisory Committee Member
Contra Costa County Prehospital Data Advisory Committee Member
California Fire Chiefs Association Member 2002-Present
EMS Leadership Program Graduate 2013
FEMA Disaster Management Team Member
FEMA EMS Disaster Management Graduate 2014
California Infection Control Officers Academy 2010
California Fire Chiefs EMS Leadership Academy Graduate 2008
FEMA Emergency Management Institute Graduate 2009
Contra Costa Fire EMS Academy, Lead Instructor
American Academy of Pediatrics PEPP Instructor (PEPP)
International Trauma Life support Instructor (ITLS)
National Pool Safety Council member
National Drowning Prevention Alliance member
Co-Chairman for the Pre- Hospital Committee for Solano County 2004 - 2006
Contra Costa County Executive Leadership 2001 Management Certificate
Certified Flight R.N. (CFRN)
Critical Care Registered Nurse (CCRN)
Flight Nurse Advance Trauma Course certificate (FNATC)
Neonate Advance Life Support Certificate (NALS)
Registered Nurse (RN)
Mobile intensive Care Nurse Instructor (MICN)
Contra Costa County Critical Incident Stress Debriefing Team Member
Trauma Nurse Core Course Instructor (TNCC)
Advanced Trauma Life Support (ATLS)
Pre-hospital Trauma Life Support (PHTLS) Instructor
Basic Trauma Life Support (BTLS)
Advanced Trauma Life Support attendee (ATLS)
Advanced Cardiac Life Support (ACLS) Instructor
Pediatric Advanced Life Support (PALS) Instructor
Certified Emergency Nurse (CEN)
Paramedic Certification (EMTP)
Bachelors of Science in Nursing (BSN)
AWARDS:
Contra Costa County Fire Academy Instructor Excellence Award 2012
Queen of the Valley Medical Center Values in Action Award for Trauma Care Excellence 2011
Northern California Pool Safety Program Excellence Award 2010
Contra Costa County Fire Chiefs Award for saving drowning child 2009
ZOLL Field Save Award 2009
ZOLL STEMI Educator Award of Excellence 2009
Contra Costa County Stemi Star Award for leadership 2009
Sutter Health Clinical Excellence Award 2003
Sutter Health Hospital Employee the year o 2002
John Muir Trauma Clinical Excellence Award 1997
John Muir Employee of the Quarter 1998
Calstar Employee of the quarter Award 1994
United States Air Force Commendation Medal (2)
Humanitarian Aid Medal (1989)
U.S. Air Force Good Conduct Medal (2)
Military Airlift Command
Non Commissioned Officer of the Quarter (2)
Military Airlift Command USAF
Military Airlift Command Professional Image Award 1986
U.S. Air Force Airman of the Quarter 1985
Queen of the Valley Hospital Achievement Scholarship to Sac State University 1990
Outstanding College Student of America 1989 - 1992
U.S. Air force NCO Leadership course honor graduate
Susan Fitzgerald
PROFESSIONAL EXPERIENCE
American Medical Response, Concord, CA
Nation’s leading medical transportation company
Regional Operations and Finance Officer 2007 to present
Finance Officer for Western Region (Northwest, California and Hawaii) with revenues
over $750 million. Reporting to the Regional CEO, direct financial affairs, supervise the
functions and activities of financial reporting and analysis, payroll, business planning,
capital budgeting, acquisitions and proposal development. Hold fiduciary responsibility to
corporate for the integrity of financial reporting and other reported information. Manage
seven direct reports and total team of fourteen.
Lead and deliver to senior management annual budget of revenue, expense,
volume, utilization and other income statement items with focus on operational
improvement and bottom line growth.
Partnered with billing services, corporate finance and operations to continuously
improve revenue recognition accuracy and maximize cash yield, mitigating
government reimbursement challenges.
Finance lead in multiple RFPs and acquisitions.
Supported VP of labor relations in union negotiations, providing financial
guidance and participating in overall strategy.
Working with legal and operations, ensured regulatory compliance and provided
leadership on contract review, negotiations, and pricing.
Oversee and present financial results and audits to county leaders for various
911 contracts.
Covidien (Formerly Tyco Healthcare and Nellcor Puritan Bennett), Pleasanton, CA
Global Manufacturer of Medical Devices
Sr. Financial Analyst, Respiratory Division 2001-2007
Responsible for month end close, financial reporting, budgets, forecasts, and strategic
planning. Managed monthly forecast and annual budget processes, served as strategic
partner and finance advisor to Marketing, R&D, and Management. Involved in various
significant projects including business development valuations and due diligence,
Sarbanes Oxley implementation and testing, and new product development analysis.
Led conversion of manufacturing budgeting and forecasting to ESSBASE,
designed process, developed templates, and provided training to both US and
International manufacturing sites. This produced enhanced reporting and allowed
visibility of key metrics by business line.
Developed complex analysis tools including Price/Volume analysis, revenue and
margin budgeting and forecasting models, and close, forecast and budget
reporting packages.
Led Global Demand project team, designed, developed, and integrated
budgeting process for $1 billion in volumes, manufactured worldwide at 7 sites.
Susan Fitzgerald Page 2
Wells Fargo Bank, Walnut Creek, CA
Electronic Payment Services Division (Merchant Card Services and Business Payroll)
Division Finance Officer, Electronic Payment Services Division 1997-2001
Managed finance and general ledger operations; directed month end close, budgeting,
forecasting and business analysis including preparation and presentation of monthly
Operating Reviews. Supervised professional staff of four and total staff of eight.
Re-engineered general ledger operations resulting in reduction of 2 FTE.
Developed with alliance partner (First Data) a single planning model which
resulted in consistent reporting, improved accuracy, and better variance
explanations.
Consistently identified and recovered bottom line savings including re-negotiation
of a portfolio purchase, which resulted in an additional $1million in annual
revenues.
Crystalline Materials Corporation (CMC), San Ramon, CA
Multi-national start-up engaged in the manufacture of electronic substrates
Controller 1995-1997
Finance Manager 1993-1995
Responsible to CEO with total accountability for integrity of external and internal
accounting and financial reporting and analysis including detailed budgets and forecasts,
cash flows, consolidated financial statements, variance analysis and product costing.
Coordinated year-end audits and tax filings for US and Canada. Served as Corporate
Secretary interfacing with Board of Directors, investors, and outside council.
Participated as a member of the Senior Management team in acquisition of an
electronic package manufacturing company. Coordinated due diligence, prepared
and presented combined financial forecasts to investors, lenders, and financing
institutions. Contributed to the overall design and structure of financing.
Maintained monthly burn rate by actively monitored expenditures, implemented
purchasing and spending controls, and maintained budgets.
Phase Two Industries, Santa Clara, CA
Finance Manager 1991-1993
Accounting Manager 1990-1991
Start up Defense Contractor specializing in software engineering and small-scale
hardware manufacturing
Managed all accounting activities including establishing and maintaining appropriate
systems. Designed and implemented budget/cost control system and cost pool
structure. Managed banking relationships, established lines of credit as required for cash
flow management.
Susan Fitzgerald Page 3
EDUCATION
California State University, Hayward, CA and Golden Gate University, San
Francisco, CA Graduate Business Course work towards MBA degree. Emphasis on
Finance and Accounting.
California State University, Hayward, CA Bachelor of Arts Degree.