Wednesday, October 22, 2014

ESD 4 Fire Chie Resigns Over Nepotism



GOVERNMENT ACCOUNTABILITY TRAVIS COUNTY ESD 4
 
Fire chief with kin on staff resigns
Employment of future son-in-law, 2 daughters raised questions.

ByTony Plohetski TPLOHETSKI@STATESMAN.COM
   

Amid pressure from his bosses, the chief of a Travis County Emergency Services District has stepped down after a recent American-Statesman and KVUE-TV report raised questions about his employment of two daughters and future son-in-law.     

In a special meeting Monday night, the five-member board of Emergency Services District No. 4 accepted a one-page resignation letter from Chief Florencio Soliz. Soliz said he planned to continue serving through Jan. 23 to fulfill the term of his appointment, but the board made the resignation effective immediately.     

The board has scheduled a special meeting for Monday to discuss the appointment of an interim chief.    Board President Frank Fuentes said Soliz’s employment of his daughters and future son-in-law remain under a board review. Those employees will stay in their current positions for now, he said.    

In his letter, Soliz did not specifically mention issues about the employment of family members but said, “I am comfortable in stating that the time has come for me to move on to other ventures while opportunities are being presented. So, it is with a heavy heart and hearty smile that I am tendering my notice to terminate the fire chief agreement I have with Travis County ESD No. 4.”    

The district, which is funded by sales and property taxes, serves a 54-square-mile area throughout Travis County. The board had recently given Soliz a raise from $85,000 to $110,000.    

The American-Statesman and KVUE in September reported that board members overseeing the district were not aware Soliz had family members on the payroll.     

The arrangement appeared to violate rules Soliz himself had helped set up.    According to the district’s employee handbook, dated June 25, 2012, related employees are allowed to work in the same department as long as no “direct reporting or supervisor-subordinate relationship exists.”    

Soliz, 57, wasn’t the immediate supervisor of either daughter or his soon-to-be son-in-law, but the handbook also says that “members may have no influence over the wages, hours, benefits, career progress and other terms and conditions of their related staff members.”    

Although Soliz did not directly supervise any family member, he had final authority over raises and assignments.     

Soliz, who had been the district’s chief since 2010, said in previous interviews that his younger daughter, Heather Soliz-Mendoza, was already on the payroll as the district’s field medical officer.    

In June, her father signed off on a 6.5 percent salary increase to $54,898 at the recommendation of her immediate supervisor, the department’s assistant chief.    

Last fall, Soliz also began employing his other daughter, Traci Soliz, at an annual salary of $48,731 and assigned her to a position in one of the department’s new single-medic response units.    Then this spring, Florencio Soliz added that daughter’s fiancé, Joshua Cote, to his workforce as a firefighter and assigned him to the same eastern Travis County station where Traci Soliz is based on an opposite shift.    The hirings meant that 10 percent of the 30-member district have family ties to Florencio Soliz.     

Soliz declined to comment Monday night about his resignation.     

In September, he said, “I have not done anything I would be concerned about or ashamed of. I know I didn’t do anything wrong, and that I take comfort in that. I didn’t do anything in malice. I don’t get the issue.”

Wednesday, February 19, 2014

Why We Desperately Need A County-Wide Unified Fire Service



Open Letter to Travis County Commissioners Court From Steiner Ranch Homeowner:




Travis County Commissioners Court,  


On Saturday, February 8, a home sustained major damage as a result of a fire in the Steiner Ranch subdivision of Travis County.  This fire, in and of itself, a tragedy for the family, would otherwise simply be another blurb on the local news.  The first-in fire apparatus arrived on scene within a minute or two of the initial 911 call because it came from a fire station that is literally 2 blocks from the home.  This fire station, operated by Emergency Services District (ESD) #6, is staffed full-time with at least three firefighters and provides service using a state-of-the-art “quint” fire apparatus.

What makes this devastating fire noteworthy is, unfortunately, it is not an isolated event, in fact it was quite the opposite, and it had a common outcome.  Why would a common event be noteworthy?   The home that was on fire essentially was destroyed by this fire.  Time after time, in all areas of the county, we see simple structure fires turn into out of control infernos resulting in significant loss.  This takes place even when the closest fire station is literally right down the street, as in this case.  This takes place while often times the staff and equipment from the ESD is on scene. 

Anyone in the fire industry will tell you some simple facts about structure fires:

1.  Fire doubles in size for every minute it burns.

2.  The first few minutes of a fire attack are the most crucial.

3.  Four firefighters on an apparatus are much more efficient and effective than three (as sited in a recent national scientific study).

4.  Training is the key to operational performance. 

5.  The level of skill, knowledge, and experience of the on-scene command staff can make or break a fire.

Those facts cannot be argued.  The departments that recognize those facts and perform well in those areas lead the industry in performance.  A great example of this is the Austin Fire Department.  In my opinion, they are second to none.  They have a goal of containing 90% of all structure fires to the room of origin and they routinely meet (and beat) that goal year after year.  When a structure burns to the ground in Austin, it is the exception rather than the rule.

Fire extinguished at Lakeway homeUnfortunately, in Travis County, as we again recently witnessed in Steiner Ranch and Lakeway, the opposite can be said.  It is ironic that a local West-Travis County newspaper carried an article on the investigation of the recent Steiner fire.  Buried in the same paper was a photo and brief story of similar house fire in the City of Lakeway, another area covered by ESD #6.  The Lakeway picture showed a large home fully involved in fire.  Again, ESD #6 has a staffed fire station in close proximity. 


http://www.newscastic.com/news/firefighters-battle-house-fire-in-lakeway-1410321/



This problem is not confined to ESD #6, but is rather a frequent occurrence throughout all of Travis County. I believe these types of outcomes are mostly avoidable, though with such a larger number of small independent fire departments, it is almost impossible to achieve the necessary performance outcomes the public expects and pays for.

How so?  Simple.  The existing system of fire protection in Travis County utilizing 13 different ESD’s with 13 Fire Chiefs, each earning over $100,000 annually (some with just ONE fire station!) , 13 administrative operations, and 13 different fire staffing protocols and fire fighting standards is horribly inefficient and ineffective.  Too much TAXPAYER money is wasted on duplication of management and support services (I am told the waste is between $4-6,000,000 annually!!!!).  It is for this reason that I write to you;

The Commissioners Court should make immediate efforts to consolidate and manage these services to ensure that the waste is redirected towards service to the tax payers.  In addition, consolidated training efforts and programs would produce a more effective firefighting system in which all firefighters would be trained to the same level and be taught to use the same procedures.

A combined county-wide fire system could integrate with and find economies with the Austin Fire Department for support services such as training, supply, administration, payroll, HR, fleet, facility maintenance, and yes even operations, and the list goes on and on.  In short, we have one of the most effective fire departments in the nation surrounded by some of the least effective departments.  To leave it alone is nonsensical and is resulting in devastating loss to both families and business’ all across Travis County.   The entire system of firefighting in Travis County needs to be revamped.  We currently have 13 ESD’s.

When one steps back and objectively looks at the performance of the various ESD’s it is not impressive.  ESD #6 is supposedly referred to as one of the elite ESD’s in Travis County and yet time after time they continue to be involved with structure fires that result in complete loss of the property and contents.  These dollar amounts are, over time, quickly adding up to millions of dollars in fire related losses.  We have been fortunate the loss of life has not followed this trend.   ESD #6 is just an example but this problem is systemic within the entire Travis County ESD network.     

Taxpayers in Travis County are spending millions of dollars annually and in return are getting a mediocre level of fire protection.  If the results of structure fires are going to routinely result in complete fire loss, I would argue we could accomplish the same with significantly fewer dollars using a system of volunteer fire-fighters. 

This is in no way intended to be an indictment of the individual fire-fighters that staff the ESD’s throughout Travis County.  These dedicated professionals are working very hard to do the very best of which they are capable.  Unfortunately, the old adage “work smarter not harder” comes into play.  They are placed in an environment in which they are predestined to fail because the ESD structure is designed to support the low volume fire and medical demands of a rural area, not the high demands of the suburban-urban environment of Travis County.   It is up to the County policy makers and elected officials to take aggressive steps toward consolidation of these departments before the local papers are not just showing pictures of damaged homes, but also telling stories of lives lost.  Your leadership here can make a meaningful difference to the people of Travis County.

This is admittedly a political hotbed.  Often times doing the right thing is not always the easy thing.  Change is rarely met with open arms.  That said, it is more than obvious that in the best interest of property owners and taxpayers in Travis County the time has come for you to act.

Doing nothing is doing something and brings along with it the realization that nonfeasance is worse than malfeasance.

As a Travis County homeowner, former business owner, and taxpayer,  I implore you to act with a sense of urgency and immediately start the process of consolidation of all the existing Emergency Service Districts.

Steiner Ranch Homeowner

Thursday, August 22, 2013

Is Austin’s EMS System Broken? We take a macro-level viewpoint when looking at the Austin-Travis County EMS system




Journal of Emergency Medical Services- JEMS, September 2013 Issue
By David M. Williams, PHD
Published on jems.com (http://www.jems.com)

Austin, Texas is on the rise. It’s the 11th most populous city in America, and it’s one of the fastest growing metro areas in the country. Featured on virtually every top-10 list, Austin is known as a hub for high technology, education, government and being the live music capital of the world. The capital city is also home to the nationally respected Austin-Travis County EMS (ATCEMS) System. But there might be trouble in the capital of the Lone Star State. Local press reports from the past 24 months have raised concerns about the system’s performance and sustainability, and some stakeholders are calling for significant change. Is Austin’s EMS system in distress or broken?

Quick Assessment

According to the International City/County Management Association’s (ICMA) report EMS in Critical Condition:

Meeting the Challenge, an EMS service is in distress if it meets any of the following six signs.1

1. Media or council investigations: The Austin-American Statesman and local media regularly report on issues with the Austin-Travis County EMS department, including stories on problems between Travis County and Austin about the interlocal EMS agreement funding and the results of City Auditor reports that are critical of the department’s safety and billing practices.2–4 The Austin Public Safety Commission has advised the Austin City Council to request a full department audit.5

2. Response time troubles: Fiscal year 2013 first-quarter performance reports to the ATCEMS Advisory Board show urban response time compliance for Priority 1 calls under 10 minutes at 91.24%; suburban compliance at less than 12 minutes was 75.09%.6

3. Internal issues: A November proposition resulted in voters approving an amendment of the city charter to grant uniformed, certified EMS employees collective bargaining rights, as well as stronger arbitration rights for hiring and firing disputes and the department’s commanders (field supervisors) sued the department over overtime pay.7,8

4. Turf battles: Tiffs between agencies have been minor, but media reports present relations between Austin-Travis County EMS and the County Emergency Services
departments as stressed. Stakeholders’ proposals that the county pull out of the EMS system or that EMS be merged into the fire department are reported.9–11

5. Lack of accountability or transparency: County administrators have expressed concerns about performance outside the city and with reporting reliability.10 Limited performance data is publically accessible, but it’s not easily accessible and is reported only quarterly.

6. Financial distress: In 2012, the Austin-American Statesman reported the EMS department was to overrun its budget for the first time in 12 years by an estimated $910,000, and the City Auditor released a report on the department’s billing operations that identified several issues including not appropriately handling cash and other payments and failing to bill Medicaid for an estimated $150,000–$345,000.4,12

Given that ATCEMS meets all of the ICMA signs of distress, it’s easy to understand why Austin Public Safety Commission Vice Chair and Texas Monthly founder Michael Levy has described the system as “broken” and expressed concern about its leadership and sustainability.

The Method

Local stakeholder and media attention on the EMS system focuses on the pieces of the puzzle that frequently result in a negative assessment of the ATCEMS department. Still, these assessments haven’t taken a look at the macro level, and instead remain focused on individual processes or issues. Local stakeholders also haven’t attempted to apply reasonably accepted industry criteria to evaluate the current state of the system. This review attempts to follow a systematic assessment and present the findings in objective framework to understand the current state of the Austin-Travis County EMS system.

There are no universally accepted criteria for assessing EMS system quality. Most consultant reviews pull together evidence from firsthand experience and best practice from position papers, federal studies and consensus reports to develop a framework. This review mirrors that method and uses two primary sources: the American Ambulance Association (AAA) EMS Structured for Quality guide developed for communities to effectively contract for high-performance ambulance service and a paper published in the peer-reviewed journal Prehospital Emergency Care by physicians from the U.S. Metropolitan Municipalities EMS Medical Directors Consortium on evidenced-based performance measures.13,14

System Description

For the purpose of this report, ATCEMS is the main focus of analysis. Due to the climate in the EMS system at the time of research for this article, the author decided to focus on publicly accessible information. The majority of the information to follow was pulled from city and county documents, performance reports, and firsthand experience and knowledge of the EMS system. City and county elected officials and department leaders, labor representatives and oversight members also provided context and background about the state of the EMS system.

It’s acknowledged the 9-1-1 communications center and transport entity are only components of a complete EMS system, and success also depends on partners, such as medical first-response agencies and air medical providers. The following describes the full EMS system serving Austin and Travis County.

ATCEMS includes volunteer and paid medical first-response organizations, a municipal emergency-only transport provider, private interfacility transport providers and a public helicopter.

Medical first response is provided by a spectrum of organizations around the county, including corporate response groups, volunteer and combination fire districts, and the Austin Fire Department. MFR patient care is primarily delivered at the EMT-basic level.

ATCEMS is the exclusive provider of 9-1-1 ground response and transport in Travis County.

ATCEMS is a municipal third-service agency within the city of Austin and is jointly funded by the city and the county. ATCEMS is an all-ALS system and primarily uses a fixed-station deployment model.

The EMS department was founded by city ordinance in 1976 as the exclusive provider of emergency and non-emergency ambulance service in the city. Prior to 1976, a private service had an exclusive franchise to provide ambulance services. In 1980, the non-
emergency business was transferred to an exclusive private franchise provider.15

The Framework: Five Hallmarks 

The AAA EMS Structured for Quality guide describes five hallmarks to ensure high-performance emergency ambulance service:
1) hold the emergency ambulance service accountable,
2) establish an independent oversight entity,
3) account for all service costs,
4) require system features that ensure economic efficiency, and
5) ensure long-term high-performance service.

The following applies this framework to the Austin-Travis County EMS system.

Transport Accountability

Accountability includes monitoring clinical results and response time compliance, customer feedback, and evidence-based protocols. Austin is no different than most metropolitan EMS systems, and its performance accountability is reflective of most government EMS systems. Performance measurement occurs for several purposes and is reported in a number of venues. Measures aren’t publicly available in a single, easily accessible place.

Austin’s budget requires certain key performance indicators (KPIs) are measured and reports the data in a system known as the ePerformance Measures. The data is accessible publically—but not easily—from the city’s website. The measures are tied to the budget process and aren’t changed frequently. Measures aren’t updated in real-time and the reason why they aren’t isn’t clear.

Response times are an indicator for the Austin ePerformance Measures and for the Travis County interlocal agreement. Only the city compliance is reported in the ePerformance system, and there’s no publically reported county data. Reports to the ATCEMS Advisory Board include response-time compliance to an urban goal of 9 minutes 59 seconds and a suburban goal of 11 minutes 59 seconds. There appears to be no penalty for failure to achieve the response-time goal.

Out-of-hospital cardiac arrest survival has been a singular evidence-based measure since the 1980s. ATCEMS reports a 12.1% survival rate for the 2012 fiscal year in the Austin ePerformance system.16 Additional measures are internally tracked, consistent with the recommendations from “Evidence-Based Performance Measures for Emergency Medical Services Systems: A model for expanded EMS benchmarking.”14 ATCEMS Advisory Board minutes show time series charts of data on EMS call to door interval time for ST-segment elevated myocardial infarction (STEMI), cerebrovascular attack (CVA) and trauma. No industry standard performance goal exists, but each measure shows a mean of less than 40 minutes.

There’s no evidence that the EMS department surveys feedback from customers and reports the results. The EMS System's standards of care are developed through the Office of the Medical Director and are available online. Protocols appear to be evidence-based and reflective of industry standards and there’s no indication that medical equipment isn’t current.

Independent Oversight

Independent oversight can occur through boards or committees charged with direct performance oversight, external accrediting organizations (e.g., National Academies of Emergency Dispatch) or physician oversight.

Boards and commissions: ATCEMS falls under the authority of two oversight groups: the ATCEMS Board and the Austin Public Safety Commission.

The ATCEMS Advisory Board was originally defined by city ordinance and then further described in the EMS interlocal agreement between Travis County and the city of Austin. The Board’s aim is to monitor the performance of the whole system, not just the EMS department, and make recommendations to the city council and county commissioners related to EMS delivery. The Board receives performance reports from leaders in the EMS department, helicopter service and the Office of the Medical Director. Medical first response is not included.

The Board doesn’t have the authority to provide administrative control over any of the entities. Members are appointed by city council members and county commissioners, and include representation from consumer groups including neighborhood associations and two large hospital networks. The Board meets only quarterly, and its materials are accessible on the Austin website.

The Austin Public Safety Commission has a broader charge to provide budget and policy guidance to the Austin City Council related to the three public safety departments—EMS, fire and police—serving the city. It includes members from the community appointed by city council members. The Commission doesn’t receive standard reporting from the EMS department, and EMS agenda items are more topic-specific. The Board, which meets monthly, doesn’t have the authority to provide administrative control over any of the entities.

The Advisory Board and Public Safety Commission are external oversight bodies charged with reporting recommendations to elected officials. Neither has authority to direct the activities of any entity in the EMS system, and there’s no direct penalty for not acting on a recommendation or concern that has been raised. Absence of defined performance dashboard makes it difficult for the bodies to monitor performance reliability.

Accrediting bodies: The Austin-Travis County EMS medical communications center is accredited by the National Academies of Emergency Dispatch (NAED) as an Accredited Center of Excellence. It received initial accreditation in 2000 and was the first ACE center in Texas. Travis County’s STAR Flight. rescue helicopter program was accredited in 2000 by the Commission on Accreditation of Medical Transport Systems (CAMTS). ATCEMS was awarded accreditation by the Commission for the Accreditation of Ambulance Services (CAAS) in July.17 One of the two non-emergency franchise companies—Acadian Ambulance–Texas—is also accredited by CAAS.

Accreditation is a valuable process and provides standardized, industry recognized criteria and external evaluation. It ensures that an organization meets minimum standards for key structures and processes. The NAED’s accreditation includes confirmation of process reliability, but CAMTS and CAAS don’t assure performance reliability.

Physician medical oversight: Medical first response organizations and the ATCEMS 9-1-1 transport provider fall under the clinical oversight of the Office of the Medical Director. One of the EMS system associate medical directors is the medical director for STAR Flight. The private franchise providers have independent medical direction.

Accounting for All Service Costs

Often, EMS providers get squeamish when discussing the dollars and cents of their system. Public officials and citizens are often rather uninformed about EMS economics and whether their community is receiving a good value for their investment.

It can be difficult to quantify the true cost of operations for public entities because governmental accounting may not identify all of the actual costs of delivering service. This is especially true when departments benefit from shared services like public relations, legal, fleet or human resources. The numbers described below are sourced from publically accessible, self-reported data.

The ATCEMS budget is $56,058,891, which includes the communication center and the Office of the Medical Director, but not non-emergency transport.18 Based on the county’s current Census population estimate of 1.063 million, that’s a cost per capita of $52.68. A benchmark study in 2010 including 21 North American cities reported a median cost per capita of $42.43.19 The majority of the cities participating in the benchmark study deliver both emergency and non-emergency transport service. ATCEMS delivers only emergency transport service, meaning addition of the non-emergency transport costs would increase the cost per capita further. ATCEMS is also significantly subsidized through tax dollars; the department’s 2013 budget goal is to recover $18 million in user revenue, which is a third (32%) of the overall 2013 budget.

To put this in context, consider another Texas metro area—Ft. Worth. MedStar Mobile Healthcare covers a smaller geographic area (421 square miles vs. 1,022 square miles), but it serves a similar population and has a similar EMS incident volume. MedStar had a 2012–2013 budget of $33,118,507, which was funded almost completely through non-tax subsidy revenue.20 MedStar also achieves comparable clinical and operational outcomes.

Austin has been recognized as a heavily tax-funded EMS system for 30 years. EMS System Consultant Jack Stout once described Austin as an old Jaguar car he had a love/hate relationship with: “It was capable of combining superb performance with real luxury, but maintaining that performance required a high-capacity dollar injection system.”21 He also compared it on more than one occasion with high-performance EMS system models in Tulsa, Okla., and Kansas City, Mo., challenging that, with the ATCEMS budget, he could serve both the emergency and non-emergency transport volume and still pay every patient $50 back.22,23 Consultant Frank Heyman also noted the high cost of the EMS service in a 1985 benchmark report, but commented that “no one in the Austin area seems to think that is a significant factor.”15

Economic Efficiency

Several factors influence the economic efficiency of an EMS system, including covering multiple contiguous jurisdictions, providing emergency and non-emergency ambulance services, matching the supply of ambulance and caregivers to the predictable call demand, and having the right resources to do the job.

One element of efficiency comes from the economies of scale present in a larger service. Economies of scale are savings that can come from covering a larger region, which means more resources to provide coverage and response while sharing costs. ATCEMS is currently the exclusive provider of 9-1-1 ambulance service to Travis County. If the county, or one of the smaller cities, were to pull out of the system, economies of scale would be lessened for all parties.

Economies of scale can further be enhanced if the EMS organization provides both emergency and non-emergency services, further increasing the resources and diversifying the payer mix. ATCEMS doesn’t benefit in this case. Non-emergency ambulance service in Austin is provided through two companies—American Medical Response and Acadian Ambulance Service—that hold franchises with Austin, serving 42,572 responses (transports were not reported).24,25 The franchise process is unique because Austin is a closed system requiring city council approval for a provider to enter the market. Franchise providers then compete with minimal restriction or regulation. Franchise providers are required to be made available for disaster needs but aren’t called on to support or back up the 9-1-1 volume.

How a system deploys its resources and matches it to predictable call patterns can also significantly improve efficiency.26 ATCEMS primarily uses a fixed-station deployment model with some peak-load units. Ambulances perform move-ups as demand and coverage require, but it isn’t a dynamic deployment system. This limits the efficiencies of managing demand and reduces the flexibility to move resources. Lots of waste and crew fatigue is created by returning units to assigned stations vs. the next station requiring coverage.

Long-term High Performance

Sustainable high performance is described in “Hallmark 5” of EMS Structured for Quality as a service that includes a continuous improvement system that enhances performance without always requiring added cost.13 If the EMS system is unable to perform, then are mechanisms in place to use lateral benchmarking to confirm if the system remains a value and there’s a process to replace an unsuccessful provider?

ATCEMS has a business analysis and research function reporting to the EMS director and a traditional clinical quality improvement function in its professional practices and standards division.27 The Office of the Medical Director staffs a performance management and research coordinator.28  From published reporting, data is measured in such areas as response times, cardiac arrest, STEMI and stroke.  Data is presented in a mix of aggregate summary statistics and time-series charting, but there doesn’t appear to be regular application of statistical process control.

Quality is one of the department’s pillars; there’s no reference to an improvement methodology for enhancing process performance in use in the system.28

Similar to other communities with municipal EMS departments, there isn’t a process to routinely benchmark performance and confirm if the system remains a value to the community. The city doesn’t have a performance-based contract with its own department and, although the county has some performance expectations in the EMS Interlocal Agreement, they aren’t equivalent to the expectations in a traditional performance-based contract. There’s also no process to consider replacing the provider and doing so could be very disruptive.

Summary of the Hallmarks

Applying the AAA’s five hallmarks to ATCEMS reveals several quality factors are in place, and there are opportunities for improvement and development that may enhance the sustainability and results of the organization.

Limitations & Discussion

Use of the five hallmarks and evidence-based performance measures as a framework for evaluating an EMS system enables a high-level view and degree of objectivity. Stakeholders on the ground may struggle with this analysis because it doesn’t provide the whole story, nor does it provide analysis of organizational culture, workforce morale, operational process reliability, inter-agency relations or community relations. The overview does support answering the opening question of whether the EMS system is in distress (yes) or “broken” (no), but it does not evaluate every issue.

A contributing factor not discussed is the role of elected officials. In speaking with current elected officials for the county and city, there’s universal concern that the EMS system isn’t where they desire it to be. But there isn’t consensus on what’s wrong or how to repair it. Cost and reliability are common themes. This is made more complicated by conflicting lobbying from across the local EMS and fire community and ongoing press attention. Added to the noise is a pending Travis County judge election in November, which has included focus on EMS service in the county and proposals for system change.29,30

Local perception of ATCEMS’ national reputation is also a challenge. Local stakeholders believed the system was a national model or best practice of EMS service. The strong positive national reputation is true, but many are surprised that the system has also been used as a benchmark for high cost and low efficiency since its inception.

Two very real concerns include that
 1) elected officials will feel the pull to act and will make significant change to the system without understanding what the community needs or what the system is capable of doing, affecting access, cost and quality, and
2) the continuing scrutiny and issues identified will erode confidence in the EMS department leadership forcing a change.

Conclusion

Using the ICMA six signs as a diagnostic, one could conclude the Austin-Travis County EMS system is in distress. The EMS system’s current performance, structure and funding do make it stable. Stakeholders may not be comfortable with the current outcomes, but the system is not “broken” and could be repaired. Doing so would require laser focus on shared outcomes, heavy emphasis on engagement and communication, and a collaborative action plan to change. The will and resources are present to achieve the aim if there’s community interest and strong leadership to do so. jems

David M. Williams, PhD, is the founder of TrueSimple Improvement (www.truesimple.com) and collaborates on Urban EMS System Design projects with Washko & Associates. He works in healthcare, education and ambulance service systems as an improvement advisor. He is on the faculty of the Institute for Healthcare Improvement and an alumnus of Leadership Austin. He serves on the board of a local federally qualified health center system and has lived and worked in Austin, Texas, for 15 years.

References

1. Fitch J, Griffiths K. (2005.) EMS in critical condition: Meeting the challenge. In International City/County Management Association. Retrieved Aug. 3, 2013, from www.fitchassoc.com/download/ICMA%20IQ%20Report%20-%20EMS%20Critical%20Co....
2. O’Rourke C. (May 23, 2013.) Council postpones vote on expanding EMS service in Travis County. Austin-American Statesman. Retrieved Aug. 3, 2013, from www.statesman.com/news/news/local/council-postpones-vote-on-expanding-em....
3. O’Rourke C. (Feb. 27, 2013.) City audit details worker safety shortcomings at EMS. Austin-American Statesman, Retrieved Aug. 3, 2013, from www.mystatesman.com/news/news/local/city-audit-details-worker-safety-sho....
4. George P. (Oct. 31, 2012.) Audit slams Austin-Travis County EMS’ billing, collection practices. Austin-American Statesman. Retrieved Aug. 3, 2013, from www.statesman.com/news/news/local/audit-slams-austin-travis-county-ems-b....
5. Ulloa J. (Jan. 7, 2013.) Commission: Austin-Travis County EMS should face audit. Austin-American Statesman. Retrieved Aug. 3, 2013, from www.statesman.com/news/news/crime-law/commission-austin-travis-county-ems-should-face-au/nTpyB/.

6. Austin-Travis County EMS. (Feb. 6, 2013.) Advisory board packet. Retrieved Aug. 3, 2013, from www.austintexas.gov/edims/document.cfm?id=188499.
7. George P. (Oct. 26, 2012.) With Proposition 11, paramedics seek civil service protection like police, firefighters. Austin-American Statesman. Retrieved Aug. 3, 2013, from www.statesman.com/news/news/crime-law/with-proposition-11-paramedics-see....
8. Davis J. (Nov. 16, 2012.) Texas jury splits verdict in EMS commander’s FLSA suit. Law 360. Retrieved Aug. 3, 2013, from www.law360.com/articles/394422/texas-jury-splits-verdict-in-ems-commanders-flsa-suit.
9. Eichmiller JP (March 4, 2013.) Travis County Commissioners Court rejects petition to create new EMS taxing district. Community Impact Newspaper. Retrieved Aug. 3, 2013, from www.impactnews.com/austin-metro/round-rock-pflugerville-hutto/travis-cou....
10. George P (Nov. 10, 2011.) Study: Travis County should unify fire, emergency services. Austin-American Statesman. Retrieved Aug. 3, 2013, from www.statesman.com/news/news/local/study-travis-county-should-unify-fire-....
11. Hobby D. (May 13, 2013.) Briefing and discussion on fore and EMS service options in Travis County Outside of the City of Austin. Memorandum to the Travis County Commissioners Court. Retrieved Aug. 3, 2013, from www.co.travis.tx.us/commissioners_court/agendas/2013/05/backup/item_back....
12. O’Rourke C. (March 19, 2013.) City auditor finds EMS billing problems in 2009–2010. Austin-American Statesman. Retrieved Aug. 3, 2013, from www.statesman.com/news/news/local/city-auditor-investigation-finds-ems-b....
13. American Ambulance Association. EMS structured for quality: Best practices in designing, managing and contracting for emergency ambulance service. American Ambulance Association: McLean, Va., 2008.
14. Myers JB, Slovis CM, Eckstein M, et al. Evidence-based performance measures for emergency medical services systems: A model for expanded ems benchmarking, Prehosp Emerg Care. 12:2008;(2)141–151.
15. Heyman, FW. Sirens are a warning sound: A glimpse at ambulance service in America by comparing nine city’s prehospital ambulance care systems. Prepared for Three Rivers Ambulance Authority, Ft. Wayne, Ind., 1985.
16. Austin ePerformance Measures: EMS, Office of the Medical Director. Austin Texas Gov. Retrieved Aug. 3, 2013, from www.austintexas.gov/budget/eperf/index.cfm?fuseaction=home.PerfMeasure&D....
17. Austin-Travis County EMS (July 29, 2013.) Emergency Medical Services receives CAAS Accreditation. Retrieved Aug. 3, 2013, from austintexas.gov/news/emergency-medical-services-department-receives-caas-accreditation.
18. Austin ePerformance Measures. Emergency Medical Services Department. Austin Texas Gov. Retrieved Aug. 3, 2013, from www.austintexas.gov/budget/eperf/index.cfm?fuseaction=home.Department&DE....
19. Regional EMS Authority (May 2010.) REMSA Benchmark Survey. www.washoecounty.us/repository/files/1/REMSA%20Benchmark%20Report%202010.pdf.
20. MedStar Mobile HealthCare (Aug. 6, 2012.) Operating and Capital Budget FY 2012–2013. In Mobile Health Care. Retrieved from www.medstar911.org/Websites/medstar911/files/Content/862581/MedStar_Annual_Operating_Budget_FY_2012-2013.pdf.
21. Stout JL. Public utility model revisited: Part 2–10 essential features. JEMS. 1985;10(3):71–74.
22. Stout JL. The public utility model: Part 1: Measuring your system. JEMS. 1980;5(3):22–25.
23. Stout JL. Tulsa: Public utility model revisited, part 3. JEMS. 1985;10(5):58–64.
24. Austin-Travis County EMS. (Nov. 14, 2012.) Recommendation regarding renewal of city of Austin non-emergency medical transfer franchise for American Medical Response of Texas, Inc. Retrieved Aug. 3, 2013, from www.austintexas.gov/edims/document.cfm?id=182534.
25. Austin-Travis County EMS. (May 2, 2012.) Recommendation regarding renewal of city of Austin non-emergency medical transfer franchise for Acadian Ambulance Service Inc. Retrieved Aug. 3, 2013, from www.austintexas.gov/edims/document.cfm?id=171572.
26. Dean SF. The origins of system status management. Emergency Medical Services. 2004;33(6):116–118.
27. Austin-Travis County EMS. (2010) Annual report 2010. Retrieved Aug. 3, 2013, from issuu.com/atcems/docs/atcems_2010_annual_report.
28. Austin-Travis County. Office of the medical director staff. Retrieved Aug. 3, 2013, from www.atcomd.org/index.php/staff.
29. Eckhardt S. (May 27, 2013.) County emergency services at a crossroads. Austin-American Statesman. Retrieved Aug. 3, 2013, from www.mystatesman.com/news/news/opinion/echardt-county-emergency-services-....
30. Mashhood F. (June 7, 2013.) Some chiefs, politicians push for single Travis County fire department. Austin-American Statesman. Retrieved Aug. 3, 2013, from www.mystatesman.com/news/news/local-govt-politics/some-chiefs-politician....
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Administration and Leadership




Saturday, June 8, 2013

Proposal to Unify Travis County Fire Departments into One County Fire Agency

Some chiefs, politicians push for single Travis County fire department


By Farzad Mashhood - American-Statesman Staff

In the small northwest Travis County village of Volente, the fire department spent $4,335 per call last year. Meanwhile, the average fire department call in the Pflugerville area cost $1,637. The department near Lake Travis that includes Lakeway spent $2,330 per call.
The disparities illustrate the patchwork system of 13 fire departments serving Travis County, outside the city of Austin, where about a quarter-million people live. Some departments contend with an eroding tax base as Austin grows and annexes land formerly taxed by fire districts. And tax revenue varies widely depending on property values and the population in each district.
As poorer departments struggle to balance their budgets, one chief is pushing for a countywide department that would pool the 13 emergency services districts’ tax revenues to run a single department. Unified fire protection would give residents equal service across the county while cutting back on the overhead associated with running many departments, each with separate administrations and different training, staffing and equipment standards. The plan could also provide a remedy for diminishing revenues by taxing Austin residents to subsidize fire service outside the city, similar to taxes Austin property owners pay for sheriff’s patrols.
But some chiefs don’t want a single department pooling all the tax revenue — projected to total about $44 million in 2013 — calling it a “Robin Hood” plan that takes away revenue from wealthier districts to subsidize poorer ones with lower property values.
The disparity cleaves along a familiar divide, between the historically poorer eastern side of the county and the wealthier western half: West of Interstate 35, the departments handle 44 percent of calls countywide and collect about twice as much tax revenue as the departments east of the interstate.
The consolidation plan, quietly introduced by Emergency Services District No. 11 Fire Chief Ken Bailey, gained some traction with county commissioners when, in a May 21 meeting, they directed staffers to look into the proposal and possibly hire a consultant to study it more fully.
Merging the districts would make Travis County unique among large counties in Texas.
“We’re looking at providing a universal level of care in Travis County. I’m not proposing reducing service in one area to subsidize service in another area. Rather, with excess dollars, we can improve service” in parts of the county with less tax revenue, Bailey said.
The single fire service would also have its own paramedic and ambulance service, freeing up about $12 million the county spends on Austin/Travis County Emergency Medical Services, the city-run ambulance service.

Single county fire department?
Consolidation would benefit some service areas, such as Bailey’s district in southeastern Travis County that would get back more money than taxpayers in the district pay. But richer areas would pay much more than they’d get back.
“I think the idea of unifying the fire service is good, but the financial aspects don’t work for us,” said Chief Mike Elliott of Emergency Services District No. 9, mostly in West Lake Hills and Rollingwood. “I can’t go to my taxpayers and say, ‘I’m going to raise your taxes by a cent and a half, and you’re not going to get anything for it, and, actually, we’re going to reduce your service slightly.”
Elliott’s district, where homes have an average taxable value of $730,000, has the lowest tax rate among districts in the county, 8.45 cents per $100 of property valuation, and is one of only three to charge less than the state-imposed cap of 10 cents. Homeowners in that district have the highest average annual tax bill, however, of about $617.
Former county Commissioner Sarah Eckhardt, who recently resigned to run for county judge, called it “a model worthy of further exploration” in a May meeting. Other commissioners signaled their approval of looking into the plan further, but offered no opinions about the merits of the idea.
Commissioner Gerald Daugherty, whose Precinct 3 includes most of the districts in the western part of the county, told the American-Statesman he favored a unified fire service that would redistribute revenue “to take care of the areas that really do need the help.”
Excess revenue from some districts, as well as savings from consolidation, could increase the pool of money and stretch it further, though it’s not clear how much, Bailey said.
“If we continue to operate under the same funding structure, all you’re doing is transferring the misery,” said Ron Moellenberg, chief of Emergency Services District No. 2 in the Pflugerville area.
The 10-cent property tax cap is the real problem for districts seeing diminishing revenue, as it hinders raising more revenue as costs go up, Moellenberg said.
“When you talk about consolidation and mergers and one unified fire service, what you need to talk about philosophically is a level playing field, that everybody has the same access to resources throughout the county,” said Buddy Crane, who heads a 10-square-mile district in western Travis County, where property values are among the highest in the county.
A unified department, overseen by elected officials, would likely see more fiscal scrutiny than 13 small agencies each with five appointed board members.

Tale of two departments
Personnel costs in Volente, which has the smallest district in Travis County, are lean: The department pays a part-time fire chief, seven full-time firefighters and 17 part-timers.
Three firefighters are on duty at all times at the single station, which houses the village offices. There are no fire hydrants in the district so the department relies on former Mayor Jan Yenawine, a volunteer, to drive its 2,000-gallon water truck to fires.
Despite the struggles, there’s no evidence that this district, or other smaller districts in the county, are unable to provide adequate fire protection.
Just across Lake Travis from Volente, Emergency Services District No. 6 covers 200 square miles — including Lakeway, Bee Cave and Steiner Ranch — and has the largest budget in the county, with $11.5 million in revenue expected this year.
The department keeps at least four firefighters around the clock at three of its five stations, occasionally with a fifth, unlike most other county departments, which have three-person staffing at each station. During some shifts, firetrucks have a paramedic on board, also rare for the other departments, who can give a higher level of emergency care before an ambulance arrives. Lake Travis Fire Rescue also keeps a 28-foot fire boat in Lake Travis and responds to most emergencies on the lake.
The current emergency services district system “works for some (areas). It does not work for the county as a whole. As a first responder to fire, flood and emergency medical, it is a very fractured and lumpy system,” said Eckhardt, who is making consolidation a central part of her early campaign for county judge.
“You get a fairly wide spectrum on response times, a fairly wide spectrum on per-incident cost, a wide spectrum on training levels, property tax revenue and sales tax revenue,” Eckhardt said.
Andy Brown, the other Democratic candidate for county judge, has also said he supports consolidation. “We need to increase communication and decrease bureaucracy by having a countywide system so more dollars go directly to capacity and the trained responders our safety depends on,” Brown said this week.

Funding squeeze
As Austin and other cities with their own fire departments annex unincorporated areas, the loss in service area for emergency services districts doesn’t necessarily equate to lower costs.
“Once you commit to having a professional fire service it costs you X amount of dollars to open the doors and to operate no matter if you have one call or 500 calls. … You still have to pay for insurance, the truck, personnel, the whole thing,” said Chief Walter Groman of the Volente district.
This year, to counteract a recent annexation by Cedar Park that took about 30 percent of the Volente district’s tax base, Groman is relying on reserves for about 20 percent of the department’s $884,000 budget.
At Lake Travis Fire Rescue, officials worry about Austin’s imminent annexation of subdivisions such as River Place, which would take away $600,000 in property tax revenue and is proposed to happen in 2017.
Fire departments, meanwhile, have tried to find new sources of revenue. County commissioners this year rejected a plan proposed by residents in the Pflugerville district that would have allowed the department to double property tax revenue by establishing a second, overlapping district. In Travis County, nine departments collect sales tax, with the Volente department winning approval last month.
Efforts in the Legislature to expand the 10-cent sales tax cap have failed in the past, and this year, a joint bill in the House and Senate proposed creating a new type of fire district without a tax cap. That bill failed.


Monday, April 16, 2012

How to provide Austin with higher quality emergency medical response and better overall services at HALF THE COST to the TAXPAYER!



 Open Letter to the City of Austin Council and Executive Management


I have offered my opinion before on how to provide our community with higher quality emergency medical response and better overall services at half the cost.  I’d like to offer another consideration along the same theme but it offers even better outcomes than what was suggested earlier in reconfiguring EMS response for the City of Austin. 

There are three countywide and one tri-county EMS system (similar demographics to the City of Austin) that would be worth looking at as an alternative to the present configuration used by the City of Austin.  Their approach provides their communities with faster response, better quality pre-hospital medicine and at NO TAXPAYER SUBSIDY. For one of the systems it also provides funding (at no taxpayer expense) for AEDs for ALL law enforcement vehicles (police and sheriff) that are now part of the countywide first response network.  It is an extraordinary approach to building a viable and high quality EMS system and worth your time and attention given the potential it could offer in saving tax dollars and dramatically improving EMS services. 

The four “systems” are Portland, Oregon (a three county system), San Mateo County, California, Solano County, California, and Contra Costa County, California.  Each of these county operations have similar demographics to Austin. 

Each “system” is a combination public/private configuration.  The public side of the system is fire based paramedic first responders, and the private side an ambulance transport vendor.  What is so fascinating about their approach is that all of the governments “bid” out the “rights” to provide countywide ambulance service.  The ambulance vendor “pays” each county fees for the exclusive franchise rights for 9-1-1 transport services.  For example, in the Portland EMS System, one of the three participating county’s is Washington County, and they receive over $424,000 a year in franchise fee for this exclusivity (and that is just one of the three county’s for the Portland EMS System).  The money the private vendor pays for the “rights” to serve a county are typically used by the county to fund its EMS oversight operation and system medical direction.  All of this is under a very sophisticated performance contract which stipulates response times by geo-zones (urban-8 minutes, rural-11 minutes, frontier-30 minutes) at 90% or greater performance compliance, regulates the fee structure patients can be charged for transport services, vehicle requirements, employee compensation minimums, including benefits, work conditions, etc.   Not only are their response standards more rigorous than what the City of Austin requires from its own EMS Department but their basic fee structure for services are equivalent to user fee's charged by the City EMS Department for its services. It is also worth noting, the salary a 6 year private paramedic earns in this "system" averages $64,000, not including overtime.  They work 8 & 12 hours shifts.  You will find this competitive to what Austin pays its municipal ambulance paramedic. 

What makes this approach even more attractive for a city like Austin is its existing franchise process for non-emergency ambulance transports.   The city could easily and profitably offer to grant exclusive emergency and non-emergency services to a single private ambulance vendor based on “highest” bid basis.  The profitability of that offering would be very attractive to any well-managed and professional run private ambulance vendor.  The potential savings in taxpayer dollars could be enormous even though a portion of the savings in EMS costs would have to be reinvested in the enhancement of Austin Fire Department first response medical capability it would still offer taxpayer savings for other much needed city projects. Not only would the city get a more reliable and higher quality ambulance response network (at no cost to the city) but an expanded and enhanced fire first response that would dramatically improve the ability to get a first responder paramedic to the side of a patient in 6 minutes or less, all at a cost substantially less than what the City pays now for its ambulance operation.  It would also solve the 4 person staffing issue for Austin Fire and resolve the concern about the added staffing cost being without merit or benefit.  Adding paramedic capacity (or EMT-intermediate in certain cases) to the 4th position offers unquestionable benefit because of its dual productivity: fire-fighting and paramedic.  The key difference is the cost for this additional duty is an annual stipend of $7,500.  Contrast that to the annual salary of a tenured EMS paramedic who does only one job: $65,000, not including overtime.  The fire-fighter-paramedic is substantially cheaper, gets to the scene faster and offers better quality medicine because time to scene matters in life-threatening emergencies.

Even if you back out the user fee’s the City EMS Department claims offsets 50% of its operational cost, the net cost to city taxpayers is still over $15,000,000 a year.  Contrast the Austin EMS System with these no subsidy high performance EMS systems and its very clear Austin is getting short changed… by about $15,000,000 a year… and that amount will only grow each year.

Ambulance transport is a profit center under the private ambulance model, and a loss leader (big one at that) under government simply because government cannot work at the same pace and under the same private protections the private business can.  Government has special rules that offer the public protection from unethical Tammany Hall practices but they play havoc on its ability to act as a business enterprise.  

The rule of thumb for good government is if the area of service is already efficiently provided by the private sector, its best to let that portion of services fall under private service contract using best practices and a well-written performance contract.   

Government does best in the high risk or regulatory, no profit center areas of service like fire fighting, rescue, medical first response and law enforcement or other regulatory services.  

 Ambulance transport operations, in urban areas like Austin, would be better managed under a performance contract with a well qualified, ambulance contractor. 

When Austin got into ambulance transport no such private solution existed, at least not in this state, but after 30 years a lot has changed.  The private ambulance industry has evolved into a highly refined service operation that offers better services (transporting from point A to B)  and, under the right contract configuration (performance contracting),  can provide those services to a government without a taxpayer subsidy.

By shifting the role of government from a very expensive, subsidy based ambulance transport program with terrible performance, to a rapid response paramedic first response (fire medics on Austin Fire Department apparatus) you reduce the time to a life-threatening emergency from the current 10-12 minutes to an average 5-6 minute or less response time  (50-60% faster).  Plus the cost for outfitting a first response vehicle with equipment and trained fire-fighter medics is around $150,000 per vehicle, about 1/10th the cost of an ambulance. If transport is required, the private contractor provides those services under a very structured performance contract and all cost for these services are paid for as noted by user fees.  Its win-win for all involved. Taxpayers get better emergent service and the cost savings can, in turn, be used to improve fire services, police services, parks, libraries, etc.   

It is also worth noting the City could still retain some of its ambulance operation specific to the high priority acutely critical calls, all other lower priority call types would be managed by referral to the private ambulance contractor.  My point is that the City continues to support a public safety program that is no longer meeting its base mission and has become a huge drain on public safety funding, and will continue to do so.  There are better, faster, cheaper options that deliver exceptional performance at much cheaper costs to the taxpayer, example: Seattle, a highly respected fire based operation, clinically sophisticated and provides exceptional emergency medical services to its residents.  Seattle uses a public/private model.  The fire department operates a small fleet of critical care "medic" units for the critical call types and paramedic first response engines, supplemented by a private ambulance provider to manage transports for the lower priority call types.  The quality of Seattle's fire paramedics provide clinical care far and above what Austin's EMS operation offers.  

Before I close, one question that will undoubtedly be raised is what happens to the existing city EMS ambulance staff?  The short answer is they would be integrated into the fire department, trained as fire-fighters.  Those who could not meet the physical qualifications or would prefer not to “fight fires” as a secondary role, could be grandfathered into a transition status under their existing salary structure, and operate the fire departments critical care ambulances I mentioned above.  As those individuals retired or left for other career reasons, their positions would be absorbed into the fire ops side.  The initial cost savings for the city would be in eliminating all the duplications in management, logistics, and the reduction in required ambulances.  With the potential for 44+ paramedic first response vehicles, you don’t need as many ambulances, and as ambulance paramedics are transitioned over to fire-fighting, the ambulances they staffed could be shifted to the private ambulance vendor. It also offers the benefit and cost savings of eliminating the currently proposed EMS civil service option with all its layers of expensive and redundant bureaucracy which only adds to the complexity and overall cost of union negotiations for public safety. 

I will be happy to offer you RFP’s used by these counties to select their ambulance vendors, including a full description of performance requirements if you are interested.   They offer great background on how they operate and will shed some interesting light on how Austin could also operate.

Below are some contact references you or your staff can use to verify what I am offering.  All but one is specific to Washington County (Portland EMS System).  Feel free to grill them on their operation; I am betting you will find all are very candid and forthcoming. 

 
Metro West Ambulance-Washington County Ambulance Contractor
Larry Boxman            Director of Operations       
503-648-6658         

Washington County (Portland EMS System)
Jonathan Chin         EMS Administrative Supervisor- Washington County
971-226-4507
503-846-4956
jonathan_chin@co.washington.or.us


Tualatin Valley Fire Rescue-Washington County
MarK Stevens           EMS Batt Chief- Tualatin Valley Fire Rescue
503-649-8577

Abaris Group EMS Consultants-Developed RFP for Portland EMS System
Mike Williams           President


Hope this helps.  If you would like more info, I’ll be happy to visit with you. 

Gordon Bergh
Retired (2006) City of Austin- Assistant Director-EMS
Small Business Owner




Wednesday, April 4, 2012

Why Travis County Residents Are Poorly Served By Travis County’s Inter-Local for Ambulance Service with the City of Austin




The current EMS inter-local between the Travis County and the City of Austin does not serve the Travis County taxpayer or most importantly the patient.


The average response time for a City of Austin ambulance IN Travis County is over 16 minutes!  In a life-threatening emergency, brain cells begin to die after 4 minutes, and after 6 minutes, the potential for successful resuscitation falls to the single digits.  Those County residents who do get pulled back from the brink of death do so not because of the ambulance but because of the local fire department fire fighters who respond to these calls and the air rescue services provided by Travis County’s STARFlight helicopters.   For this extraordinarily bad performance Travis County forks over an amazing amount of taxpayer money (over $12,500,000) with virtually no control over the services provided.  Even worse, the inter-local does not allow Travis County to utilize existing qualified area fire department resources to mange cost of service and improves response time.  The inter-local offers only a City of Austin solution at a whopping $1.5 million dollars per ambulance and for 2013, the City is proposing another hefty $4,500,000 increase in its cost for services (33% increase)!   To fully appreciate the problem, Travis County could pay to put dual role fire-fighter paramedics on EVERY fire truck in Travis County, maintain higher training quality under a contract with Seton and the UT medical school than the City’s ambulance medics receive under their in-house program and have their own medical director with far more active and transparent oversight of paramedic performance than the City ambulance medical director provides to the County fire department EMT's now, for $4,050,000 ($450,000 less than what the City is proposing for just 4 ambulances and it would reduce response times from 16 minutes to under 8 for county suburban areas and under 12 minutes for rural areas.   The three proposed City of Austin ambulances would improve response times by only about 1-1.5 minutes.  Of course, Travis County doesn't need all its fire apparatus staffed with a paramedic, my point is to simply illustrate how a more common sense approach in delivering EMS can save lots of taxpayer dollars and dramatically improve response time AND capacity.  Travis County needs to do what is right for the patient AND its taxpayers by fixing the existing contract issues with the City of Austin.    

Where’s the Problem?

The City/County Inter-Local has no substantive performance requirements for EMS services other than vague references, my favorite: “ provide emergency medical services in accordance with recognized standards to access, triage, treat, evacuate and transport patients in the most timely manner possible” (and which standards would those be?). 

Additionally, it provides:
  • no direct financial controls,
  • no accounting of direct services costs by ambulance management,
  • no managerial accountability of any type, and
  • no transparency in any phase of the services provided

In fact, this inter-local essentially requires Travis County to sign away its contractual "rights" for ambulance contract oversight under the assumption an "EMS system" approach through a inter-governmental partnership provides the county with maximum benefit. 

Unfortunately, what may have provided maximum benefit 25 or even 15 years ago is no longer the case given other cheaper, faster, higher quality EMS delivery options. It essentially relegates Travis County to the role of contractual hostage to a City of Austin managed ambulance service where County needs are always second to those of the City

What makes this even more amazing is this particular inter-local agreement has been going on for 25 years, but it has:
·      Never been Independently audited,
·      Never competitively bid  
·      Consistently delivers mediocre to poor service for county residents (and I happen to be one of those) at an extraordinarily high cost for those services 


Violates Core Tenets of Responsible EMS Contracting

This City/County EMS inter-local agreement VIOLATES EVERY CORE TENET of responsible EMS contracting (Ref: The American Ambulance Associations Guidebook- Best Practices in Designing, Managing and Contracting for Emergency Ambulance Service).  

What’s so revealing in this quoted reference is it represents the gold standard for the private ambulance industry inter-governmental contracting.   Typically governments have higher performance standards than private industry for matters of public safety, but for the City/County EMS inter-local, there are no standards of any consequence or value even close to private EMS industry standards, which should be a BIG RED FLAG for Travis County leadership! .  The irony is the privates have HIGHER STANDARDS for public services than either Travis County or the City of Austin.  I am not promoting privatization as the solution, but its worth noting not only for the above reason but because the City’s EMS Union has tried to depict ambulance privatization as a step down when in terms of patient services and cost to the taxpayer for Travis County it would be a step up! 

To fully appreciate how bad the Travis County EMS Inter-local really is, compare it to the following contracting essentials and see for yourself how poorly written the EMS Inter-Local really is. 



Best Practices in Contracting for Emergency Ambulance Service

#1: Hold the EMS service accountable-TC’s EMS Inter-local does not.

Every ambulance service should be evaluated on its ability to deliver results in the areas of clinical excellence, response-time reliability, economic efficiency, bill collection and customer satisfaction. This should be accomplished through performance-based assessment.  A high-performance emergency ambulance service achieves clinical excellence, response-time reliability, economic efficiency, and customer satisfaction—simultaneously. The designated emergency ambulance provider should be required to meet or exceed specified levels of performance in each of these four operational areas. Without accountability, there are no assurances.


  • Travis County Inter-local has no stipulations to hold the City of Austin Ambulance Department (EMS) accountable for its performance.  
    • There are no meaningful performance outcomes for ambulance response time
    • There is no penalty for under performance or incentives for exceptional performance
    • There are no monthly data  reporting requirements
    • There are no performance requirements for financial controls
    • There are no economic efficiencies identified
    • There are no clinical benchmarks (other than CPR save rate which represents less than 1% of the work load and is not an indicator of overall effectiveness or clinical competence)
    • Bottom line: there are no contractual repercussions for the City of Austin's Ambulance Department for any of their activities, operational, clinical or financial

What are the consequences? 
      • At an average 16 minute response time the ability of the ambulance paramedics to make a difference in saving a life is clinically impossible.
      • The City ambulance department consistently recommends annual increase in City & County funded ambulances based on a computerized dispatching program that has never been audited for accuracy.  In fact, the City ambulance departments own Medical Director complains that the computer aided dispatching program the City uses to prioritize 9-1-1 medical calls is inherently “flawed and should not be used or relied on for determining future ambulance resource needs”. 
        • After the City ambulance department invested millions of dollars in a electronic patient record keeping system, which Travis County had to pay its 30% share, the billing process which was suppose to see huge dollar improvements in its efficiencies, requiring less billing staff remains terribly back logged (45 days) and for the fiscal year 2011 the City approved "adding" billing staff.  So much for cost savings and improved services. 
        • Just for fiscal year 2010, STARFlight medical billings, which until recently have been managed under the inter-local by the City ambulance billing section, was discovered to be over $2,500,000 in arrears just for medicare bills!   Any idea how many dollars they are behind in ground ambulance billing?! 
        • There is no independent customer satisfaction appraisal process to gauge user satisfaction other than a annual sampling the City does for its various departments, and a less than objective, outdated ambulance department customer service process
        • The City ambulance management's only solution for their poor performance is recommendations that Travis County add more  ambulance resources (at over $1,500,000 per unit). For fiscal year 2013, the ambulance director is pushing for Travis County to fund three more ambulances at a cost of almost $5,000,000 and will only improve services by "2%".   An expensive solution given other cheaper and more effective management options including better utilization of existing ambulances using dynamic deployment and peak load staffing, and upgrading County ESD's (fire departments) to paramedic first response (at $150,000 per fire apparatus, considerably cheaper than adding ambulances). 



    #2:  Establish an independent oversight entity- TC’s EMS Inter-local does not.

    This is a body that has an arm's-length relationship with a provider organization and regularly monitors how it is performing. It periodically requires independent outside audits. To be effective, the independent oversight entity should consist of an unaffiliated and objective group of people selected for their expertise in specific professional disciplines required in the development and oversight of the emergency ambulance service. Community representation on the independent oversight entity should include leaders from areas such as the following:

    • Legal
    • Accounting
    • Business
    • Medicine
    • Patient advocacy
    • Hospital and/or health care
    • Local government (elected official)


    • Travis County has no "independent" oversight, only a toothless body called the EMS Advisory Panel which meets for one hour, every  month.  It was purposely made impotent by the City to minimize its oversight potential. 
    • To effectively manage a "vendor" for emergency ambulance service, be it another government or a private contractor, there MUST be effective oversight including monthly review of actual performance data and regular outside audits of the contract.  
      • As noted, this contract has never been independently audited or any consideration given to competitively bidding out service to qualified governmental agencies (example: county fire departments) or private ambulance contractors (example: AMR, Paramedics Plus) over its entire 25 year history.  A fundamental violation in contract best practices. 
      • Additionally, the City ambulance management has told County administration their requests for ambulance performance data specific to ESD jurisdictions “yields no benefit” even though this was requested to aid the County and ESD’s in evaluating  how to serve emergency patients more effectively.   In fact the ambulance director stated to a Travis County executive sharing such information with the ESD’s would be “dangerous”.   
      • To date, both Travis County and the City Ambulance Departments own Medical Director, have been refused direct access to the agency's computer aided dispatch data on ambulance response and all patient related data from the agency's "paramedic run forms"  for independent performance assessment and medical oversight.  


    #3:  Account for all service costs- TC’s EMS Inter-local does not.

    An effective emergency ambulance service accounts for all its costs—direct, indirect, and shared.  Cost calculations should include labor, medical communications center, buildings, vehicles, equipment, supplies, liability exposure, administrative overhead, and independent oversight costs.

    • In spite of the language in the inter-local allowing only "at cost" expenses, the City of Austin regularly over prices its various direct and indirect services to Travis County. 
      • Example:  billing for STARFlight:  earlier in the year the cost for this service was $250,000 but the price "magically" shrunk to under $20,000 when the City became aware Travis County was seeking outside bill collecting services. 
    • None of the ambulance cost are itemized with specific correlation between cost for the item and benefit to Travis County residents for the services it receives. 
    • None of the new or supplemental costs are required to be OK'd by Travis County's auditor first.
    • None of the ambulance service costs are regularly accounted for and certified accurate by an independent audit authority.


    #4:  Require system features that ensure economic efficiency- TC’s EMS Inter-local does not.

    The volume and location of medical emergencies vary by hour of day and day of week. To reflect this reality, ambulance deployment should be based on geographically deploying the right number of ambulances according to historical call demand and redeploying as events occur. In contrast, “fixed base” or “static” deployment (which is the model the City uses for ambulance deployment), in which shift schedules and unit locations are fixed, is generally discouraged and should not occur other than in remote, low-volume locations.

    • The City ambulance operation does not match staffing with demand, resulting in not enough resources during peak demand, and too many during low demand periods. 
      • Travis County could use more of its ambulance assets during peak periods and a smaller number for slow periods, supplementing the gaps in service with beefed up ESD first response paramedic engine companies at 1/10th the cost of an ambulance and 40% -60% faster. 
      • It could also hold on dispatching a county ambulance resource for the lower priority medical calls until first response confirms a need for patient transport. Rather than fixed deployments, Travis County ambulances should use a combo of fixed and dynamic deployment based on demand levels.  Fixed for slow periods, dynamic for busy periods.    Plus, the two paramedic  supervisors (who drive fully equipped paramedic vehicles), and are paid by Travis County, per the inter-local to oversee county ambulance staff and operations, should be routinely required to stay in the county and actively integrate into ambulance gap coverage when a county ambulance is on a call.     



    #5: Ensure long-term high-performance service- TC’s EMS Inter-local does not.

    This includes requiring results-oriented performance standards to be met, and then either benchmarking the clinical and financial performance against other recognized high-performance services or engaging in competitive procurement

    • Travis County has no such standards.  At the very least the County should bring in a professional EMS contract consultant to establish requirements for ambulance service with clear, concise, measurable performance requirements centered on patient services and cost controls, and cross reference performance between cost of service, quality of care and customer satisfaction (none of which is achieved under the present inter-local agreement).   

    Why does Travis County continue to renew a service agreement that cost more than what other communities pay for comparable EMS service and delivers far less?

    The answer:

    Travis County, like most municipal and county governments, lacks in-house executive administrative expertise with professional experience and knowledge of EMS best practices, performance contracting and the EMS industry in general. 




    What to do?

    Solve the one-sided contracting problems and the County regains the critical foot hold needed to responsibly address the future direction of ambulance services and EMS for Travis County.  It does not mean the County has to pull out of a "the present EMS system", it can still be an active participant but under it own terms including how ambulance and first response is delivered in its area of "the system".  But, the County can no longer ignore these contract problems and if it does, only guarantee more of the same: poor service, high operational cost, no say, no control, no standards. 

    To Travis County's credit they have taken the first big step and hired an experienced consultant team to evaluate the current EMS level of services.  The results of the consultants report was no surprise, ambulance service is not good in Travis County (that is in terms of operational management, deployment and response, not the quality of the paramedic services once it gets on scene).   Now Travis County must take the next step and hire another professional EMS consultant group with proven EMS contract experience, including writing a real EMS performance contract, developing a master plan for integrating County Fire Department paramedic first response and ambulance operations, and developing a competitive procurement process for county-wide EMS services or more dramatic, a process to cede direct responsibilities for EMS to qualified County ESD fire departments (of the current 13 ESD's, only 6 would fall into this category but they cover the majority of County population).   In the interim, at the very least, the next pending EMS inter-local agreement should be modified as follows:

    .   
          1)  The County’s Purchasing and Audit Departments should manage the EMS inter-local with support from the County Emergency Services Executive and the County’s EMS Officer (STARFlight Program Manager).  This joint sharing of oversight provides the critical  financial depth and experience in contract oversight that does not exist in the County’s emergency services section.  This group should also be authorized to use outside legal counsel familiar with performance specific EMS contracting as its counsel and guide for managing the contract and developing new service contracts to be competitively bid for all future service contracts. 

          2)  Either the Auditors Office or preferably an independent accounting firm familiar with this type of service contract should audit the inter-local annually.  Poor performance should be financially penalized as they are in other communities and in turn exceptional performance should be rewarded financially also.