executive summary - acphd county amr proposal...notes sarah had an episode of atrial fibrillation in...

OUR PURPOSE IS TO REDUCE SUFFERING AND IMPROVE HEALTH

EXECUTIVE SUMMARY Sarah (not her real name) walks home from the grocery store pulling her wheeled

cart the three blocks to her Newark, CA bungalow every Friday afternoon. When she woke

up this morning, she noticed a “faint whisper” in her chest and now she’s having a hard

time catching her breath. Paramedics from Newark Fire Station #1 arrive in less than 5

minutes and their lead paramedic, Paul, begins care. Two minutes later Alameda County

AMR arrives and our paramedic Bonnie reviews the 12-lead EKG with Paul while her

partner and student intern prepare the stretcher. Both medics instantly recognize the ST

segment elevation indicating that Sarah is having an inferior wall myocardial infarction.

They notify Washington Hospital, the closest cardiac receiving facility, and head to the

hospital.

Sarah is barely settled on the Emergency Department bed before she’s whisked to

the cath lab where the cardiologist threads a wire through the clot in her coronary artery

to restore flow to her oxygen-starved heart muscle. He reads our patient care report that

notes Sarah had an episode of atrial fibrillation in the field. Based on that, he prescribes a

medication to prevent its recurrence in the hospital and after she goes home.

Our crews run hundreds of calls like this each day, as our organization and its

predecessors have for nearly 50 years. Most EMS calls are for someone who is suffering,

someone like Sarah. The ability to provide Sarah and people like her with the best care

possible involves a complex network of systems, organizations, practices, technologies,

and relationships all working together.

We are proud of our patient-centered contribution to the healthcare system in

Alameda County. This proposal renews our commitment to be the best possible partner for

the County, Fire Agencies, Hospitals, Police Departments, and Community Groups who

work with us every day to help relieve the suffering of the people we serve.

Commitment to Quality

Our Alameda County quality/leadership team possesses a level of quality

competencies unusual to find in any organization much less in one EMS operation,

including advanced statistical analysis, process design, research study design, database

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development, and more. Our award-winning team members are the people who teach the

EMS industry's leaders how to design, implement, and lead quality management systems.

Commitment to Employees

People in our organization are here because they are committed to serving the

people of Alameda County. In our January, 2010 quarterly employee satisfaction survey

94% responded, "I'm very happy" or "more often than not I have a good time at work,"

when asked how they would rate their morale.

Commitment to Community

In addition to life-saving clinical care and fast response times, Alameda County

AMR is leading an innovative, integrated EMS Community Health Partnership Model. We

are committed to helping measurably improve the health status of our community. This

focus unlocks a tremendous range of opportunities for us to help people better manage

chronic disease and to help them prevent serious illness or injury. We've partnered with

the Ethnic Health Institute, an Oakland-based, physician-led organization whose 250+

members include the Alameda County Health Care Services Agency and Medical Director.

This partnership helps us identify and implement EMS actions that help fill the gaps

between our community's current health needs and resources.

Commitment to our Fire First Responder Partners and EMS System

Every day we work side by side with the Fire First Response Agencies as we care

for the ill and injured. As part of our commitment to this partnership we open all our

education to First Responders, offer credentials tracking, materials management, supply

purchasing, a new mobile simulation center and more at no cost to their organizations.

AMR provides more financial support to Fire First Responders than any other private

ambulance provider in the U.S. With our partners, we are committed to helping the

County’s vision of Fire Station-Based Health Clinics become a reality.

Commitment to Excellence in Operations and Management

Our skills in operations and management have allowed our organization and its

predecessors to serve this community successfully and sustainably for more than four

decades. In addition to our track record of performance, we offer the best available

technology today including our exclusive Optima™ planning and deployment software.

This technology uses the same principles as flight simulators that allow pilots to learn

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without crashing. It allows us to test a variety of system designs in a simulation to evaluate

their performance before implementing them for the people of Alameda County. We will

provide access to Optima™ to enable the County to test the deployment systems proposed

under this RFP as well as any modification contemplated in the future.

This proposal is packed with additional enhancements including an all-new fleet of

environmentally-friendly Sprinter ambulances wrapped as public health mobile billboards,

a new facility with more classroom and community meeting space, a collaboratively

developed, new co-located dispatch center with partner Alameda County Regional

Emergency Communications Center, new hybrid supervisors vehicles, a million dollar Fee

Forgiveness Fund, Palantir information integration and visualization software, MEDS 3.0

ePCR, Power Pro Stretchers, LifePak 15 monitors, and more.

We offer these enhancements along our financial strength, acumen and experience,

particularly in Northern California, which allows us to plan for and deliver on the

complexities of serving high performance systems like Alameda County. For example,

during the Summer of 2005, Monterey County selected another company to provide 9-1-1

emergency medical ambulance services for the County. The other provider was selected

over AMR in that process because they promised to provide faster service for a lower price

than AMR, the 20-year incumbent. Within two years, the new provider was more than

$2,000,000 in debt, unable to make payroll, and unable to meet the response time

requirement of their performance-based contract with the County. The Board of

Supervisors provided a $991,356 subsidy in March of 2007 to enable the Company to make

payroll. In September of 2008, the County requested AMR assist with its takeover of the

County's 9-1-1 service on the terms in AMR's original losing proposal. Today Monterey

County continues to be served by AMR under a new 5-year contract.

At the end of the day Sarah does not care about the details of the EMS system that

covers the community where she lives, the awards it's applying for or the technologies it

uses. Sarah cares that when she her life is in danger, someone comes quickly who is nice

and knows what to do. She cares that when Friday rolls around a couple of weeks from

now, she’ll be able to walk her groceries home from the store. We hope you will choose us

to continue to serve the people of Alameda County like Sarah.

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REQUIRED FORMS

These required forms appear on the following pages:

• Face Sheet - RFP Exhibit F .....................................................................................5

• Completed Proposal Checklist (Exhibit P) ..............................................................6

• Proposal Form: Proposed Patient Charges - RFP Exhibit G .................................11

• Evidence of Insurance - RFP Exhibit C ................................................................19

• Debarment and Suspension Certification - RFP Exhibit K ...................................22

• Exceptions, Clarifications, Amendments - RFP Exhibit H ...................................23

• References - RFP Exhibit D ..................................................................................24

• Additional Requirements - RFP Exhibit J (includes Key Personnel) ...................37

• First Source Agreement - RFP Exhibit L ..............................................................61

• Investigation Release Form - Individual - RFP Exhibit M ...................................62

1. Mike Taigman, General Manager (E.2.4)

2. Dr. Gene Hern, MD, Medical Director (E.2.5)

3. Luis Diaz, RN, Quality Manager (E.2.6)

4. Diane Akers, Baldrige National Quality Award Consultant

5. Davis Balestracci, Healthcare Statistician

Our 27 additional quality/leadership team members' Investigation

Release Forms and resumes can be found in Attachments 1 and 2.

• Investigation Release Form - Entity - RFP Exhibit N ...........................................67

• Budget Compliance Form - RFP Exhibit O (for each pricing model)...................69

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EXHIBIT F

FACE SHEET

***THIS FORM MUST APPEAR AS THE FIRST PAGE OF THE PROPOSAL***

This is a proposal to contract with Alameda County to provide emergency medical ground ambulance services to persons requesting said service through the County or a County Dispatch Center(s).

Name of Proposer: American Medical Response West (AMR West)

Dba: Alameda County AMR

Type Of Organization: Corporation LLC Partnership Other

Date Founded Or Incorporated: 05/27/1992

Legal Address: 640 143rd Avenue, San Leandro, CA 94578

Phone: (510) 593-‐5730 ext.: ___ Fax: (510) 895-‐7617 (Required For Notification)

Federal Tax Identification Number: 77-‐0324739

Contact person: Mike Taigman,

Title: General Manager

Phone: (510) 593-‐5730 E-Mail: [email protected]

Address For Mailings: (If different from above): Same as above

Authorized Signature: ________________________ Date Submitted: 02/01/2010

Print Name: Mike Taigman

Title: General Manager, Alameda County AMR

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EXHIBIT P

PROPOSAL CHECKLIST AND MANDATORY TABLE OF CONTENTS [Updated per Addendum I, Part I, #12]

Section and subsection references have been provided to make finding the required information efficient. BINDER #1 – NARRATIVE Page #

Executive Summary (optional) .........................................................................................................1 Required Forms:

✔ Face Sheet (Exhibit F) ..........................................................................................................................5 ✔ Completed Proposal Checklist (Exhibit P)..........................................................................6 ✔ Proposal Form: Proposed Patient Charges (Exhibit G) .........................................11 ✔ Evidence of Insurance (Exhibit C) ..........................................................................................19 ✔ Debarment and Suspension Certification (Exhibit K) ............................................22 ✔ Exceptions, Clarifications, Amendments (Exhibit H) ..............................................23 ✔ References (Exhibit D) .....................................................................................................................24 ✔ Additional Requirements (Exhibit J) ....................................................................................27 ✔ First Source Agreement (Exhibit L).......................................................................................61 ✔ Investigation Release Form -‐ Individual (Exhibit M) ..............................................62 ✔ Investigation Release Form -‐ Entity (Exhibit N) .........................................................67 ✔ Budget Compliance Form (Exhibit O)..................................................................................69

Credentials and Qualifications: (See General Information Section) ✔ Experience (See 4.1)..........................................................................................................................81 ✔ Demonstrated ability to meet response time standards (See 4.2) .............82 ✔ Financial Stability (See 4.3).........................................................................................................88 ✔ Outstanding/Pending Litigation (See 4.4) ......................................................................93 ✔ Current contracts in Good Standing (See 4.5)..............................................................94

Clinical Quality Improvement: See Exhibit A – Scope of Work for the required contents of each of the following:

✔ Quality Management (See Section D[1]) ...............................................................................95 ✔ Quality Processes and Practices (See Section D[2]) ................................................ 127

✔ Leadership....................................................................................................................... 127 ✔ Strategic Planning ..................................................................................................... 146 ✔ Customer Focus........................................................................................................... 150

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✔ Customer Service Hotline ................................................................................... 164

✔ Measurement, Analysis, and Knowledge Management.............. 167 ✔ Process Management.............................................................................................. 205 ✔ Results ................................................................................................................................ 211

✔ Commitment to Employees (See Section E) ................................................................. 216 ✔ Workforce Engagement........................................................................................ 222 ✔ Dedicated Personnel ............................................................................................... 244 ✔ Key Personnel............................................................................................................... 252 ✔ Continuing Education Program...................................................................... 254 ✔ Clinical and Operational Benchmarking................................................. 258

✔ Minimum Clinical Levels and Staffing Requirements (See Section F) .... 264 ✔ Ambulance Staffing Requirements.............................................................. 264 ✔ Work Schedules and Human Resource Issues................................... 265 ✔ Personnel Licensure/Certification/Training Requirements . 266 ✔ Personnel Training................................................................................................... 266 ✔ Character Competence and Professionalism of Personnel...... 283 ✔ Internal Health and Safety Programs........................................................ 284 ✔ Evolving OSHA and Other Regulatory Requirements.................. 286 ✔ Treatment of Incumbent Workforce (if applicable)...................... 287

✔ Transport Requirement and Limitations (See Section G) ................................. 288 ✔ Destinations ................................................................................................................... 288 ✔ Prohibitions Against Influencing Destination Decisions........... 288

✔ Operations Management Provisions (See Section H) ........................................... 289 ✔ Services Description................................................................................................ 292 ✔ Response Time Performance/Reliability/ Measurement Methods.......................................................................... 296

✔ Commitment to EMS System and Community (See Section I) ...................... 325 ✔ Coverage/Dedicated Ambulances/Use of Stations, Posts ........ 328 ✔ Collaboration with First Responder Agencies ................................... 329 ✔ Electronic Data Collection System............................................................... 338 ✔ Health Status Improvement/Community Education ................... 347 ✔ Support of Local EMS Training Activities .............................................. 361

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✔ Participation in EMS System Development.......................................... 362 ✔ Customer Feedback Surveys ............................................................................ 362 ✔ Accreditation................................................................................................................. 363 ✔ Disaster Assistance and Response............................................................... 365 ✔ Mutual Aid Requirements................................................................................... 376 ✔ Deployment Planning............................................................................................. 378 ✔ Environmentally Friendly Business Practices ................................... 378

Regulatory Compliance and Financial Provisions:

See Exhibit B for the required contents of each of the following. If no specific requirement is stated, provide a statement that the Proposer will comply with the requirement.

✔ Federal Healthcare Program Compliance Provisions (See Section A) .... 381 ✔ Medicare Compliance Program Requirements ................................. 381 ✔ HIPAA Compliance Program Requirements........................................ 381

✔ State and Local Regulations Compliance Provisions (See Section B) ...... 381 ✔ Contractor Revenue (See Section C) ................................................................................... 381

✔ Patient Charges............................................................................................................ 381 ✔ Fee Adjustments......................................................................................................... 381 ✔ Billing/Collection Services................................................................................. 381 ✔ Contractor Compensation to the County and the System ........ 381 ✔ Market Rights................................................................................................................ 381 ✔ Air Ambulance Agreements .............................................................................. 381 ✔ Accounting Procedures......................................................................................... 381

✔ Administrative Provisions (See Section D) ................................................................... 381 ✔ Service Plan .................................................................................................................... 381 ✔ Annual Performance Evaluation ................................................................... 381 ✔ Continuous Service Delivery ............................................................................ 381 ✔ Material Breach and Provisions for Termination of the Agreement ............................................................ 381 ✔ Definition of Breach................................................................................................. 381

✔ County Remedies (See Section E) ...........................................................................381 ✔ Provisions for Curing Material Breach/ Emergency Takeover (See Section F)..................................................... 381 ✔ Termination (See Section G)...................................................................................................... 381

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✔ Written Notice.............................................................................................................. 381 ✔ Failure to Perform..................................................................................................... 381

✔ Emergency Takeover (See Section H)................................................................................ 381 ✔ Transition Planning (See Section I)..................................................................................... 381

✔ Competitive Proposal Required..................................................................... 381 ✔ Current Service Provider’s Employees .................................................... 381

✔ “Lame Duck” Provisions (See Section J) .......................................................................... 381 ✔ General Provisions (See Section K)...................................................................................... 381

✔ Assignment ..................................................................................................................... 381 ✔ Permits and Licenses.............................................................................................. 381 ✔ Compliance with Laws and Regulations................................................. 381 ✔ Private Work.................................................................................................................. 381 ✔ Retention of Records .............................................................................................. 381 ✔ Product Endorsement/Advertising............................................................ 381 ✔ Observation and Inspection.............................................................................. 381 ✔ Omnibus Provisions................................................................................................. 381 ✔ Small Business Utilization .................................................................................. 381 ✔ Relationship of the Parties................................................................................. 381 ✔ Right and Remedies Not Waived .................................................................. 381 ✔ Consent To Jurisdiction ........................................................................................ 381 ✔ End-‐Term Provisions...............................................................................381 ✔ Cost Of Enforcement ............................................................................................... 381 ✔ General Agreement Provisions....................................................................... 381

BINDER #2 – ATTACHMENTS Page #

✔ ELECTRONIC COPY OF FULL PROPOSAL AND ATTACHMENTS...........................................CD ✔ AUDITED FINANCIAL STATEMENTS FOR THE PAST THREE YEARS ............CD & 1 Binder ✔ CREDENTIALS AND QUALIFICATIONS ADDITIONAL INFORMATION..................................CD ✔ OPTIMA LIVETM MOVIE...........................................................................................................CD

✔ 1. ADDITIONAL INVESTIGATION RELEASE FORMS -‐ INDIVIDUAL (EXHIBIT M) ....................1 ✔ 2. ADDITIONAL QUALITY/LEADERSHIP TEAM RESUMES ................................................. 28 ✔ 3. CERTIFICATES OF INSURANCE IN COMPLIANCE WITH RFP EXHIBIT C....................... 55

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✔ 4. NEW FACILITY FLOOR PLANS........................................................................................... 58 ✔ 5. INSTITUTE FOR HEALTH CARE IMPROVEMENT IMPROVEMENT ADVISOR COURSE .. 60 ✔ 6. CLINICAL IMPACT OF RESPONSE TIMES INITIAL STUDY OVERVIEW........................... 68 ✔ 7. RAPID ACUTE PHYSIOLOGY SCORE (RAPS) CLINICAL STUDY LITERATURE............. 74 ✔ 8. BALDRIGE SELF-‐ANALYSIS WORKSHEET........................................................................ 83 ✔ 9. SAMPLE MONTHLY REPORTS............................................................................................ 87 ✔ 10. ENROUTE CAD BROCHURE ........................................................................................... 96 ✔ 11. OPTIMATM ANCILLARY INFORMATION .......................................................................... 98 ✔ 12. SAMPLE CHECKLISTS .....................................................................................................153 ✔ 13. INVESTING IN YOUR SUCCESS BROCHURE ..................................................................164 ✔ 14. PRE-‐EMPLOYMENT STANDARDS AND BACKGROUND CHECK ..................................191 ✔ 15. “TAKING EMS INTO TOMORROW” PUBLISHED ARTICLES ........................................204

PLEASE NOTE: To increase transparency and to enable reviewers to easily measure

our response against the RFP requirements, we have included the requirements in each

section along with supplemental information issued by the County where relevant. Quoted

material from the Alameda County RFP, its Addenda, and County written responses to

questions are indicated by blue italics like this or THIS. As part of our environmentally-

friendly green practices, this proposal is printed on recycled paper and colors do not appear

as vibrant as they might otherwise appear.

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EXHIBIT G (revised) PROPOSAL FORM: PATIENT CHARGES

1. Patient Charges shall be submitted on this exhibit in Table C 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. Proposals that do not comply will be subject

to rejection in total. The primary means of Contractor compensation is through fee-‐for-‐

services reimbursement of patient charges.

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,

mileage, and Treat-‐No transport; there is no distinction between ALS and BLS base rate.

The selected Contractor should be able to operate for six (6) months after contract start

date without revenue.

3. Table A shows the current approved charges in Alameda County.

Table A - Current Approved Charges

Bundled Base Rate $1,294.90

Mileage/mile $29.80

Oxygen $97.63

Treat, Non-‐transport rate* $359.70 *Treat, Non-transport rate applies to patients who receive a treatment intervention (such as 50% Dextrose) and subsequently refuse transport. Assessment (vital signs, EKG, etc.) does not constitute treatment interventions

4. Table B shows the current service provider’s experience over the past 3 years. We are

providing this information to enable Proposers to make revenue projections, which will

assist them in determining the appropriate patient charges

Table B – 2006-2008 Data

Year Total # of Trips

Total Mileage

Average Trip Miles

# of trips with oxygen

% of trips with oxygen

2006 84,143 489,514 5.82 44,025 52.32%

2007 86,031 494,428 5.75 49,434 57.46%

2008 87,389 493,608 5.65 53,759 61.52% Grand Total 257,563 1,477,550 5.74 147,218 57.16%

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5. The patient charges quoted in Table C 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 negotiated with the County.

Table C - Proposed Charges (based on all specifications contained in the original RFP)

Complete the proposed charge for each item listed below. No other patient charges will be considered.

Bundled Base Rate Mileage/mile Oxygen Treat, Non-‐transport rate*

$3,237.24 $74.49 $244.08 $500.00

*Treat, Non-transport rate applies to patients who receive a treatment intervention (such as 50% Dextrose) and subsequently refuse transport. Assessment (vital signs, EKG, etc.) does not constitute treatment interventions

6. Table C 1-3 Although Proposers are not require to, the County will accept additional pricing configurations based on the following options:

Table C -1 - Proposed Charges (based on a response time to ECHO and DELTA calls in 10 minutes)



$2,890.30 $66.51 $217.92 $500.00

Table C -2 - Proposed Charges (based on dispatch of Contractor’s ambulances by Contractor)



$n/a. $n/a $n/a $n/a

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Table C -3 - Proposed Charges (based on a response time to ECHO and DELTA calls in 10 minutes; and,

dispatch of a Contractor’s ambulances by Contractor) Complete the proposed charge for each item listed below. No other patient charges will be considered.


$n/a. $n/a. $n/a. $n/a.

The County will accept alternate pricing configurations based only on the following options: [Per Addendum I, Part I, #10:] a) Ambulance response in 10 minutes to Echo and Delta Calls; b) Ambulance dispatch by Proposer’s dispatch center; c) Ambulance response in 10 minutes to Echo and Delta Calls; and, ambulance dispatch by Proposer’s dispatch center. Table C should reflect patient charges based on the specifications contained in the RFP. Alternate pricing options must be submitted on the new Tables C-1 through C-3; Note, however, Proposers are not required to submit revised pricing options. Proposers are required to describe in detail each option proposed and how each options will be implemented. A revised Exhibit G is in this document.

A detailed description of each option proposed and how each option will be

implemented can be found below. Each option reflects our proposed blended co-location

of all ambulance dispatch functions within the Alameda County Regional Emergency

Communications Center (ACRECC) and will be implemented using the sophisticated

processes and tools described in this proposal. We have agreed to move into the new

center when it is scheduled to open January 2011, and we are prepared to transition earlier

should our ACRECC partners desire.

Our team has been in extensive collaborative discussions with the ACRECC team

and Fire Chief Sheldon Gilbert of the Alameda County Fire Department who oversees

ACRECC. Based on these discussions we have jointly created a plan that will provide the

greatest value to the communities we serve. Achieving all the performance benefits that

come from having the public service answering point and the dispatch center joined with

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the ambulance dispatch function as the County has envisioned. All our pricing reflects this

blended, co-located communications center.

Table C: Description based on all specifications contained in the original RFP

In EMS a provider can never expect to receive 100% of its charged amounts as

revenue, and an increase in rates does not result in a corresponding increase in revenue.

Further, depending on a particular community’s payer mix, increased charges above a

certain threshold will have very little impact on the amount of revenue collected to

continue funding the system.

The next two pie charts show Alameda County’s payer mix and the relative

responsiveness of those payers to increased charges.

ALAMEDA COUNTY PAYER MIX AND PAYER RESPONSIVENESS

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We believe the bundled base rate of $3,237 may exceed the threshold of charges

appropriate to a sustainable, clinically robust EMS operation in Alameda County. As the

preceding pie charts show, currently 63% of the payers in Alameda County are Medicare,

Medi-Cal, or self pay (no pay), and are unaffected by rate increases. That means 37% of

our payers must cover 100% of increased costs needed to fulfill additional RFP

requirements.

Our recent experience in Monterey County indicates that there is a threshold as to

how much rates can be raised before private insurance companies, HMO’s, and auto

insurance providers begin to limit ambulance reimbursement. As our Monterey rates

exceeded $3,000 per transport, we have found third-party payers limit reimbursement to

varying levels below billed charges and require us to seek payment from patients.

As the pie charts above reflect, collections from patients typically result in limited

or no payment and create a politically-sensitive situation for County officials. The average

patient charge required to sustainably cover the increased costs contained in this proposal

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under the base option could be more than the upper threshold of what can be expected on

reimbursement.

As outlined in the RFP, one of the three major consumer objectives of a successful

emergency medical system is reducing expenses associated with catastrophic injury or

illness. The chart above demonstrates how year over year inflation combined with

increased system performance demands can quickly escalate ambulance rates well beyond

today’s level. While we do not recommend a shift to a subsidized model for Alameda

County, some systems use government subsidy as a mechanism to ensure sustainability

when costs exceed available resources. For reference, the information below demonstrates

how subsidy amounts can offset ambulance rates in lieu of performance modifications.

YEAR 2010-2011

TRANSPORTS 90,617

YEAR 2011-2012

TRANSPORTS 92,438

CURRENT SYSTEM MODEL

CURRENT SYSTEM MODEL

8:30 RESPONSE CLOCK MODEL

10:00 RESPONSE CLOCK MODEL

ANNUAL SUBSIDY AVERAGE PATIENT CHARGE

$0 $2,053 $2,156 $3,819 $3,410 $1,000,000 $1,992 $2,096 $3,759 $3,350 $2,000,000 $1,930 $2,036 $3,699 $3,290 $3,000,000 $1,869 $1,976 $3,639 $3,230 $4,000,000 $1,808 $1,916 $3,579 $3,169 $6,000,000 $1,685 $1,795 $3,459 $3,049 $8,000,000 $1,563 $1,675 $3,338 $2,929

$10,000,000 $1,440 $1,555 $3,218 $2,809 $12,000,000 $1,317 $1,435 $3,098 $2,689 $14,000,000 $1,195 $1,315 $2,978 $2,568 $16,000,000 $1,072 $1,194 $2,858 $2,448 $18,000,000 $949 $1,074 $2,737 $2,328 $20,000,000 $827 $954 $2,617 $2,208

We have presented the above information to demonstrate the effect of multiple

scenarios on ambulance rates.

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Table C-1: Description based on a response time to ECHO and DELTA calls in

10 minutes

We propose conducting a research study to evaluate the clinical and life saving

impact of various ambulance response times to be performed in collaboration with the

County EMS Agency, researchers at the University of Arizona, and our national clinical

team. Current scientific literature does not provide sufficient evidence of the clinical value

of faster response times than those required in the system today to justify their

exponentially higher cost to achieve. Should evidence from this collaborative study

indicate statistically-significant clinical justification for faster response times we will work

with the County to ensure our patients receive the best possible clinical care while

maintaining system costs at a sustainable level.

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PROPOSER AGREES THAT THE PRICES QUOTED ARE THE MAXIMUM THAT WILL

CHARGE DURING THE TERM OF ANY CONTRACT AWARDED, WITH THE

EXCEPTION OF FEE INCREASES BASED ON THE CONSUMER PRICE INDEX.

FIRM: American Medical Response West dba: Alameda County AMR

SIGNATURE:____________________________________________________ DATE: 02/01/2010

PRINTED NAME: Mike Taigman

TITLE: General Manager, Alameda County AMR

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EXHIBIT C

INSURANCE REQUIREMENTS Note: Certificates of Insurance that meet the requirements of this Exhibit can be found in Attachment 3. We have included a Cashier's Check for the Proposal Bond amount identified in this Exhibit should Alameda County AMR be awarded the contract. This check is located in the proposal binder identified as "Originals."

1. EVIDENCE OF INSURANCE: Certificates of insurance are required from

a reputable insurer evidencing all coverages 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 insureds 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 (see table on page 93 for insurance requirements)

Contractor shall keep in effect during the entire term of Contract and any extension or modification of Contract, insurance policies meeting the following insurance requirements unless otherwise expressed in Contract:

3.1 Contractor shall provide malpractice insurance and comprehensive

liability insurance, including coverage for owned and non-‐owned

vehicles, each with a minimum combined single limit coverage of not

less than $5,000,000.00 for all damages, including consequential

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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 act, omission, or occurrence. Such

insurance shall be endorsed to include the County of Alameda and their

respective officers and employees as additional named insured as to all

services performed by the Contractor under this contract.

3.2 Contractor shall provide workers’ compensation insurance coverage for

its employees.

3.3 Contractor shall provide County with a certificate(s) of insurance

evidencing liability, medical malpractice and workers’ compensation

insurance as required herein no later than the effective date of Contract.

If Contractor should renew the insurance policy(ies) or acquire either a

new insurance policy(ies) or amend the coverage afforded through an

endorsement to the policy(ies) at any time during the term of Contract,

then Contractor shall provide (a) current certificate(s) of insurance.

3.4 The insurance policies provided by Contractor shall include a provision

for thirty (30) days written notice to County before cancellation or

material change of the above specified coverage. Said policies shall

constitute primary insurance as to County, State and Federal

Governments, and their officers, agents, and employees, so that other

insurance policies held by them or their self-‐insurance program(s) shall

not be required to contribute to any loss covered under Contractor’s

insurance policy or policies.

4. PROPOSAL BOND: Upon award of the contract by the Board, the successful

Proposer will post a bond in the amount of one hundred thousand dollars

($100,000), which shall be payable to County if the proposal is withdrawn

prior to execution of an agreement for ambulance services.

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COUNTY OF ALAMEDA MINIMUM INSURANCE REQUIREMENTS Without limiting any other obligation or liability under this Agreement, the Contractor, at its sole cost and expense, shall secure and keep in force during the entire term of the Agreement or longer, as may be specified below, the following insurance coverage, limits and endorsements:

TYPE OF INSURANCE COVERAGES MINIMUM LIMITS

A Commercial General Liability Premises Liability; Products and Completed Operations; Contractual Liability; Personal Injury and Advertising Liability; Abuse, Molestation, Sexual Actions, and Assault and Battery

$5,000,000.00 per occurrence (CSL) Bodily Injury and Property Damage

B Commercial or Business Automobile Liability All owned vehicles, hired or leased vehicles, non-‐owned, borrowed and permissive uses. Personal Automobile Liability is acceptable for individual Contractors with no transportation or hauling related activities

$5,000,000.00 per occurrence (CSL) Any Auto Bodily Injury and Property Damage

C Workers’ Compensation (WC) and Employers Liability (EL) Required for all Contractors with employees

WC: Statutory Limits EL: $1,000,000.00 per accident for bodily injury or disease

D Professional Liability/Errors & Omissions Includes endorsements of contractual liability and defense and indemnification of the County

$5,000,000.00 per occurrence $10,000,000.00 project aggregate

E

Endorsements and Conditions:

1. ADDITIONAL INSURED: All insurance required above with the exception of Professional Liability, Personal Automobile Liability, Workers’ Compensation and Employers Liability, shall be endorsed to name as additional insured: County of Alameda, its Board of Supervisors, the individual members thereof, and all County officers, agents, employees and representatives.

2. DURATION OF COVERAGE: All required insurance shall be maintained during the entire term of the Agreement with the following exception: Insurance policies and coverage(s) written on a claims-‐made basis shall be maintained during the entire term of the Agreement and until 3 years following termination and acceptance of all work provided under the Agreement, with the retroactive date of said insurance (as may be applicable) concurrent with the commencement of activities pursuant to this Agreement.

3. REDUCTION OR LIMIT OF OBLIGATION: All insurance policies shall be primary insurance to any insurance available to the Indemnified Parties and Additional Insured(s). Pursuant to the provisions of this Agreement, insurance affected or procured by the Contractor shall not reduce or limit Contractor’s contractual obligation to indemnify and defend the Indemnified Parties.

4. INSURER FINANCIAL RATING: Insurance shall be maintained through an insurer with a minimum A.M. Best Rating of A-‐ or better, with deductible amounts acceptable to the County. Acceptance of Contractor’s insurance by County shall not relieve or decrease the liability of Contractor hereunder. Any deductible or self-‐insured retention amount or other similar obligation under the policies shall be the sole responsibility of the Contractor. Any deductible or self-‐insured retention amount or other similar obligation under the policies shall be the sole responsibility of the Contractor.

5. SUBCONTRACTORS: Contractor shall include all subContractors as an insured (covered party) under its policies or shall furnish separate certificates and endorsements for each subContractor. All coverages for subContractors shall be subject to all of the requirements stated herein.

6. JOINT VENTURES: If Contractor is an association, partnership or other joint business venture, required insurance shall be provided by any one of the following methods: – Separate insurance policies issued for each individual entity, with each entity included as a “Named Insured (covered

party), or at minimum named as an “Additional Insured” on the other’s policies. – Joint insurance program with the association, partnership or other joint business venture included as a “Named Insured.

7. CANCELLATION OF INSURANCE: All required insurance shall be endorsed to provide thirty (30) days advance written notice to the County of cancellation.

8. CERTIFICATE OF INSURANCE: Before commencing operations under this Agreement, Contractor shall provide Certificate(s) of Insurance and applicable insurance endorsements, in form and satisfactory to County, evidencing that all required insurance coverage is in effect. The County reserves the rights to require the Contractor to provide complete, certified copies of all required insurance policies. The require certificate(s) and endorsements must be sent to: – Department/Agency issuing the contract – With a copy to Risk Management Unit (125 – 12th Street, 3rd Floor, Oakland, CA 94607)

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EXHIBIT K

DEBARMENT AND SUSPENSION CERTIFICATION

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: American Medical Response West dba: Alameda County AMR

Proposer Signature: ________________________________________________________________


Date: 02/01/2010

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EXHIBIT H REQUEST FOR EXCEPTIONS

List below requests for exceptions, if any, to the RFP and its exhibits; and

submit this form with your proposal. The County is under no obligation to

accept any exceptions and such exceptions may be a basis for proposal

disqualification.

Reference To: Item No. Page # Paragraph # Description

1. None.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Proposer Name: American Medical Response West dba: Alameda County AMR

Proposer Signature: _________________________________________________________

Date: 02/01/2010

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EXHIBIT D

REFERENCES

1. Proposers are to provide a list of three (3) current and three (3) former governmental clients on the following form. References must be satisfactory as deemed solely by County. References should have similar scope, volume and requirements to those outlined in these specifications, terms and conditions.

2. Reference information is to include:

2.1 Company/Agency name

2.2 Contact person (name and title), contact person is to be someone

directly involved with the services

2.3 Complete street address

2.4 Telephone number

2.5 Type of business

2.6 Dates of service

3. The County may contact some or all of the references provided in order to determine Proposer’s performance record on work similar to that described in this request. The County reserves the right to contact references other than those provided in the response and to use the information gained from them in the evaluation process.

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EXHIBIT D REFERENCES

CURRENT REFERENCES Proposer name: American Medical Response West

Company Name: Contra Costa County EMS

Address: 1340 Arnold Drive, Suite 126

City, State, Zip Code: Martinez, CA 94553

Contact Person: Art Lathrop, EMS Director

Telephone Number: 925-‐646-‐4690

Service Provided: 9-‐1-‐1 ALS Ambulance Service

Dates/Type of Service: 1959 to present Company Name: San Mateo County EMS Agency

Address: 225 37th Avenue

City, State, Zip Code: San Mateo, CA 94403

Contact Person: Sam Barnett, EMS Administrator



Dates/Type of Service: 1990 to present Company Name: Coastal Valleys Regional EMS Agency

Address: 475 Aviation Blvd, Suite 200

City, State, Zip Code: Santa Rosa, CA 95403

Contact Person: Bryan Cleaver, Regional EMS Administrator



Dates/Type of Service: 1991 to present

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EXHIBIT D

REFERENCES

FORMER REFERENCES Proposer name: American Medical Response West

Company Name: VeriHealth (reference’s current employer)

Address: 200 Montgomery Drive, Suite D

City, State, Zip Code: Santa Rosa, CA 95404

Contact Person: Bruce Lee, President Former EMS administrator for Santa Clara County


Service Provided: ALS 9-‐1-‐1 Ambulance Service

Dates/Type of Service: Bruce Lee’s tenure spanned 2/2004 to 3/2009. AMR West continues to serve this County.

Company Name: Barbara Pletz

Address: 3348 Market Street

City, State, Zip Code: San Francisco, CA 94114

Contact Person: Barbara Pletz Former EMS administrator for San Mateo County



Dates/Type of Service: Barbara Pletz’s tenure spanned 1/1990 to 1/2009. AMR West continues to serve this County.

Company Name: Ventura County Public Health Department

Address: 2220 E. Gonzales Road, Suite 130

City, State, Zip Code: Oxnard, CA 93036

Contact Person: Barry Fisher Former EMS administrator for Ventura County



Dates/Type of Service: Barry Fisher’s tenure spanned 2000 to 2008. AMR West continues to serve this County.

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Exhibit J

ADDITIONAL REQUIREMENTS ✔ 1. FINANCIAL REQUIREMENTS: Responses are to include: ✔ 1.1 Externally audited financial statements for the past three (3) years. Proposers’ audited financial statements must be satisfactory, as deemed solely by County, to be considered for contract award. [Per Addendum 1, Part II, #4:]One printed copy and ten electronic copies will be acceptable for financial statement only.

A copy of externally audited financial statements for the past three years for our

ultimate parent company EMSC can be found on CD and printed in the Audited Financial

Statements binder.

✔ 1.2 Contractor shall provide annually an externally audited financial statement for the entire term of the contract by the end of the 1st quarter (October 1st), following the end of the County fiscal year.

We agree to this requirement.

✔ 1.3 Estimated amount of start-up capital required to finance administration and ambulance operations for the first 90 days of the contract. 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 pre-qualified to borrow sufficient funds. Contractor should be able to operate for six (6) months after contract start date without revenue.

Start-up capital includes both the capital required for major expenditures such as

facility, ambulances, and medical equipment, along with the necessary working capital to

conduct day-to-day operations such as payment of suppliers and employees. As the

incumbent, our existing revenue stream will support day-to-day operations.

Our estimated amount of start-up capital is $12,214,323. Based on our cash

reserves, we will be able to operate without revenue for a period of time that far exceeds

the minimum of six months following the start of the contract. Given the state of the

economy and recent delays in obtaining Medicare and Medi-Cal provider numbers in

California, that is a fraction of the capital that would be necessary for an outside provider

to begin service. Based on our recent experience assuming EMS services in Monterey

County, even as an existing California Company, it took AMR over 12 months to receive

provider billing authorization from the Center for Medicare Services (CMS) and the State

of California Medi-Cal provider. Additional financial information about our company can

be found in the Credentials and Qualifications section.

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✔ 2. KEY PERSONNEL - Qualifications and Experience [Required Form Exhibit J, Section 2]

Proposals shall include a complete list of and resumes for all Key Personnel associated with the RFP. Provide no more than two pages of information for each person. Include all Key Personnel specified in Exhibit A – Scope of Work, Section E -2 2.4 - 2.6 [per Addendum III, #2]. The following information shall be included: ✔ 2.1 Relationship with Proposer, including job title and years of employment with Proposer ✔ 2.2 Role that the person will play in connection with the RFP ✔ 2.3 Address, telephone, fax numbers, and e-mail address ✔ 2.4 Educational background ✔ 2.5 Relevant experience ✔ 2.6 Relevant awards, certificates or other achievements

A proposal is only as good as the people who will be there to implement it day in

and day out throughout the term of the contract, and their ability to inspire, support, and

collaborate with the people with whom they work.

Alameda County AMR Workforce of 450+ Dedicated Team Members

All our team members are key personnel. Below are some facts about the members

of our 450+ person team, many of whom you see pictured on the tabs and throughout this

proposal:

• Together we have more than 4,300 years of EMS experience, more than half of it

serving Alameda County’s patients and community.

• 214 of us currently live in the County and many of us were born and raised in the

same communities as those we serve.

• Our team reflects the rich diversity of our community, with 36% of us identifying

as other than “white” compared to 15% for EMS organizations in the U.S.

• Our team members speak Spanish, Cantonese, Japanese, German, Tagalog,

Mandarin, American Sign Language, Portuguese, Russian, French, Dutch,

Kapampangan, Italian, Ilocano, and Farsi, in addition to English.

• We hold 102 Associates Degrees, 114 Bachelors Degrees, 12 Masters Degrees, 2

Chiropractic Doctorate Degrees, and one MD.

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• We are all committed to saving lives, relieving suffering, improving health, and

serving our community. We all contribute daily operations and ongoing care and

service.

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We propose the following team members for the roles in Section E.2.4-2.6

• Mike Taigman, General Manager

• Dr. Gene Hern, M.D, Medical Director

• Luis Diaz, RN, Quality Manager

The following two consultants are also core members of our senior

quality/leadership team. They have been contracted to provide their world-class expertise

on an ongoing basis now and are committed through the term of a new contract:

• Diane Akers, Malcolm Baldrige National Quality Award Consultant

• Davis Balestracci, Healthcare Statistician

Our expert consultants’ roles include participating in monthly Quality Steering

Committee meetings and providing ongoing coaching and additional project-specific

expertise and assistance as needed. While our additional quality/leadership team members

are primarily responsible for implementing day-to-day running of the system, the world-

class quality expertise of our contracted consultants together with our General Manager,

Medical Director, and Quality Manager set the priorities and guide these day-to-day

activities.

Our actions are also guided by extensive input from our patients and regulators who

we invite and will continue to invite to our monthly Quality Steering Committee meetings

for collaboration and as a supplement to our other reporting and update communications.

We consider our regulators to be partners in measurably improving community health,

whose expectations our team and our systems are designed to fulfill.

Our proposal includes our entire team who will implement this contract, which

includes all personnel specified in the RFP in addition to those above. As you will read in

the Clinical Quality Improvement section, our approach to quality management means

quality principles and practices are infused throughout our organization, which is why we

call our leadership team the “quality/leadership team.”

Resumes for our senior quality/leadership team members and brief biographies of

our additional quality/leadership team members listed on the next page can be found on the

pages that follow.

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Alameda County AMR Additional Local Quality Leadership and Operational Support

1. Lauri McFadden, Operations Manager

2. Leslie Simmons, Administrative Supervisor

3. Elsie Kusel, Clinical/Education Staff (E.2.7)

4. Lee Siegel, Clinical/Education Staff (E.2.7)

5. Bert Burk, Operational Field Supervisor (Deployment) (E.2.9)

6. Shahloh Jones, Data and Performance Analyst (E.2.10)

AMR Key Shared Operational Support/Expertise

7. Cathy Mickle, Manager of Finance

8. Jason Sampson, Communications Center Manager

9. Kim Vaughn, Director of Patient Business Services

10. Tom Wagner, CEO AMR West (Bay Area AMR operations)

Alameda County AMR Dedicated Operational Support

11. Louis Ho, Information Technology Specialist

12. Tammy Kuhlmann, Scheduling Supervisor

13. Wilma Owen, Operations Analyst

14. Mike Peterson, Deployment Coordinator

15. Al Zambito, Fleet Manager

Alameda County AMR Operational Field Supervisors (E.2.9)

16. Fran Adams

17. David Beahm

18. Bruce Hagen

19. Rick Oliver

20. Scott Salter

Alameda County AMR Clinical Supervisor/Specialists (E.2.8)

21. Louis Abaunza

22. Frank Intelisano

23. Patrick Lickiss

24. Donny Reis

25. Julie Silva

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26. Larry Sweetman

27. Bonnie Taxera

Resumes for additional quality/leadership team members can be found in

Attachment 1. All personnel can be reached directly at the phone number and email

addresses provided and through our main fax number 510-895-7617, and street address:

Alameda County AMR, 640 143rd Ave., San Leandro, CA 94578.

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MIKE TAIGMAN GENERAL MANAGER

Phone: (510) 593-5730 / E-mail: [email protected] Mike Taigman has been one of the most influential people in modern emergency medical services. He is a nationally-recognized educator, author, and consultant with more than 36 years in EMS including 30 years as an instructor on clinical, operational, and personnel issues. Mike is also the published author of more than 500 articles related to pre-hospital emergency medicine in publications such as Journal of Emergency Medical Services, The Ambulance Industry Journal, Emergency Medical Services Magazine, Emergency Care Quarterly, EMS Review, EMS Best Practices and Ambulance World: Australia’s Journal of Pre-Hospital Emergency Care, as well as past columnist for EMS Best Practices, Ambulance Industry Journal, Merginet, and the National Association of EMS Quality Professionals Journal. In the late 1980s while working for the Medical Director in Pinellas County, Florida, Mike began learning about quality and performance management. Since then he’s co-founded the National EMS Quality and Performance Workshop and the Effective QI Workshop through which he’s trained thousands of EMS leaders across the world in practical ways to improve quality for the people they serve while maintaining high levels of employee satisfaction and system sustainability. Mike’s designed, implemented, and led two award-winning quality management systems, one for EMSA in Oklahoma and the other for Sunstar in Pinellas County Florida. He regularly attends the Institute for Healthcare Improvement’s National Forums. He wrote the curricula for and still teaches the Quality Management course that’s part of the Masters Degree program in Emergency Health Services at the University of Maryland Baltimore County. Mike is also a certified Six Sigma Black Belt. Mike’s first leadership experience came as the head of the technical rock rescue team for the Arapahoe Rescue Patrol during his 1976 senior year in high school. Shortly after graduation from high school he became the Manager for Care Ambulance Service in Delta, Colorado. He moved back to Denver to attend paramedic school and then worked as a senior paramedic and lead Field Training Officer for the Denver Paramedic Division. During that time he won numerous awards including Colorado State Paramedic of the year in 1983 and the Gold Honor Award for the under gun fire extrication of two Denver Police officers shot by a deranged assailant. In 1998, Mike and Tom Wagner, now AMR West CEO, founded PARAMEDICS PLUS to embody the values of clinical excellence, employee satisfaction, community focus, and system sustainability they envisioned. Working together, their innovative start-up quickly became the EMS provider of choice in the public utility model world. Mike is known as a staunch advocate for patient-centered care and system design. In addition to encouraging EMS providers to push the clinical envelope on behalf of their sickest patients, he’s led the industry to think about ways it can do more. As the creator and host for the 1994 original “Sand Key EMS Conference” on the Expanded Scope of

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EMS Mike challenged EMS leaders to go beyond their comfort zone to think about new ways they can serve their patients.

Recently he published a series of seven articles on “What’s Next in EMS?” These articles provided the foundation for EMS to transform itself into a community health improvement partner. One of those articles on EMS and Asthma Self-Care served as the foundation for the Alameda County AMR Asthma Team that launched last Fall. Mike was awarded the 2009 Community Service Award by the Ethnic Health Institute, a robust community health organization in Alameda County. In his role, Mike is responsible for overall quality and performance as well as quality and performance improvement.

CAREER SUMMARY American Medical Response and Predecessor Companies

General Manager, Alameda County March 2009 -Present Corporate Director of Quality and Research and National Manager of Staff Development, Medtrans 1992-1997 Clinical and Quality Improvement Manager, Baystar Medical Services 1990-1992

Paramedicine ECR (Education, Consulting, and Research), Founder and President 1983-Present

Paramedics Plus, Co-Founder and Consultant for both high performance locations 1998-2008

Emergency Providers Incorporated (EPI), Kansas City, MO, QI Manager 1988 - 1990

Pinellas County EMS Foundation, Pinellas County, FL, Assistant to Medical Director 1988

City and County of Denver, Paramedic Division, Denver, CO Senior Paramedic, Paramedic, Field Training Officer, and Dispatcher 1980-1988

Care Ambulance Service, CastleRock and Delta, CO Youth Volunteer, EMT, Paramedic, and Branch Division Manager 1974-1980

SELECT EDUCATION, AFFILIATIONS, AND HONORS

M.A., Organizational System, Saybrook University, anticipated completion 2010 Graduate Certificate in Socially Engaged Spirituality, Saybrook University, 2007 Becoming a Better Intervener, Gestalt Institute of Cleveland, San Mateo, CA, 2001 B.A., Business Management, University of Phoenix, On-Line Campus, 1999 Somatic Psychology and Education, The Lomi School, Petaluma, CA, 1993-1996 Certified Lean Six Sigma Black Belt, Aveta Business Institute, Cleveland, OH, 2006 Certified Master Trainer, Development Dimensions International, SD, CA, 1995 Certified Total Quality Management Facilitator, QCI, California, 1992 Gold Honor Award for Saving Life, State of Colorado 1987 AMI St. Luke’s EMS Responder Award, 1987 Kenny Edwards Award for Excellence in Paramedicine, 1985 and1987 Paramedic, Swedish Medical Center/Arapahoe Community College, Englewood, Colorado (with honors), 1980

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HERBERT E. “GENE” HERN, JR., MD, MS MEDICAL DIRECTOR

Phone: (510) 589-3254 / E-mail: [email protected]

PROFESSIONAL BIOGRAPHY

Dr. Hern brings to our team more than a decade serving patients in Alameda County, including serving as Program and Residency Director for Alameda County Medical Center, Highland Hospital Campus. As our Medical Director and member of the Alameda County AMR Quality Steering Committee, Dr. Hern has overall responsibility for care provided by our paramedics and EMTs including clinical quality, training, and education. In this role, Dr. Hern facilitates monthly presentations for paramedics and EMTs on EMS Hot Topics, cutting-edge developments from expert physicians on advanced clinical issues. He also created and coordinates the STEMI Summit, where local cardiologists review challenging cardiac cases for our clinicians. Dr. Hern is available 24/7 to assist with clinical investigations and provide in-depth, one-to-one coaching for paramedics as needed to improve clinical performance. Additionally, he actively participates in the development of new protocols and practices working with EMS system participants and the County Medical Director. Dr. Hern has lectured on a wide range of clinical topics as well as medical ethics and cross-cultural ethics. An extensive list of publications and presentations is available on request.

EXPERIENCE American Medical Response, Medical Director 2007 - Present

Oakland Police Department SWAT Team, Medical Director 2003 - Present

Alameda County Medical Center, Highland Hospital Campus 1996 - Present Attending Physician, Dept. of Emergency Medicine 2000 - Present Program and Residency Director 3/2009 - Present Residency Director 2007 - Present Chief Resident 1999 - 2000 Resident 1996 - 2000

Kaiser Permanente Medical Group, Oakland, Emergency Physician 1999 - Present

UCSF School of Medicine, Assistant Clinical Professor 1999 - Present

UC Berkeley/UCSF Joint Medical Program 1999 - Present Guest Lecturer, Introduction to Clinical Medicine 1999 - Present Clinician Instructor, Suitcase Homeless Clinic 1999 - 2004 Clinical Procedures Course Coordinator ‘01/02, Instructor, ‘00 2000 - 2002

EDUCATION M.D. May 1996, University of California, San Francisco. M.S. in Health and Medical Science (Bioethics), May 1994, University of California, Berkeley, School of Public Health. Thesis topic: “Value Conflicts in Cross-Cultural Medicine.” UCB/UCSF Joint Medical Program. 1991-1994. B.A. Bioethics (Special Concentration), 1991, Pomona College. Magna Cum Laude. Honors Thesis Topic: “Rationing Health Care for the Elderly.”

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University College, Fall Term 1989, Oxford University. Main Tutorial in Bioethics and the British National Health Service. PROFESSIONAL ACTIVITIES / AFFILIATIONS American College of Emergency Physicians American College of Emergency Physicians/California Chapter Board of Directors, 2006 - present Education Committee, Co-Editor – Lifeline Newsletter, 2002-present American Academy of Emergency Medicine, 2006-present Society of Academic Emergency Medicine, Ethics Committee, 1999-2000, 02-03, 07-08 Council of Residency Directors (CORD), 2001 – present Standardized Evaluations Committee, Year End Competency Committee, Chair, 2005-2006 Bioethics Committee Member, ACMC, 1997 – 2002 Bed Availability Committee, ACMC, 2000 – 2002 Committee on Inter-Disciplinary Practice, Chairman, April 2001 – present GME Committee, ACMC, 1998 – present SCHOLARSHIPS / HONORS UCSF Kaiser Award for Excellence in Teaching by a Volunteer Clinical Faculty Nominee 2008 UCSF Teaching Award Nominee 2007 – Outstanding Foundations of Patient Care Preceptor Resident of the Year 2000 Gary P. Young Award for Excellence in Academic Medicine 2000 Chief Resident 1999 - 2000 Kay Simmons Award 1998, ACMC Dept. of EM (Humanitarianism) Urgent Care Resident of the Year 1998 Phi Beta Kappa Vigil Honor (Order of the Arrow, BSA), Eagle Scout SELECT PUBLICATIONS AND PRESENTATIONS 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. Acad Emerg Med. 2006 Jul;13(7):727-32.

Hern, HE Jr, Koenig BA, Moore LJ, Marshall PA. The difference that culture can make in end-of-

life decision making. Camb Q Healthc Ethics 1998;7(1):27-40. Ethical Dilemmas in Consultation with Chinese-American Patients. Joint presentation with

David Elkin, MD, Dept. of Psychiatry, San Francisco General Hospital, 8th Annual Meeting of The Society for Bioethics Consultation, “Conflict and Power in Bioethics Consultation,” October 8, 1994, Pittsburgh, PA.

Cross Cultural Issues in Bioethics. Joint presentation with David Elkin, MD, Dept. of

Psychiatry, San Francisco General Hospital, American Medical Student Association Convention, March 11, 1995, San Francisco, CA.

Other Interests . Singing (Pacific Mozart Ensemble 1998-present), reading, camping, hiking, skiing

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LUIS DIAZ, RN QUALITY MANAGER

Phone (510) 326-9874 /E-mail: [email protected]

PROFESSIONAL BIOGRAPHY:

Luis Diaz is a Registered Nurse and San Leandro resident who brings to our team more than thirty years in health care, many with our partners in Alameda County’s hospitals and Fire First Response agencies. For the past decade, Luis has served in pre-hospital coordinator and quality roles with the Oakland Fire Department. During his tenure he has led the quality improvement effort for Oakland Fire Dispatch to the point where they will soon be accredited by the NAED as an Accredited Center of Excellence. Additionally, Luis has conducted ALS training for all paramedics and EMTs, implemented audio and video training modalities, conducted performance evaluations, provided administrative oversight, and acted as primary point of contact for ALS Narcotic Control Program. In addition to Luis’ stellar clinical credentials, he possesses extensive background and knowledge in a number of technologies related to data collection, analysis, reporting, and communication. Luis’ customized software solutions have been used in Fire Department EMS training divisions including Alameda Fire Department and Oakland Fire Department, which continues to use his customized database solutions. In his role as Quality Manager, Luis will be a key participant in all quality-related activities. Luis’ advanced database skills will facilitate easy data collection and in-depth statistical analysis. As part of our partnership with area Fire First Responders, Luis will continue to support the database functions of our partners. Luis was the candidate selected by our team members as the person we all would most look forward to having join our team for the new contract on both a professional and personal level. Luis has signed a contingent employment agreement with Alameda County AMR based on our selection to continue providing service to the County. EXPERIENCE:

American Medical Response Alameda County AMR Quality Manager To begin upon EMS contract finalization

Oakland Fire Department 1999-Present EMD-Q Dispatch Quality 2008-Present EMS Coordinator 1999-2008

Merritt College, EMT Faculty 1999-2006 Alameda Fire Department, Pre-hospital Care Coordinator 1994-2004

Emergency Department RN, Alameda County hospitals 1994-2004 Alameda Hospital, Alameda, Pre-hospital Care Coordinator 1994-2004 Eden Hospital, Castro Valley 1998-1999 Washington Hospital, Freemont 1994-1998

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San Leandro Hospital, San Leandro 1994-1995 Children’s Hospital, Seattle, WA 1991-1994

Emergency Department Lead Supervisor 1992-1994 Emergency Department RN 1991-1992

U.S. Navy Hospital Corp., Submarine Medicine 1974-1981

EDUCATION, LICENSES, ASSOCIATIONS, ADDITIONAL:

Nursing Degree, Merritt College, 1987 B.A. Health Sciences, Charter Oak College, 1982

Registered Nurse Certified EMT

Advanced EMD-Q Certified Certified Instructor ACLS, ITLS, PEPP

Member, California Disaster Medical Team 40/8 Honor Society Nursing Scholarship Awards Chair

Current Fire RMS specialist for new employee training, quality assurance, and data reporting.

Skilled in database creation, report generation, and website maintenance. Fluent in Spanish and English.

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DIANE AKERS

MALCOLM BALDRIGE NATIONAL QUALITY AWARD CONSULTANT Phone: (510) 524-8152 / E-mail: [email protected]


Diane brings to our team a vast wealth of knowledge, expertise, and experience in designing and implementing award-winning quality programs and initiatives. She has more than 30 years of experience in leadership and staff development both public and private, including more than 16 years directly implementing quality improvement programs and developing improvement-related training and curricula. As a member of the Alameda County AMR Quality Steering Committee, Diane will identify actions for our organization to take to fulfill intense and competitive quality award application process requirements. Diane’s background of service with more than a decade as Examiner and Alumni Examiner for the prestigious Malcom Baldrige National Quality Award, and Judge for the California Award for Performance Excellence, the state award based on Baldrige criteria, provide us with a tremendous opportunity to learn and advance in these areas and customize national quality criteria to meet local needs. EXPERIENCE American Medical Response

Alameda County AMR Malcom Baldrige National Quality Award Consultant 12/2009 - Present

EMS Consultant 1989 - Present Select representative clients: Kettering Medical Center Network, California State University Chico, County of Sonoma, State of California EMS Administrators

Malcolm Baldrige National Quality Award 1997-2009 Alumni Examiner 2002-2009 Examiner, for full term allowable 1997-2001

Alameda County Emergency Medical Service District, Oakland, CA 1984-1997 Director 1993-1997 Assistant Director 1986-1994 Pre-hospital Care Coordinator 1984-1985

Alameda County Conference Center, Trainer 1989-2007

Memorial Hospital, San Leandro, CA, Emergency Department Supervisor 1978-1991

SELECT EDUCATION AND HONORS AA, Nursing, CHABOT COLLEGE, Hayward, CA BA, Health Care Services, ST. MARY’S COLLEGE, Moraga, CA MBA, Health Services minor, GOLDEN GATE UNIVERSITY, San Francisco, CA Judge, California Award for Performance Excellence (CAPE Award), 2006-2008 Qualified to administer the Myers-Briggs Type Indicator Certified Achieve Global Trainer

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DAVIS BALESTRACCI, JR. HEALTHCARE STATISTICIAN

Phone: (207) 899-0962 / E-mail: [email protected]


Davis Balestracci is the world’s leading expert on healthcare statistics. Davis’ expertise is relied on and sought by organizations such as England’s National Health Service Modernisation Agency, for whom he conducted a multi-year improvement project with nearly 100 hospitals and strategic health authorities. Davis’ day-long educational sessions also regularly enhance the Institute for Healthcare Improvement Annual and European conferences. Famous for his influential book, Data ‘Sanity’: A Quantum Leap to Unprecedented Results, recently released in third edition, Davis is known for de-mystifying statistics with a practical, results-oriented perspective. As a member of our Quality Steering Committee, Davis enables our team to conduct world-class, complex statistical analysis for quality improvement as well as research projects. Davis also will provide ongoing support and coaching for our organization and our quality/leadership team so our performance data is analyzed and displayed appropriately and our actions inspired by data analysis are reasonable and likely to produce the best possible results for our patients and community.

EXPERIENCE American Medical Response

Alameda County AMR Healthcare Statistician November 2009 -Present

Harmony Consulting, LLC, Principal 2001 - Present Select representative clients: Institute for Healthcare Improvement, National Health Service of the United Kingdom, University Research Corporation, and other major public and private healthcare organizations

Institute for Healthcare Improvement (IHI), Presenter 1993-Present Editor/Abstractor, Eye on Improvement, IHI’s national publication 1993-1998 Select IHI Annual National Conference Sessions, All-Day Seminars, and European Healthcare Improvement Forum Presentations: “Leading True Excellence: Beyond the Platitudes;” “The Psychology of Culture Change;” “Data ‘Sanity’: You’re Already Using Statistics (Whether You Know It or Not!)”

American Society for Quality (ASQ), Member/Senior Member 1985-Present Statistics Division Chair (10,000 members) 2003-2004 Select ASQ Annual National Conference Sessions and All-Day Seminars: “Real World Teaching through Data ‘Sanity;’“ “Mapping Your Processes via Response Surface Methodology;” “Emotions: The Wildcard of Quality;” and “Statistical Issues in Improving and Managing Administrative and Service Quality.”

BlueCross and BlueShield of Minnesota Research Analyst, reporting to Chief Medical Officer 1998-2001

Park Nicollet Clinic (400 physicians, 2000 support staff, 25 locations, hospital) Statistical Specialist, reporting to Medical Director & CEO 1998-2001

3M Corporation, St. Paul, MN 1985-1991

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Lead Statistician 1990-1991 Senior Statistician 1985-1990

RCA, David Sarnoff Research Center, Princeton, NJ, Technical Staff 1984-1985

FMC Corporation, Princeton, NJ, Statistician 1980-1984

SIGNIFICANT PUBLICATONS Data Sanity: A Quantum Leap to Unprecedented Results, 3rd edition, Medical Group Management Association, Englewood, Colorado, 2009 (300 pages) Statistical Thinking Applied to Everyday Data, May 1999 edition of The Quality Letter, Volume 11, No. 5 (25 pages)

Data ‘Sanity’: Statistical Thinking Applied to Everyday Data, solicited special publication for the Statistics Division of the American Society for Quality (39 pages, sent to 11,000 people), Spring 1998 Quality Digest, monthly magazine distributed to more than 70,000 people, Monthly Statistical Columnist, 2005-2008

EDUCATION, AFFILIATIONS, HONORS

MS, Statistics, University of Minnesota, 1980 BS, with high distinction, Chemical Engineering, Worcester Polytechnic Institute, Mass.

Additional graduate studies in music history, theory, and conducting; mathematics, transport phenomena, design and polymers.

Keynote speaker for statewide conferences of healthcare quality organizations in Kansas, Minnesota, Michigan, Washington, California, Alabama, British Columbia, and Maryland

Faculty Member, ALUMNI SOCIETY OF THE HARVARD MIDDLE EAST INSTITUTE’s 1995 Quality Management Program for Health Care Organizations in the Middle East, Dahab, Egypt (for healthcare executives from Egypt, Israel, Palestine, Jordan & Morocco) Consultant, HARVARD INSTITUTE OF INTERNATIONAL DEVELOPMENT, Palestinian Quality Improvement Project, 1997 Presenter, TECHNION, HAIFA, ISRAEL, All-Day Statistical Thinking Seminar for Practicing and Academic Healthcare Improvement Leaders, 1997 Presenter, SOCIETY FOR HEALTHCARE EPIDEMIOLOGY OF AMERICA, Hospital Epidemiology, 1996 (request of Don Berwick, M.D. and Donald Goldmann, M.D., Harvard Medical School) Past President and Board Member, Twin Cities Deming Management Forum, 1992-1994

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Our proposal includes the entire leadership team we propose for the County. As an

enhancement, before the start of a new contract we will also add a Community Health

Coordinator to be collaboratively selected with our Community Health Advisory Board, the

Ethnic Health Institute (EHI). EHI’s members include the Alameda County Health Care

Services Agency, County Medical Director, and other organizations detailed in the

introduction to the Clinical Quality Improvement section. References to the proposer or

AMR include AMR West and predecessor companies.

ADDITIONAL ALAMEDA COUNTY QUALITY LEADERSHIP AND OPERATIONAL SUPPORT

Lauri is a key member of our quality/leadership team. Lauri has been in this role

for the past eight years, during which time she has ensured the successful ongoing day-to-

day functioning of all operations. A recipient of Alameda County’s EMS Circle of Life

Award, Lauri is known for her nurturing and connected leadership style. Employee

satisfaction surveys list her as one of the main reasons people like working on our team.

Leslie has worked in Alameda County EMS for twenty-nine years and in her

current role for nineteen of them.. Leslie supports the effective and efficient performance

of all day to day operations including quality and performance improvement activities,

scheduling, employee matters, education, and supervisor oversight and support.

LAURI MCFADDEN, OPERATIONS MANAGER Years Employed with Proposer: 8 Years in EMS: 8 Relationship with Proposer: Full-Time Employee Cell Phone/Email: 510-867-6286 /

[email protected]

Education: EMT, B.A. Social Ecology, M.A.c Divinity

LESLIE SIMMONS, ADMINISTRATIVE SUPERVISOR Years Employed with Proposer: 29 Years in EMS: 30 Relationship with Proposer: Full-Time Employee Cell Phone/Email: 510-376-4944 /

[email protected]

Education: EMT-P, Certified ICISF CISM provider, all training for California Task Force 4, 4th Degree Black Belt - Aikido.

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Additionally, Leslie helped develop our peer-based interviewing process and CISM

program. In 2008, Leslie received the Alameda County Heart of EMS Award for her

contributions.

Elsie has been with our organization for twenty-five years and has been educating

Alameda County’s EMTs and Paramedics for more than two decades. In addition to being

an Alameda County-certified CE provider, Elsie continues to run calls in the field which

gives her ongoing current insights into the educational needs of our system and personnel.

Elsie helps ensure all our training meets and exceeds all requirements, facilitates

improvement projects, and engages our crews. Elsie’s past honors include Star of Life

winner, Paramedic of the Year, and FTO of the Year.

Lee has been with our organization for twenty-one years. Lee works with the

County, the Medical Director, and other system participants to help develop and implement

clinical improvement projects such as the airway management checklist, a cardiac care/12-

ELSIE KUSEL, CLINICAL EDUCATION STAFF Years Employed with Proposer: 25 Years in EMS: 25 Relationship with Proposer: Full-Time Employee Cell Phone/Email: 510-774-5373 /

[email protected] Education: EMT-P; A.A. Business; Certified Alameda County CE Provider; Certified Instructor Non-violent Crisis Intervention; Certified ACLS Instructor; Trained in AHA Advanced Cardiac Life Support, AHA Basic Cardiac Life Support, AHA Pediatric ACLS, International Trauma Life Support; Certified Personal Trainer and Corrective Exercise Specialist; Karate Black Belt, and others.

LEE SIEGEL, CLINICAL EDUCATION STAFF Years Employed with Proposer: 21 Years in EMS: 21 Relationship with Proposer: Full-Time Employee Cell Phone/Email: 510-750-3474 /

[email protected] Education: EMT-P, CCT-P, Certified Alameda County CE Provider, U.S. Naval Training in Leadership, Management, Education, and Nuclear Power

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lead checklist, and a method to measure pain management effectiveness. A past Star of

Life winner, Lee is also responsible for leading clinical investigations and works closely

with our education team to ensure training is customized to address specific needs and that

appropriate steps are taken to measure its effectiveness.

Bert has twenty-four years with our organization and in EMS. Bert brings his

operational field leadership experience to the implementation of our system status plan

using advanced technology, detailed system knowledge, and sophisticated analysis. Bert

continually monitors response time performance and acts as liaison to dispatch to ensure

appropriate levels of resources are available to fulfill the system’s needs and that Optima

real-time dispatch and deployment recommendations are being effectively implemented.

Shahloh has been with our organization for four years, with a decade of experience

in data and customer service. Shahloh acts as the hub of the wheel of key performance

indicator data gathering, analysis, and reporting. As a member of our most important

improvement projects, Shahloh identifies sources and mechanisms for data collection and

analysis.

BERT BURK, OPERATIONAL FIELD SUPERVISOR Years Employed with Proposer: 24 Years in EMS: 24 Relationship with Proposer: Full-Time Employee Cell Phone/Email: 510-377-1747 /

[email protected] Education: EMT-P

SHAHLOH JONES, DATA AND PERFORMANCE ANALYST Years Employed with Proposer: 4 Years in EMS: 4 Relationship with Proposer: Full-Time Employee Cell Phone/Email: 925-765-3355 /

[email protected] Education: B.A. Clinical Psychology, San Jose State University, 2003

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AMR KEY SHARED OPERATIONAL SUPPORT AND EXPERTISE

Cathy has twenty-four years experience in financial operations and management,

including cash management, cash and financial forecasting, financial analysis, financial

statement preparation, internal controls, internal auditing, management of accounting

personnel, collaboration in developing internal software, and internal administration of

401(k) and ESOP. In her role as the Finance Manager, Cathy will provide financial

reporting and analytical support to our operation, including financial modeling and

forecasting to ensure our operation is able to provide the best possible service for our

community within a sustainable framework.

Jason has 17 years in EMS and dispatch. Jason will continue to direct and manage

our communications center personnel’s activities to implement our performance

management and response time strategies and practices in the co-located dispatch center

planned for the Alameda County Regional Emergency Communications Center

(ACRECC).

CATHY MICKLE, FINANCE MANAGER Years Employed with Proposer: 1.5 Years in Finance: 24 Relationship with Proposer: Full-Time Employee Phone/Email: 924-454-6007 /

[email protected] Education: B.S, Accounting (CPA curriculum), Utica College, Syracuse University, Utica, NY

JASON SAMPSON, COMMUNICATIONS CENTER DIRECTOR Years Employed with Proposer: 15 Years in EMS and Dispatch: 17 Relationship with Proposer: Full-Time Employee Cell Phone/Email: 925-250-5473 /

[email protected] Education: A.S. Diablo Valley College

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Kim has twenty-one years of experience in California health care billing, including

fifteen with AMR. With a customer-service oriented approach, Kim is responsible for

ensuring that all billing practices and policies including the Alameda County Fee

Forgiveness program described in Exhibit B are strictly followed day-to-day to ensure

prompt customer service and compliance with all applicable laws and regulations. Kim is

also responsible for implementing any billing-related improvement projects and producing

reports and updates to enable the quality/leadership team to monitor the effectiveness of

implementation and maintenance of rigid compliance with County, State, Federal and other

regulations and policies.

Tom has been a leader in EMS for twenty-five years, and in his current role since

2006 when he returned to AMR. Tom ensures the Alameda County AMR team has the

resources it needs to meet and exceed all its obligations and produce results for Alameda

County’s patients and communities. In addition to winning the State quality award during

his tenure as co-founder of Paramedics Plus and COO for Oklahoma and Tulsa from 1998-

2006, Tom served as an evaluator for the Oklahoma State Quality Award. Tom is known

for helping systems achieve extraordinary levels of performance in quality improvement,

customer service, employee satisfaction, and other areas.

KIM VAUGHN, DIRECTOR OF PATIENT BUSINESS SERVICES Years Employed with Proposer: 15 Years in EMS: 21 Relationship with Proposer: Full-Time Employee Cell Phone/Email: 209-595-5113 /

[email protected] Education: Galen College, 1988

TOM WAGNER, CEO AMR WEST Years Employed with Proposer: 11; 2006-present, 1991-1998 Years in EMS: 25 Relationship with Proposer: Full-Time Employee Cell Phone/Email: 925-817-9328 /

[email protected] Education: EMT, M.B.A, B.S. Biology

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ALAMEDA COUNTY AMR DEDICATED OPERATIONAL SUPPORT

Louis has worked in technology services for more than eight years and with our

organization for three years. Louis holds a B.S. in Computer Information Systems and is

responsible for efficient ongoing maintenance and trouble-shooting for hardware and

software related to ePCR, Mobile/GPS, and other technology-driven functions day-to-day.

He also serves as key contact for AMR’s dedicated national technology team.

Tammy has more than a decade experience in employee services and has served in

her current role for the past eighteen months. Tammy manages one of our most vital

functions, coordinating with payroll, human resources, union representatives, supervisors,

and crews to ensure all shifts are filled at all times and that personnel records are up to date

and accurate.

LOUIS HO, INFO TECH SPECIALIST Years Employed with Proposer: 3 Years in Technology: 8 Relationship with Proposer: Full-Time Employee Cell Phone/Email: 510-292-7853 /

[email protected] Education: B.S. Computer Information Systems; Network Management Certified, A+ Certified Professional CompTIA

TAMMY KUHLMANN, SCHEDULING SUPERVISOR Years Employed with Proposer: 1.5 Years in H.R. Administration: 12 Relationship with Proposer: Full-Time Employee Cell Phone/Email: 510-377-6559 /

[email protected] Education: College coursework in Math and Accounting

WILMA OWEN, OPERATIONS ANALYST Years Employed with Proposer: 8 Years in EMS: 8 Relationship with Proposer: Full-Time Employee Cell Phone/Email: 510-377-6657 /

[email protected] Education: B.A. Journalism, University of Santo Tomas, Manila,

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Wilma has been with our organization for eight years. Wilma provides invaluable

service coordinating events such as our annual holiday party, employee Christmas Dinner,

and employee bake-off, maintaining internal schedules and office supplies, monitoring

accounts payable and receivable, facilitating training and community outreach materials

production and delivery, and other functions. Wilma’s past experience includes working

for the Transnational MBA Program at Cal State Hayward and the Oakland Tribune.

Mike has twenty-two years in resource management and ten with our organization.

In his role, Mike oversees a team of vehicle services technicians. Mike is responsible for

ensuring all our vehicles are properly stocked with the right supplies and equipment so

clinicians have with what they need to serve patients at all times. Mike also oversees

materials management for First Responder partners who use this service. Mike oversees all

procedures for stocking including the use of the Demolizer to convert biohazardous waste

to recyclable material.

Al has more than 40 years of experience in vehicle maintenance, including 30 with

our organization. Al is well versed in all vehicles and ambulance maintenance procedures

necessary to keep our fleet ready to respond. Al overseas a team of five full-time

mechanics who work on-site at our Alameda County vehicle maintenance facility.

MIKE PETERSON, DEPLOYMENT COORDINATOR (MATERIALS MANAGEMENT)

Years Employed with Proposer: 10 Years in Resource Management: 23 Relationship with Proposer: Full-Time Employee Cell Phone/Email: 510-895-7620 /

[email protected] Education: High School, College coursework in law and marketing

AL ZAMBITO, FLEET MANAGER Years Employed with Proposer: 30 Years in Vehicle Maintenance: 41 Relationship with Proposer: Full-Time Employee Cell Phone/Email: 510-719-6566 /

[email protected] Education: High School, specialized vehicle maintenance trainings

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ALAMEDA COUNTY AMR OPERATIONAL FIELD SUPERVISORS

Fran has two decades with our organization and twenty-one years in EMS. Fran is

responsible for overseeing day-to-day customer service and ensuring crews have what they

need to serve patients and other customers effectively. Additionally, Fran maintains our

certification and licenses database to ensure all personnel keep up to date with trainings and

other requirements.

Dave has nineteen years with our organization and twenty-five in EMS. Dave

provides support and guidance for crews working in the field and helps ensure the

continual smooth running of the system and patient/customer satisfaction. Dave

established and trained our local Honor Guard, acts as Bike Team Coordinator, participates

in local and State disaster and MCI drills, and leads our participation in the annual U.S.

Marine Corps Toys for Tots donation drive. Dave oversees our standby service for all

events at the Oracle Arena and Oakland-Alameda County Coliseum including acting as

Incident Commander for all Oakland Raiders home games to ensure a safe and positive

event experience for fans and players.

FRANCIS ADAMS, OPERATIONAL FIELD SUPERVISOR Years Employed with Proposer: 21 Years in EMS: 21 Relationship with Proposer: Full-Time Employee Cell Phone/Email: 510-774-1896 /

[email protected] Education: EMT-‐P, Reserve Police Academy, U.S. Marine Corps Infantry School, training and education in Helicopter Crew Chief, Nuclear, Biological, Chemical Warfare, Intelligence Analyst

DAVE BEAHM,, OPERATIONAL FIELD SUPERVISOR Years Employed with Proposer: 19 Years in EMS: 25 Relationship with Proposer: Full-Time Employee Cell Phone/Email: 510-557-6086/

[email protected] Education: Daniel Freeman Paramedic School, 1990, Paramedic, San Pedro Wilmington Skill Center,. 1984, EMT

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Bruce has twenty-

nine years of experience in Alameda County EMS. Bruce provides guidance and coaching

to our crews as well as ongoing feedback to our clinical and education staff and other

personnel so management actions are aligned with the needs of our system. As the leader

of our Equestrian Team, Bruce is trained to provide EMS in environments where large

animals are present such as racetracks, which without proper training can cause additional

dangers. Bruce has an extensive background in disaster and rescue including a Certificate

of Valor from the CHP and several other awards for his efforts on the Cypress Freeway

Collapse, Chief Instructor and founder of Belize’s first rescue team, member of NASA

Geo-Science Medical Expedition to K2, the USAR/FEMA team CATF-4, and Global

Medical Rescue Services International.

Rick has twenty-four years with our organization and in EMS. Rick fulfills all

duties related to field supervision including moment-by-moment problem solving and

coaching, resolving customer service complaints, and ensuring clinical and education staff

are immediately alerted to any clinical issues. Special projects with which Rick has been

BRUCE HAGEN, OPERATIONAL FIELD SUPERVISOR Years Employed with Proposer: 29 Years in EMS: 33 Relationship with Proposer: Full-Time Employee Cell Phone/Email: 831-596-0184 /

[email protected] Education: EMT-P, B.A. Anthropology, FEMA Medical Specialist; Medical Specialist Instructor; CAL OES USAR Medical Specialist Instructor; Vertical/ High Angle Rescue Instructor; Cave and Wilderness Rescue Instructor; Ambulance Strike Team Member; Ambulance Strike Team Leader; Risk Management and Investigations certification; Heavy Rescue I & II; Large Animal Rescue; ICS 100-200-300-400, and others.

RICK OLIVER, OPERATIONAL FIELD SUPERVISOR Years Employed with Proposer: 24 Years in EMS: 24 Relationship with Proposer: Full-Time Employee Cell Phone/Email: 510-867-6837 /

[email protected] Education: EMT-P, Paramedic Preceptor, FEMA Medical Specialist, Weapons of Mass Destruction Train-the-Trainer, Medical Specialist, Urban Search & Rescue Team CATF-4

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involved include the Alameda County 800 MHz Re-Banding Project, Controlled

Substances Coordinator & Implementation Project, Urban Shield, statewide MCI drills, and

SWAT team Medical Support.

Scott has more than twenty years of experience in EMS, more than sixteen with our

organization. Scott anticipates what’s going on in Alameda County that might affect our

service and works with our scheduling department to adjust to continually meet demand.

Scott analyzes staffing and its impact on operational needs of the system, makes

adjustments to deployment, and coordinates the new hiring process for part-time

supervisors.

ALAMEDA COUNTY AMR CLINICAL SUPERVISOR/SPECIALISTS

Last Fall we conducted a pilot test of the Clinical Field Supervisor concept. Our

trial was designed with the help of the County Medical Director, our Clinical Education

Services team, our General Manager, and one of our local Fire First Responder partner

agencies’ Clinical Managers. We benchmarked the Clinical Supervisor program that’s

been operational with the San Francisco Fire Department’s EMS division for the last

decade. Based on that study, we developed a comprehensive set of skills, competencies,

knowledge, and character that the ideal candidate for this new role will possess.

Each of our proposed new Clinical Supervisors/Specialists have extensive clinical

knowledge and a proven track-record of sharing that knowledge with others effectively

therefore we anticipate they will be approved by the Medical Director following this RFP

process. In their role as Clinical Supervisor/Specialist, these personnel will be responsible

SCOTT SALTER, OPERATIONAL FIELD SUPERVISOR Years Employed with Proposer: 16 Years in EMS: 21 Relationship with Proposer: Full-Time Employee Cell Phone/Email: 510-377-6559 /

[email protected] Education: EMT-‐P, Firefighter 1, Certified Firefighter I and II,

Command 1A, ICS 100-‐200, HazMat first responder, CPR instructor

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for improving patient care, serving as a team leader and facilitator for high acuity 9-1-1

calls, operating as a resource for field staff for issues related to clinical management of

patients, providing clinical coaching and mentoring for field crews, assisting with

education and implementation of new EMS system protocols and procedures, and

participating in EMS clinical research and pilot projects.

Louis has been in EMS for 24 years and enjoys sharing his knowledge and

experience with field crews and contributing to the future of EMS.

Frank has been in EMS for eighteen years and has worked for Alameda County

AMR for fourteen. Frank’s resourcefulness and leadership for the crews in the field makes

him an asset for our team.

LOUIS ABAUNZA, CLINICAL FIELD SUPERVISOR/SPECIALIST Years Employed with Proposer: 24 Years in EMS: 24 Relationship with Proposer: Full-Time Employee Cell Phone/Email: 510-331-0817 /

[email protected] Education: EMT-P, specialized trainings, and college coursework

FRANK INTELISANO, CLINICAL FIELD SUPERVISOR/SPECIALIST Years Employed with Proposer: 14 Years in EMS: 18 Relationship with Proposer: Full-Time Employee Cell Phone/Email: 510-427-9354 /

hm2ssfrankcor@comcast-net Education: EMT-‐P, specialized trainings, and college coursework

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Patrick has been a key member of Alameda County AMR for nine years and been

teaching paramedics for almost two years. Teaching these classes has given Patrick the

opportunity to develop good clinical working relationships with students and also has

enhanced his communication skills while in the field.

Donny brings 19 years of EMS experience along with a reputation for outstanding

clinical care and customer service. Donny has been named FTO of the year, EMS provider

of the year, and received the Commitment to Excellence Award.

Julie has been helping patients in Alameda County for 24 years and looks forward

to continuing to excel in the EMS industry. Julie has been honored for her clinical

excellence and her background includes service as Strike Team response.

PATRICK LICKISS, CLINICAL FIELD SUPERVISOR/SPECIALIST Years Employed with Proposer: 9 Years in EMS: 9 Relationship with Proposer: Full-Time Employee Cell Phone/Email: 707-704-0403 /

[email protected] Education: EMT-P, B.S., UC Davis, Genetics, NCTI Certified Instructor

DONNY REIS, CLINICAL FIELD SUPERVISOR/SPECIALIST Years Employed with Proposer: 16 Years in EMS: 19 Relationship with Proposer: Full-Time Employee Cell Phone/Email: 209-614-1775 /

[email protected] Education: EMT-‐P

JULIE SILVA, CLINICAL FIELD SUPERVISOR/SPECIALIST Years Employed with Proposer: 24 Years in EMS: 24 Relationship with Proposer: Full-Time Employee Cell Phone/Email: 510-821-8581 /

[email protected] Education: EMT-‐P, nursing prerequisites Peralta Community College

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Larry began his career in the EMS industry in 2001 and has been with Alameda

County AMR for seven years. Larry has extensive field experience and enjoys sharing his

knowledge with crews in the field which will serve him well in this role.

Bonnie has sixteen years of serving patients in Alameda County and during that

time she has earned the trust and respect of her fellow team members.

LARRY SWEETMAN, CLINICAL FIELD SUPERVISOR/SPECIALIST Years Employed with Proposer: 7 Years in EMS: 9 Relationship with Proposer: Full-Time Employee Cell Phone/Email: 415-309-3075 /

[email protected] Education: EMT-‐P, CCT-‐P, college coursework

BONNIE TAXERA, CLINICAL FIELD SUPERVISOR/SPECIALIST Years Employed with Proposer: 19 Years in EMS: 19 Relationship with Proposer: Full-Time Employee Cell Phone/Email: 925-918-2384 /

[email protected] Education: EMT-P

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✔ 3. IMPLEMENTATION PLAN AND SCHEDULE

✔ The proposal shall include an implementation plan and schedule, including a description of strategic deployment methodology. The plan for implementing the proposed services shall include periodic progress reports to the County EMS Director, as well as inspection of facilities and equipment by County EMS representatives. In addition, the plan shall include a detailed schedule indicating how Proposer will ensure adherence to the timetables set forth herein for the initiation of services.

ALAMEDA COUNTY IMPLEMENTATION PLAN MAJOR CATEGORY ACTIVITIES NEEDED FOR IMPLEMENTATION STATUS TODAY

PERSONNEL: Recruit, screen, hire, test, background check, drug screen, uniforms, benefits, payroll establishment for all positions, HRIS set-up, certifications check, and execute Collective Bargaining Agreement.

Fully-operational

EQUIPMENT: Identify, purchase and stock all capital clinical equipment and disposable medical supplies, develop equipment decontamination and recapture process.

Fully-operational

FACILITIES: Locate, secure, build-out for offices, materials management, fleet service management, parking, education, training, and community education, remote stations, crew stations, EMS library and resource center. Establish training facilities, offices, and meeting space.

Fully-operational

FLEET: Design and purchase ambulances. Fully-operational TECHNOLOGY AND COMMUNICATIONS: Establish telephone system, radio system, AVL, GPS, MDT, ePCR and patient data records management system, data back-up system, business intelligence and data mining software and capability for report generation, County data storage system, inventory control system, fleet management system, scheduling system, system status planning software and capability, data reporting software and capability, technology to facilitate unified patient record system. Implementation of Optima suite of advanced deployment planning and decision support tools.

Fully-operational

KEY CORE PROCESSES: Design, implement, check effective processes to: Make potential employees full employees; conduct fleet maintenance; ensure correct medical supplies and medications are always available to the patient when needed; re-stock First Responder vehicles and ambulances; respond to 9-1-1 calls; respond to complaints and unusual occurrences; assess customer satisfaction; and assess quality and performance.

Fully-operational

DISASTER RESPONSE CAPABILITY: Establish relationships and agreements with County Communications Centers, Oakland Fire, and other key partners including surrounding area providers for disaster coordination and implementation of County disaster plan, complete ICS training for key supervisor staff, develop Alameda County Strike Team, Disaster Medical Support Unit (DMSU), and disaster trailers to be towed by hybrid

Fully-operational

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ALAMEDA COUNTY IMPLEMENTATION PLAN MAJOR CATEGORY ACTIVITIES NEEDED FOR IMPLEMENTATION STATUS TODAY

supervisor vehicles, develop internal disaster plan. COMMUNITY HEALTH IMPROVEMENT: Establish relationships with community partners such as the Ethnic Health Institute, Urban Releaf, East Oakland Community Health Planning Group, Sonrise Foundation, Youth Uprising, and area hospitals, Fire First Responder agencies, and experts from our Alameda County Health Care Services Agency, EMS Agency, and Medical Director to develop and implement programs.

Fully-operational

Many of the innovations and improvements in this proposal have already been

implemented. Some significant enhancements we propose rolling out with the plan that

starts on the next page.

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ALAMEDA COUNTY ENHANCEMENTS ROLL-OUT PLAN

We will fully-implement these system enhancements before the start of a new contract with roll-out beginning February 2, 2010.

ENHANCEMENT TIMEFRAME New equipment Training for new Power-Pro Cots and Lifepak-15 equipment

November 2010, eleven months before the start of a new contract, with equipment deployed by March 2011, seven months before the start of a new contract.

New building with community classroom space

Move planned January 2011, nine months before the start of a new contract. See Attachment 4 for new facility floor plans.

New fleet of Sprinter ambulances

Fleet replacement commences July 2010, fifteen months before start of new contract. The entire fleet replacement process is anticipated to be completed by August 2011, two months before the start of a new contract

New co-located dispatch center

Relocation of our current dispatch center to the Alameda County Regional Emergency Communications Center (ACRECC) collaboration in process, anticipated move date January 2011, nine months before the new contract.

New hybrid supervisor vehicles

Replacement to be completed by March 2011, seven months before the new contract starts.

New shift schedule We will eliminate 24-hour shifts and not schedule any shifts longer than 12 hours beginning November 2010, eleven months before the start of a new contract

New mobile simulation center

We have received positive feedback in initial pre-views and will work with Fire First Responder partners to custom design this mobile simulation center in Summer of 2010 and have it on the road by March 2011.

New Fire Station-based community health clinics

We have received positive feedback in initial discussions and will work with Alameda County Health Care Services Agency and Fire First Responder partners during the first quarter of 2010 to create a timeline for this program.

New Community Health Coordinator

Before the start of a new contract, we will hire a community health coordinator who will be collaboratively selected with our Community Health Advisory Board, the Ethnic Health Institute, whose members include Alameda County Health Care Services Agency and Medical Director

Additional Enhancements

We offer additional enhancements throughout this proposal as part of our commitment to be the best possible partner in serving Alameda County’s patients and community.

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We will use the report template below to provide weekly progress reports to County

EMS Agency Acting Director Dale Fanning and we are ready for facilities and equipment

inspection at any time. We will use system status management principles enhanced by

advanced simulation-based and real-time technologies for our strategic deployment

methodology as described in the Operations Management Provisions section.

WEEKLY REPORT TEMPLATE - CURRENT STATUS

KEY PERFORMANCE INDICATORS: For start up process and timelines.

NEW EQUIPMENT:

NEW BUILDING:

NEW AMBULANCE FLEET:

NEW CO-LOCATED DISPATCH CENTER:

NEW HYBRID SUPERVISOR VEHICLE:

NEW SHIFT SCHEDULES:

NEW MOBILE SIMULATION CENTER:

NEW FIRE STATION BASED HEALTH CLINICS:

✔ 4. STATEMENT OF COMPLIANCE

✔ The proposal must include a statement that the Proposer is willing and able to comply with all terms and conditions described in Exhibit B, “Regulatory Compliance and Financial Provisions.” Any exceptions or limitations must be listed in Exhibit H and also referenced in the response to this section.

We are willing and able to comply with all terms and conditions described in

Exhibit B: Regulatory Compliance and Financial Provisions. We have no exceptions or

limitations.

✔ 5. INDEMNIFICATION

5.1 Contractor (as indemnitor) will be required to indemnify, save and hold County, its officers and employees, agents, successors and assigns (as indemnitee) harmless from and

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against and in respect of any act, judgment, claim, domain, suit, proceeding, expenses, orders, action, loss, damage, cost, charge, interest, fine, penalty, liability, reasonable attorney and expert fees, and related obligations (collectively, the “claims”) arising from or related to acts and omissions of Contractor in its performance under the Agreement, whether direct or indirect including but not limited to, liabilities, obligations, responsibilities, remedial actions, losses, damages, punitive damages, consequential damages to third parties, treble damages, costs and expenses, fines, penalties, sanctions, interest levied and other charges levied by other federal, state and local government agencies on County by reasons of Contractor’s direct or indirect actions. This indemnity will survive and remain in force after the expiration or termination of the Agreement and is unlimited; provided, however that the indemnity is not intended to cover claims against the County arising solely of County’s own negligence or intentional misconduct. For purposes of this section, the term County shall include the County, officers, its employees and consultants.

5.2 County (as indemnitor) will be required to indemnify, save and hold Contractor, its officers and employees, agents, successors and assigns (as indemnitee) harmless from and against and in respect of any act, judgment, claim, domain, suit, proceeding, expenses, orders, action, loss, damage, cost, charge, interest, fine, penalty, liability, reasonable attorney and expert fees, and related obligations (collectively, the “claims”) arising from or related to acts and omissions of Contractor in its performance under the Agreement, whether direct or indirect including but not limited to, liabilities, obligations, responsibilities, remedial actions, losses, damages, punitive damages, consequential damages to third parties, treble damages, costs and expenses, fines, penalties, sanctions, interest levied and other charges levied by other federal, state and local government agencies on Contractor by reasons of County’s direct or indirect actions. This indemnity will survive and remain in force after the expiration or termination of the Agreement and is unlimited; provided, however that the indemnity is not intended to cover claims against Contractor arising solely of Contractor’s own negligence or intentional misconduct. For purposes of this section, the term Contractor shall include Contractor, officers, its employees and consultants.

5.3 The following provisions shall control the indemnity provided hereunder:

5.3.1 Indemnity defense. Indemnitor, at its cost and expense, shall fully and diligently defend indemnitee against any claims brought, investigations undertaken or actions filed which concern claims for which Indemnitee is indemnified. Indemnitor may employ qualified attorneys of its own selection to appear and defend the claim or action on behalf of Indemnitee upon Indemnitee approval. Indemnitor, acting in good faith and in the best interest of Indemnitee, shall have the sole authority for the direction of the defense, and shall be the sole judge of the acceptability of any compromise or settlement of any claims or actions against Indemnitee so long as such compromise or settlement does not impose a liability on Indemnitee not fully covered and satisfied by the indemnity provided by this section or, in Indemnitee’s judgment, subject to any material adverse order, judgment, or decree which impairs its image or ability to operate its business as previously conducted. Otherwise, Indemnitee reserves the exclusive right to reject any such compromise or settlement and prosecute the claim, compromise or settlement. Indemnitor shall inform

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Indemnitee, on a quarterly or more frequent basis, on the progress and proposed resolution of any claim and shall cooperate in responding to inquiries of Indemnitee and its legal counsel.

5.3.2 Reimbursement for expenses. Indemnitor shall reimburse Indemnitee for any and all necessary expenses, attorney’s fees, interest, penalties, expert fees, or costs incurred in the enforcement of any part of the Agreement thirty (30) days after receiving notice that Indemnitee has incurred them.

5.3.3 Cooperation of parties and notice of claim. Contractor and County shall provide the other prompt written notice of any such audit or review of any actual or threatened claim, or any statement of fact coming to that party’s attention which is likely to lead to a claim covered by the indemnity. Each party agrees to cooperate in good faith with the other and respond to any such audit or review and defending any such claim.

We acknowledge and agree to the above provisions.

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http://www.co.alameda.ca.us/gsa/sleb/vendor.shtml

EXHIBIT L

FIRST SOURCE AGREEMENT

Contractor agrees to provide Alameda County (through East Bay Works and Social Services Agency), ten (10) working days to refer to Contractor, potential candidates to be considered by Contractor to fill any new or vacant positions that are necessary to fulfill their contractual obligations to the County, that Contractor has available during the life of the contract before advertising to the general public. Contractor will also provide the County with specific job requirements for new or vacant positions. Contractor agrees to use its best efforts to fill its employment vacancies with candidates referred by County, but final decision of whether or not to offer employment, and the terms and conditions thereof, to the candidate(s) rest solely within the discretion of the Contractor.

Alameda County (through East Bay Works and Social Services Agency) agrees to only refer pre-‐screened qualified applicants, based on Contractor specifications, to Contractor for interviews for prospective employment by Contractor (see Incentives for Contractor Participation under Contractor/First Source Program located on the Small Local Emerging Business (SLEB) Website.

If compliance with the First Source Program will interfere with Contractor’s pre-‐existing labor agreements, recruiting practices, or will otherwise obstruct Contractor’s ability to carry out the terms of the contract, Contractor will provide to the County a written justification of non-‐compliance in the space provided below.

Company Name: AMR West dba: Alameda County AMR

Contractors Signature: _____________________________________________________


Date: 02/01/2010

Date:

/

/

__________________________________________________________ Date:

/

/

(East Bay Works / One-‐Stop Representative Signature)

Justification of Non-Compliance:

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EXHIBIT N INVESTIGATIVE AUTHORIZATION – ENTITY

The undersigned entity, a prospective Contractor to provide Emergency Ambulance

Transport Services for Alameda 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 Alameda County EMS Agency, or its agents. The entity specifically agrees that

the Alameda 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 Alameda 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.

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EXHIBIT O BUDGET COMPLIANCE FORM

***THIS FORM MUST BE COMPLETED FOR THE FIRST THREE YEARS OF OPERATION AND BE INCLUDED IN THE PROPOSAL***

PROPOSED ANNUAL OPERATING BUDGET Pricing Option C

Year: 1 ANNUAL REVENUES

Patient Charges

Private payments $6,186,296 Medi-‐Cal $2,360,530 Medicare $9,688,201

Other third party payments $65,722,026 Subtotal $83,957,053

Other, Specify:

Standby, treat no transport $413,703 n/a $0 n/a $0 n/a $0 Total Revenue $84,370,756

NET INCOME $11,854,172

BASIS FOR PATIENT REVENUE PROJECTIONS:

Source of Payment Annual number of transports %

Average payment/ transport

Annual Revenue

Private 2,344 2.5 $2,639.22 $6,186.296

Medi-‐Cal Only 14,001 15.1 $149.08 $2,087,297

Medicare/Medi-‐Cal 11,016 11.9 $434.52 $4,786,573

Medicare Only 10,480 11.3 $493.77 $5,174,862

Other: Private Ins. 31,457 34.0 $2,089.24 $65,722,026

No Payment 23,140 25.0 $0.00 $0.00

TOTAL 92,438 100% $908.25 $83,957,053

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ANNUAL EXPENSES Personnel

Paramedics

Wages $25,318,244 Benefits $4,505,730 EMT-I’s

Wages $12,297,755 Benefits $2,188,555

Other Personnel

Wages $5,824,765 Benefits $1,036,597

Subtotal $51,171,645 Vehicles

Gasoline, oil, tires $1,186,863 Repair and maintenance $156,638 Depreciation $1,121,211 Subtotal $2,464,712 Medical Equipment/Supplies

Supplies $2,560,292 Equipment lease/depreciation $415,132 Maintenance & Repair $58,141

Subtotal $3,033,565 Other

Rents and leases $753,276 Insurance $2,214,971 Utilities and telephone $690,633

Office supplies & postage $118,384 Professional Services $173,988 Taxes $4,741,669

Other Depreciation $393,371 County Dispatch Fees $1,500,000 Response Time Penalties $978,000 First Responder Fees $4,600,000 Patient Billing Services $2,110,995 Other Allocation for Shared Services $2,834,075 Other Operating and Admin. Expenses $1,264,901

Subtotal $22,374,262

TOTAL EXPENSES $79,044,184

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Patient Charges



Other, Specify:

Stand by, Treat no Transport $426,114 n/a $0 n/a $0 n/a $0 Total Revenue $87,157,962





Annual Revenue

Private 2,367 2.5 $2,691.58 $6,372,123

Medi-‐Cal Only 14,141 15.1 $149.08 $2,108,170


Medicare Only 10,585 11.3 $506.12 $5,357,628

Other: Private Ins 31,772 34.0 $2,138.55 $67,945,879

No Payment 23,371 25.0 $0.00 $0.00

TOTAL 93,363 100% $928.98 $86,731,848

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Paramedics


Wages $13,035,621 Benefits $2,626,923

Other Personnel

Wages $6,059,407 Benefits $1,221,085






Office supplies & postage $120,751 Professional Services $179,207 Taxes $3,950,865 Other Depreciation $382,164

County Dispatch Fees $1,545,000 Response Time Penalties $1,007,340 First Responder Fees $4,738,000 Patient Billing Services $2,174,748 Other Allocation for Shared Services $2,919,664 Other Operating and Admin. Expenses $1,294,746

Subtotal $22,169,152 TOTAL EXPENSES $83,071,530

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Patient Charges



Other, Specify:

Stand by Treatment no Transport $438,897 n/a $0 n/a $0 n/a $0 Total Revenue $90,041,233





Annual Revenue

Private 2,391 2.5 $2,745.26 $6,564,178

Medi-‐Cal Only 14,238 15.1 $149.08 $2,129,252


Medicare Only 10,691 11.3 $518.86 $5,547,013


No Payment 23,605 25.0 $0.00 $0.00

TOTAL 94,296 100% $950.22 $89,602,336

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Paramedics


Wages $13,817,758 Benefits $2,802,135

Other Personnel

Wages $6,304,109 Benefits $1,278,425






Office supplies & postage $123,167 Professional Services $184,584 Taxes (Income) $3,562,457 Other Depreciation $336,862



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PROPOSED ANNUAL OPERATING BUDGET Pricing Option C-1


Patient Charges



Other, Specify:






Annual Revenue

Private 2,344 2.5 $2,414.75 $5,660,130

Medi-‐Cal Only 14,001 15.1 $149.08 $2,087,297


Medicare Only 10,480 11.3 $493.77 $5,174,862


No Payment 23,140 25.0 $0.00 $0.00

TOTAL 92,438 100% $835.51 $77,233,630

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Paramedics


Wages $10,923,865 Benefits $1,978,503

Other Personnel

Wages $5,824,765 Benefits $1,054,967


Gasoline, oil, tires $1,054,762 Repair and maintenance $156,638 Depreciation $900,082 Subtotal $2,111,482 Medical Equipment/Supplies





County Dispatch Fees $1,500,000 Response Time Penalties $978,000 First Responder Fees $4,600,000 Patient Billing Services $2,110,995 Other Allocation for Shared Services $2,824,075 Other Operating and Admin. Expenses $1,210,638


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Patient Charges



Other, Specify:






Annual Revenue

Private 2,367 2.5 $2,461.50 $5,827,410

Medi-‐Cal Only 14,141 15.1 $149.08 $2,108,170


Medicare Only 10,585 11.3 $506.12 $5,357,628


No Payment 23,371 25.0 $0.00 $0.00

TOTAL 93,363 100% $854.43 $79,772,277

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Paramedics


Wages $11,579,297 Benefits $2,343,070

Other Personnel

Wages $6,059,407 Benefits $1,226,121









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Patient Charges



Other, Specify:






Annual Revenue

Private 2,391 2.5 $2,509.42 $6,000,264

Medi-‐Cal Only 14,283 15.1 $149.08 $2,129,264


Medicare Only 10,691 11.3 $518.86 $5,547,013


No Payment 23,605 25.0 $0.00 $0.00

TOTAL 94,296 100% $873.82 $82,398,307

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Paramedics


Wages $12,274,055 Benefits $2,499,741

Other Personnel

Wages $6,304,109 Benefits $1,283,898






Office supplies & postage $123,167 Professional Services $184.584 Taxes $3,266,693 Other Depreciation $321,701



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CREDENTIALS AND QUALIFICATIONS 4. PROPOSER MINIMUM QUALIFICATIONS/SPECIFIC REQUIREMENTS Proposers shall demonstrate the following minimum qualifications and/or requirements:

✔ 4.1 EXPERIENCE

Experience as a sole provider of Advanced Life Support (paramedic) emergency ambulance services for a specified area comparable in size and population to the Exclusive Operating Area defined in this RFP. A population in a service area greater than 500,000 is required as a comparable service area;...

Alameda County AMR conducts business as an autonomous operation that is 100%

devoted to serving the specific needs of Alameda County’s patients, residents, and visitors

in collaboration with its EMS stakeholders and partners. We and our predecessors have

been the primary provider of Advanced Life Support (paramedic) emergency ambulance

services for Alameda County since 1962.

In addition to Alameda

County, American Medical Response

West (AMR West), the legal entity

submitting this proposal, has been

entrusted to provide Advanced Life

Support paramedic level ambulance

service for San Mateo, Santa Clara,

and Contra Costa counties, all of

which have service area populations

over 500,000. In the San Francisco

Bay Area, AMR West also serves San

Francisco, Contra Costa, San Mateo,

Santa Clara, San Joaquin, Stanislaus,

San Benito, Monterey, Santa Cruz,

Marin, Sonoma, Placer, Yolo, and

Sacramento counties. Our coverage of the Bay Area as shown on the map allows us

to provide a level of resources, shared data analysis, and disaster support capacity

unmatched by any other provider.

Current Bay Area Ambulance Fleet by County

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As described in this proposal, Alameda County AMR’s operation is designed to

work with local system stakeholders and partners and serve the specific needs of Alameda

County while leveraging the industry-leading expertise and financial support of one of the

most-trusted health care organizations. Alameda County AMR is an operating division of

AMR West, the legal entity submitting this proposal.

AMR West is a California corporation doing business as

Alameda County AMR. AMR West is a wholly owned

subsidiary of American Medical Response Inc. (AMR),

the nation’s largest provider of emergency, non-

emergency, Advanced Life Support and Basic Life

Support ambulance service. AMR’s ultimate parent

company is the publicly-traded Emergency Medical

Services Corporation (EMSC), a Delaware Corporation

entrusted to provide pre-hospital care to hundreds of

communities across the Country.

AMR’s family of companies serve more communities and customers than any other

private ambulance service provider. Our organization has more than 18,000 EMTs,

paramedics, nurses, physicians serving more than 250 communities nationwide. AMR’s

sister organization EmCare provides hospital-based physician services for Emergency

Departments, Anesthesiology, Radiology, Tele-Radiology in patient services. Founded in

1972, EmCare partners with nearly 500 hospitals in 40 states and its more than 4,500

physicians, nurse practitioners, and physician’s assistants treat nine million patients a year.

✔ 4.2 DEMONSTRATED ABILITY TO MEET RESPONSE TIME STANDARDS

✔ 4.2.1 Provide a letter from at least one jurisdiction with a population of 500,000 or more verifying that Proposer is meeting or exceeding contracted response time criteria.

A letter from Brian Zamora, Director of the San Mateo County Health System,

verifying that we are meeting or exceeding contracted response time criteria can be found

on the page following this subsection 4.2.1. If you have any additional questions about our

ability to meet response time standards, please contact any of our customers. For your

convenience, contact information is provided below. Population data is based on 2007 U.S.

Census Bureau Population Estimates July 1, 2007.

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AMR WEST REFERENCES

ALAMEDA COUNTY Dale Fanning, Acting EMS Director, Alameda County EMS Agency

1000 San Leandro Blvd, Suite 200, San Leandro, CA 94577 510-618-2024

TYPE AND LEVEL OF SERVICE PROVIDED: ALS, BLS, CCT, Bariatric, Neonatal, and Pediatric

POPULATION: 1,500,324

CITY AND COUNTY OF SAN FRANCISCO Rob Dudgeon, EMS Administrator, San Francisco EMS Agency

30 Van Ness Ave. #3300, San Francisco, CA 94102 415-487-5000

TYPE AND LEVEL OF SERVICE PROVIDED: ALS and BLS POPULATION: 795,135

CONTRA COSTA COUNTY Art Lathrop, EMS Director, Contra Costa County EMS

1340 Arnold Drive, Suite 126, Martinez, CA 94553 925-646-4690

TYPE AND LEVEL OF SERVICE PROVIDED: ALS and BLS POPULATION: 1,024,242

MARIN COUNTY Miles Julihn, EMS Administrator, Marin County EMS 899 Northgate Drive, Suite 104, San Rafael, CA 94903

415-499-7455 TYPE AND LEVEL OF SERVICE PROVIDED: ALS and BLS

POPULATION: 252,346

MONTEREY COUNTY Tom Lynch, EMS Director, Monterey County EMS Agency

19065 Portola Drive, Suite 1 Salinas, CA 93908 TYPE AND LEVEL OF SERVICE PROVIDED: ALS and BLS

POPULATION: 422,506

PLACER COUNTY Vickie Pinette, Regional Executive Director, Sierra-Sacramento Valley EMS

5995 Pacific Street, Rocklin, CA 95677 916-625-1703


SAN BENITO COUNTY Marcie Morrow, EMS Director, San Benito County EMS

1111 San Felipe Road, Ste.102, Hollister, CA 95203 831-636-4066

TYPE AND LEVEL OF SERVICE PROVIDED: ALS and BLS

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AMR WEST REFERENCES

POPULATION: 57,534

SAN JOAQUIN COUNTY Dan Burch, EMS Coordinator, San Joaquin County EMS

P.O. Box 220, French Camp, CA 95231 209-468-6818


SAN MATEO COUNTY Sam Barnett, EMS Administrator, San Mateo County EMS Agency

225 37th Avenue, San Mateo, CA 94403 650-573-2564


SANTA BARBARA COUNTY Nancy Lapolla, EMS Director, Santa Barbara County EMS

300 North San Antonio Road, Santa Barbara, CA 93110 805-681-5264


SANTA CLARA COUNTY Josh Davies, Interim EMS Division Manager, Santa Clara County EMS Agency

976 Lenzen Avenue, Suite 1200, San Jose, CA 95126 408-885-4250

TYPE AND LEVEL OF SERVICE PROVIDED: ALS and BLS POPULATION: 1,761,082

SANTA CRUZ COUNTY Celia Barry, EMS Program Manager, Santa Cruz County EMS

1080 Emeline Avenue, Santa Cruz, CA 95060 831-454-4751


SHASTA COUNTY Dan Spiess, Chief Executive Officer, Nor-Cal EMS Agency

43 Hilltop Drive Redding, CA 96003 530-229-3979


SONOMA COUNTY Bryan Cleaver, Regional EMS Administrator, Coastal Valleys Regional EMS

Agency 475 Aviation Blvd. Ste. 200, Santa Rosa, CA 95403

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AMR WEST REFERENCES

707-565-6501 TYPE AND LEVEL OF SERVICE PROVIDED: ALS, BLS, and CCT

POPULATION: 478,374

STANISLAUS COUNTY Steve Andriese, Executive Director, Mountain Valley EMS Agency

1101 Standiford Avenue, Suite D-1, Modesto, CA 95350 209-529-5085


TULARE COUNTY Dan Lynch, EMS Director, Central California EMS Agency

1221 Fulton Mall, Fresno, CA 93775 559-445-3387


VENTURA COUNTY Steve Carroll, EMS Administrator, Ventura County EMS Agency

2220 E. Gonzales Road, Suite 130, Oxnard, CA 93036-0619 805-981-5308


YOLO COUNTY Vickie Pinette, Regional Executive Director, Sierra-Sacramento Valley EMS

5995 Pacific Street Rocklin, CA 95677 916-625-1703


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✔ 4.2.2 Provide a statement that the Proposer has not lost a contract due in part to response time compliance. [Per Addendum I, Part II, #3] The Proposer must disclose and describe in detail any contracts lost because of failure to meet response times by any company under the parent company, and describe what steps have been taken to ensure that the situation will not reoccur. This requirement applies to any and all contracts for 911 ambulance services whether or not the contract was with an agency of the government or private entity. The fact that the Proposer has lost a contract due to failure to meet response times, will not necessarily disqualify the Proposer if adequate measures have been taken to ensure corrective actions have taken place.

Nationwide, companies in the AMR family hold approximately 170 emergency

medical services contracts and the vast majority of these contracts are retained year-in and

year-out. AMR has never failed, financially defaulted on, or refused to complete a contract

for emergency medical services in any region of the Country in our entire history of

operations, and has had only one emergency medical services contract terminated. That

contract was terminated in 2007 by the Richmond Ambulance Authority (RAA) partly due

to response times.

The RAA contract in Richmond, Virginia was with Tidewater Ambulance Service,

Inc. (Tidewater). Tidewater was an operating subsidiary of American Medical Response,

Inc. and a sister company to the bidding entity for this RFP – American Medical Response

West. Although American Medical Response West and Tidewater shared a common

parent company, both entities maintained a different location with separate and different

leadership, management, and systems. Tidewater operated only in the Richmond Virginia

area and American Medical Response West operates only in California. American Medical

Response West was not involved in the RAA contract at anytime. It is also important to

note that the RAA contract was for a public utility model system which is very different

than the system that the County has requested in this RFP.

Regarding the RAA contract, RAA elected to in-source the ambulance service

citing Tidewater’s inability to meet various response time requirements. These response

time issues were directly related to a severe shortage of EMTs and Paramedics in

Richmond. The turnover rate of Tidewater’s employees was largely due to the hiring

practices of the Richmond fire department, and the state of the local Richmond economy.

Tidewater took numerous steps to correct these staffing issues. Despite Tidewater’s

comprehensive efforts, RAA decided to assume operational control of the system.

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Tidewater cooperated with RAA and an orderly transition of services occurred on a

scheduled date. After the transition, RAA made changes to the system that provided the

necessary relief.

AMR’s family of companies learned valuable lessons from the RAA contract and

gained a greater appreciation of the complexities and variables involved in a public utility

model system. We learned that public utility model system design must focus on attainable

goals that realistically can be funded through the system. We also learned to better

anticipate factors outside of our control, e.g., employee pool, economic health of the

community, and consider steps to mitigate those factors earlier.

If there is a key to avoiding this type of situation, it is open and direct

communication between the parties and establishing realistic goals and expectations at the

beginning of the relationship. In Alameda County, we have taken steps to ensure that a

situation like the RAA contract will not occur. These steps include daily performance

meetings with the quality/leadership team, enhanced predictive technology including

Optima Live, doubling the number of dispatchers in our dispatch pod from 2 to 4, critically

evaluating the employee pool, as well as employee wages and benefits.

✔ 4.3 FINANCIAL STABILITY

✔ 4.3.1 Financial Statements - Proposers shall document the organization’s current estimated net worth and the form of the net worth (liquid and non-liquid assets). The Proposer shall provide evidence that clearly documents the financial history of the organization and demonstrates that it has the financial capability to handle the expansion (including implementation and start-up costs) necessitated by the award of the Agreement. The Proposer shall include copies of externally audited financial statements for the most recent three-year period. If consolidated financial statements are utilized, the individual program unit’s financial statements must be separately shown. If the Proposer is part of a larger system, furnish the financial statements of the parent entity. Such a parent entity shall be required to guarantee the performance of the proposer. [Per Addendum 1, Part II, #4:] One printed copy and ten electronic copies will be acceptable for the financial statement only.

Pursuant to our ultimate parent company EMSC’s most recent public filing, Form

10-Q for September 2009, our organization’s net worth is $641.4 million with available

working capital of $571.1 million of which $331.1 million is in the form of cash and cash

equivalents. The chart below summarizes the requested financial performance data of

EMSC, the 100% owner and ultimate parent of Alameda County AMR, and shows the

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ability to convert short-term assets into cash if needed to meet our commitments and ensure

our stability in our role as a provider of high-quality emergency medical services in

Alameda County.

FINANCIAL METRIC

DECEMBER 31, 2006

DECEMBER 31, 2007

DECEMBER 31, 2008

SEPTEMBER 30, 2009

UNAUDITED

CURRENT RATIO: 1.77 2.19 2.55 2.71 CURRENT ASSETS 532,489,000 670,760,000 815,174,000 905,295,000 TOTAL ASSETS 1,318,217,000 1,479,563,000 1,541,219,000 1,600,011,000 CURRENT LIABILITIES 300,962,000 306,891,000 320,141,000 334,172,000

TOTAL LIABILITIES 932,177,000 1,030,067,000 1,002,180,000 958,609,000

CURRENT NET WORTH 386,040,000 449,496,000 539,039,000 641,402,000

WORKING CAPITAL 231,527,000 363,869,000 495,033,000 571,123,000

CASH 39,336,000 28,914,000 146,173,000 331,105,000

As guarantor for the performance for this contract, EMSC holds the financial

reserves to sustain operations and meet its commitments during any periods of unforeseen

and unfavorable operating results. Additionally, our proposed performance bond of

$6,000,000 shows our confidence in our ability to perform and is proposed to provide the

County additional peace of mind. As documented in the accompanying audited financial

statements, EMSC has substantial net worth of $539 million as of December 31, 2008,

$449 million as of December 31, 2007, and $386 million as of December 31, 2006.

Our financial strength has resulted in an industry reputation unmatched by any of

our competitors. As an example, during a recent competitive procurement process in San

Mateo County, the County Controller conducted a financial analysis of each proposer and

concluded that “AMR would be more financially viable” than our competitors. This

analysis was key to the decision of the County Health Director to recommend AMR based

on her review that “not only does AMR have a better fiscal capability to provide the

services; it has a proven track record of actually providing such services.”

In addition to our financial strength, our financial acumen and experience

particularly in Northern California allows us to plan for the complexities of serving high

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performance systems with the variety of changing payer mixes in areas where there is no

tax subsidy. For example, during the Summer of 2005, Monterey County selected

Westmed to provide 9-1-1 emergency medical ambulance services for the County.

Westmed was selected over AMR because they promised to provide faster service for a

lower price than, the 20-year incumbent provider. Within a year, Westmed was more than

$2,000,000 in debt, unable to make payroll, and unable to meet the response time

requirement of their performance-based contract with the County. The Board of

Supervisors provided a $991,356 subsidy in March of 2007 to enable the Company to make

payroll. In September of 2008, Monterey County requested AMR assist with its

emergency takeover of the County’s 9-1-1 service on the terms in AMR’s original losing

proposal. Today Monterey County continues to be served by AMR under a 5-year

contract.

Additional evidence of our financial history and strength is provided in the three

years of externally-audited, publicly-filed financial statements, electronic copies of which

can be found on CD and printed in the binder marked Audited Financial Statements.

✔ 4.3.2 Working Capital - Proposers shall document the estimated amount of working capital that will be committed to the startup of the Agreement if awarded. Document the method of financing, attach any endorsement documents necessary, of all startup and operational costs including, but not limited to, the initial ambulance fleet and equipment required to begin operations if the Agreement is awarded. Document the amount of funding that will be dedicated to “Reserve for Contingencies”, for the startup of this Agreement, if awarded.

We will commit an estimated $12,214,323 to the startup of the Agreement to

finance our new Sprinter fleet, medical equipment, and other capital expenses.

Additionally, our ultimate parent company EMSC guarantees our performance. As shown

in the chart above, this provides Alameda County with a reserve of $571,123,000 in

working capital and $331,105,000 in cash on hand, which exceeds the amount required for

start-up. As the incumbent provider we are not burdened and the County is not at risk of

the provider not being able to cover the estimated more than $50,000,000 in working and

durable capital required to sustain operations during the first 12 months of service.

Financing for this commitment will come from our cash reserves. In addition, our

credit facility with Bank of America provides an additional measure of protection. AMR

can also draw upon a $100 million revolving credit line through EMSC.

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✔ 4.3.3 In-Kind Support - Proposer shall disclose any and all financial and in-kind support or funding from existing sources that will support the provision of ambulance services within Alameda County. This includes, but is not limited to disclosing the full cost allocation for services including, but not limited to, risk management, insurance, purchasing, maintenance, legal and human resource, or other functions if those functions are not solely dedicated to ambulance services in Alameda County and fully funded within the price proposed.

In order to reduce operational costs and ensure quality standards across many

communities, AMR is structured to provide expertise unmatched in our industry at the

regional and national level for functional areas best served by this approach. Shared

resources include regional support in areas such as finance, human resources, risk

management, data analysis, and payroll services as well as additional national support in

areas such as legal, insurance management, purchasing, finance, marketing, and human

resources.

Healthcare reimbursement is complicated and requires unique expertise. The rules

promulgated by federal and State government payers as well as third party insurance

companies require extensive knowledge to ensure full compliance with all applicable laws

and regulations. This regulatory dynamic coupled with the need to keep ambulance rates

as low as possible by maximizing reimbursement has led AMR to create a national Patient

Billing Service (PBS) Center in Northern California. Costs for comprehensive and

compliant billing services are spread among AMR operations based on annual transport

volume. On the next page is an organizational chart of support services offered for

Alameda County AMR.

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Costs for shared services are allocated to each operation are based on Generally

Accepted Accounting Principles (GAAP). A detail of the costs assigned to Alameda AMR

is provided below.

SHARED SERVICES ALLOCATION

COST PER TRANSPORT

ALLOCATION PERCENTAGE OF REVENUE

Regional support: Patient Billing Services, Finance, Human Resources, Risk Management,

Data Analysis, and Payroll Services $34.18 1% of gross

4% of net

National support: Legal, Insurance Management, Purchasing, Finance, Marketing,

and Human Resources $19.32 0.5% of gross

2% of net

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✔ 4.4 OUTSTANDING/PENDING LITIGATION

✔ Provide a statement that the Proposer’s parent company and all of its ambulance services or operations either has no pending litigation, or describe legal actions pending and the status as of the date of proposal submission. Contractor shall agree to notify County within twenty-four (24) hours of any litigation or significant potential for litigation of which Contractor is aware. [Per Addendum I, Part II, #5:] The County is seeking information related to any pending litigation. The County is requesting a brief statement of the jurisdiction, litigants, and issues. Supplemental information may be requested at a later date. Electronic submission of this information is acceptable. [Per Addendum I, Part II, # 6:] The County is requiring notification of any litigation that will materially affect services in Alameda County, and/or any litigation that may affect the financial stability of the parent company.

Over the years and in the ordinary course of business, the AMR family of

companies has been involved in litigation and has had claims made against us, principally

relating to professional liability, auto accident and workers compensation claims. An

abstract of all outstanding or pending litigation related to the ambulance services or

operations under the AMR family of companies can be found in the accompanying

Credentials and Qualifications CD. As of the date of proposal submission, there is no

outstanding or pending litigation that would affect our ability to fully perform all

requirements of the RFP or the enhancements detailed throughout this proposal. If the

County wishes to discuss any of these litigation and claims matters more specifically, we

are willing to provide updated or additional information, or meet with the County to

provide further assurances or specific details.

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, the AMR family of companies 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. As such, we are confident that

Alameda County and American Medical Response West will not be materially affected by

any litigation loss sustained by any another AMR subsidiary.

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We further agree to notify the County within 24 hours of any litigation that will

materially affect services in Alameda County, and/or any litigation that may materially

affect the financial stability of American Medical Response West’s parent companies.

✔ 4.5 CURRENT CONTRACTS IN GOOD STANDING

✔ Provide a statement that all existing contracts with any governmental jurisdiction are in good standing with no delinquent obligations, financial or otherwise. Failure to provide accurate information may lead to disqualification.

All existing contracts with any governmental jurisdiction are in good standing with

no delinquent obligations, financial or otherwise.

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CLINICAL QUALITY IMPROVEMENT EXHIBIT A — SCOPE OF WORK — SECTION D ✔ The County requires that the Contractor develops and implements a comprehensive quality management program, and recommends that it be modeled after the Baldrige criteria using statistical process control. This program should incorporate compliance assurance, process measurement and control, and process improvement that is integrated with the entire EMS system, including first responder agencies, medical communication center operations, and EMS. The clinical indicators measured by all system participants will be developed through collaborative efforts of the first responder agencies, the Contractor, and the County and will be based on current EMS research and call demand. The County ultimately will approve and implement the quality monitoring and improvement plan to be used in the County by all providers.

Our current quality management program fulfills all of the above parameters and

will continue to do so. Patient-centered quality improvement is at the heart of every plan

we develop and every action we take at Alameda County AMR. The Baldrige model is

perfect for EMS organizations and we’ve embraced it fully by adding a national level

Baldrige examiner and world-class healthcare statistician to our quality/leadership team.

The next graphic shows our collaborative approach to quality management.

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We are committed to continuing to work with the Alameda County Health Care

Services Agency, the Alameda County EMS Agency, County Communications Centers,

our Fire First Responder partners, local hospitals, and other system participants to develop

clinical indicators that can be measured by all system participants. These measurements

will be reviewed and discussed during regular meetings described below in this

introduction under the heading "Quality Structures."

Historically EMS quality means reviewing patient care reports, improving

individual performance, or gathering data without clear purpose. For us, quality processes

and practices are the essential core of how we run our organization day-to-day.

W. Edwards Deming, one of the founding thought leaders for Quality Management

in the U.S. and around the world once said, “The emphasis should be on why we do a job.”

The why behind our quality improvement thinking and actions is captured in our

organization’s purpose and vision:

Purpose: To Reduce Suffering and Improve Health

Vision: To Measurably Improve the Health of our Community

Our team members crafted our purpose and vision based on their commitment to

the people in our Alameda County community. They reflect our commitment to a

Community Health Partnership model of EMS that fulfills all traditional EMS functions

and goes beyond to be the best possible partner for Alameda County’s clinically-advanced,

progressive EMS Agency.

Values: STAR CARE

Each member of our team has been trained on our purpose, vision, and the

following STAR CARE values that key members of our quality/leadership team created 20

years ago. These values have been adopted by our employees to run our organization:

SAFE: Were my actions safe -- for my patient, for me, for my colleagues, for other

professionals, and for the public?

TEAM-BASED: Were my actions taken with due regard for the opinions and

feelings of my co-workers, including those from other agencies?

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ATTENTIVE TO HUMAN NEEDS: Did I treat my patient as a person? Did I keep

him/her warm? Was I gentle? Did I use his/her name throughout the call? Did I tell him/her

what to expect in advance? Did I treat his/her family and/or relatives with similar respect?

RESPECTFUL: Did I act toward my patient, my colleagues, my First Responders,

the hospital staff, and the public with the kind of respect that I would have wanted to

receive myself?

CUSTOMER-ACCOUNTABLE: If I were face-to-face right now with the customers I

dealt with, could I look them in the eye and say, “I did my very best for you.”

APPROPRIATE: Was my care appropriate -- medically, professionally, legally and

practically considering the circumstances I faced?

REASONABLE: Did my actions make sense? Would a reasonable colleague of my

experience have acted similarly, under the same circumstances?

ETHICAL: Were my actions fair and honest in every way? Are my answers to

these questions honest?

Our goal is to continue to push ourselves and our industry to the next level by

collaboratively designing and implementing innovations to better serve patients and the

community. All the structures, measurements, and activities we engage in related to the

leadership and management of our organization are aligned with our purpose, vision, and

values.

Everything we do must be designed to reduce suffering and improve health for our

patients and our community. All our decisions are taken with an eye toward safety,

teamwork, human needs, respect, customer focus, appropriate protocols/policies,

reasonableness, and ethics. These attributes are strongly rooted in effective

communication. We define effective communication as dialogue and actions that are

collaborative, empowering, honest, open and delivered with mutual respect. This alignment

makes our potentially complex world of quality management clear, concise, and

straightforward.

Scope of Quality Improvement

Our quality improvement activities encompass clinical quality improvement as well

as every other aspect of our organization that plays a role in our ability to serve patients

and the community better on an ongoing basis. To that end, we commit to measure and

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monitor a variety of key performance indicators (KPI) within the following key

performance areas (KRA): Clinical, Response Time Performance, Customer Satisfaction,

Human Resources/Employee Satisfaction, Community Health, Fleet, Safety, Unusual

Occurrences and Complaints, and Financial Sustainability. Specific KPIs are listed in

section D.2.5.1. As the system evolves we envision different KPIs will be added or

modified over time in conversation with the Alameda County Health Care Services

Agency, the Alameda County EMS Agency, Alameda County Medical Director, our

organization, and partners taking into account system priorities and needs.

While we are adding a Quality Manager to our quality/leadership team as part of

this proposal, our quality management function will not be turned over to an individual.

The principles and practices of quality management are hardwired into our organizational

DNA. Fulfilling our quality management system is and continues to be the responsibility

of all the members of our team. Quality leadership is and will continue to be the

responsibility of our entire leadership team, therefore we call it a quality/leadership team.

Influences for our High Performance EMS Quality Improvement Model

Our approach to quality management has been informed by and influenced by

hundreds of thought leaders, authors, books, workshops, and approaches. We’ve

synthesized this complex material and created a system that’s manageable and sustainable.

Here are some of our strongest influences:

ALAMEDA COUNTY VALUES: Alameda County’s values influence our thinking and

we are committed to abiding by and living up to these values which are aligned with the

values of our organization. These values include: integrity, honesty and respect fostering

mutual trust; transparency and accountability achieved through open communications and

involvement of diverse community voices; excellence in performance based on strong

leadership, teamwork, and a willingness to take risks; diversity recognizing the unique

qualities of every individual and perspective; Environmental stewardship to preserve,

protect and restore our natural resources; social responsibility promoting self-sufficiency,

economic independence and an interdependent system of care and support; and compassion

ensuring all people are treated with respect, dignity and fairness.

W. EDWARDS DEMING: An American statistician, professor, and author. Deming’s

approach to quality, management, and leadership are as applicable today as when they were

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created almost 60 years ago. The most progressive leaders in healthcare quality today

point to Dr. Deming as their primary source of information and inspiration.

MALCOLM BALDRIGE NATIONAL QUALITY AWARD: This award promotes

awareness of performance excellence and information sharing of successful performance

improvement strategies and the benefits achieved from using these strategies. This seven-

section framework with a strong focus on results aligns perfectly with our philosophy about

quality management. Its non-prescriptive approach allows us to create innovative

approaches to leadership and performance improvement. As an enhancement we commit

to applying for both the California Award for Performance Excellence (CAPE), the State

award based on Baldrige Criteria, and the Malcolm Baldrige National Quality Award by

the fourth year of the new contract. Two of our Quality Steering Committee members are

past examiners for Baldrige Criteria-based state awards, and our expert consultant Diane

Akers has trained examiners for the Malcolm Baldrige National Quality Award which will

help us prepare solid award applications.

“More than any other program, the Baldrige Quality Award is responsible for making quality a national priority and disseminating best practices across the United States.”

- Building on Baldrige: American Quality for the 21st Century

SIX SIGMA: This approach to management created by Motorola in 1986 is really a

compilation of quality management tools and practices designed to improve processes and

eliminate deficits. Our approach to designing and management improvement projects

draws heavily from Six Sigma. Our Quality Steering Committee includes a Lean Six

Sigma Black Belt.

THE INSTITUTE FOR HEALTHCARE IMPROVEMENT (IHI): This Cambridge,

Massachusetts based organization is leading the improvement of health care throughout the

world. They aim to improve the lives of patients, the health of communities, and the joy of

the healthcare workforce. Their focus on the Institute of Medicine’s goals of Safety,

Effectiveness, Patient-Centeredness, Timeliness, Efficiency, and Equality align perfectly

with our purpose and vision. The IHI’s Model for Improvement described in this section

launches every improvement project we charter. Our Quality Steering Committee includes

two long-standing, active IHI participants, one of whom for decades has been a regular

featured speaker inspiring statistically-valid quality improvement actions.

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As an enhancement, we will send two of our team members to IHI’s Annual Forum

and our General Manager will complete the IHI’s comprehensive 9-month Improvement

Advisor Course within the first year of contract award. This intensive program covers the

newest and most advanced healthcare improvement strategies used by the best healthcare

organizations in America. A full description of this advanced program can be found in

Attachment 5.

We are also supported in our quality approach by the National EMS Performance

and Quality Improvement Workshop, the University of Maryland Baltimore County

Masters Degree in Emergency Health Services Management Quality Management Course,

and the American Ambulance Association’s Ambulance Service Manager (ASM)

certificate program.

Quality Structures

Our quality leadership structures include mechanisms for collaboration with system

partners, oversight, community input, a statistically-valid approach to analysis, and

effective strategies for improvement. Patients and the community are at the center of our

system. They are the reason for our existence and the focus of our service. As the graphic

at the beginning of this section shows, the following structures provide leadership,

collaboration, strategy, and oversight for our quality management system:

ALAMEDA COUNTY AMR QUALITY STEERING COMMITTEE This monthly strategy and oversight group is the internal structure that drives our

quality management program. It is aligned with and inspired by the progressive, clinically-

advanced, leadership of the Alameda County Health Care Services Agency, Alameda

County EMS Agency, and County Medical Director. We consider our regulators as

partners whose expectations our systems are designed to meet and exceed. The Acting

Director of the EMS Agency, the County Medical Director, and other members of the EMS

Agency staff are invited to join these meetings.

This group meets the first Thursday of every month and is focused on

comprehensive data analysis from all KPIs and leadership for improvement projects. This

meeting is made up of Alameda County AMR senior leaders including:

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• Mike Taigman, General Manager (chairperson)

• Gene Hern, M.D., Medical Director

• Diane Akers, National Baldrige Quality Award Consultant


• Lauri McFadden, Operations Manager

• Elsie Kusel, Clinical and Education Services leader

• Lee Siegel, Clinical and Education Services leader

• Shahloh Jones, Data and

Performance Analyst

• Bert Burk, Operational

Field Supervisor and

deployment strategist

We will also include Luis

Diaz, RN, proposed Quality

Manager, in this group for the new

contract. Additional

quality/leadership team members and field employees join these meetings from time to

time for professional development and specific input on improvement projects. Monthly

meetings follow a standard agenda:

• Key performance indicator report review, analysis, and action

• Performance improvement project list review, reports, and updates

• Chartering of additional improvement projects

• Additional topics

In between these monthly meetings we have weekly update meetings with the

Alameda County EMS Agency Acting Director and Medical Director to provide updates on

all our activities and review progress on improvement projects. These meetings

supplement electronic and paper reporting as a mechanism to have ongoing input and

oversight to our operations as well as maintain open and collaborative working

relationships.

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THE ALAMEDA COUNTY EMS ADVISORY COMMITTEE The EMS Advisory Committee was created last year by the Alameda County

Health Care Services Agency and the Alameda County EMS Agency. The purpose of this

committee is to provide a forum for senior leaders of the organizations that collaborate to

provide EMS services in our community to analyze performance reports and provide input

to County leadership. This group is scheduled to meet quarterly and the membership

includes the Health Care Services Agency, the EMS Agency, the County Medical Director,

Fire Chiefs, Alameda County AMR’s General Manager, a trauma surgeon, a hospital CEO,

and representatives from the Medical Association, the City Manager’s Association, the

County Board of Supervisors and a consumer representative.

THE ALAMEDA COUNTY EMS AGENCY QUALITY COUNCIL This council is made up of quality

coordinators representing all EMS system provider

agencies including the base hospital, Fire First

Responder agencies, dispatch, and AMR. This

council is scheduled to meet monthly and is

responsible for assessing and making

recommendations to improve the policies and

procedures that contribute to the overall performance

of the system.

ETHNIC HEALTH INSTITUTE / COMMUNITY HEALTH ADVISORY BOARD

We developed our Community Health

Advisory Board in partnership with the Ethnic Health

Institute (EHI), a physician-led, Oakland-based

community health organization with an active

network of 250+ health partners that includes public,

private, academic, religious, and community-based

organizations and institutions, as well as individual

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health practitioners. EHI participants include the Alameda County Health Care Services

Agency, Alameda County Medical Director, most hospitals in our County, Stanford and

UCSF medical schools (two of the top medical schools in the Country), and UC Berkeley

School of Public Health.

In conjunction with the EHI’s quarterly Board Meeting, our General Manager and

members of our quality/leadership team will report on and be held accountable for progress

on our community health improvement projects, as well as have the opportunity to receive

guidance and coaching on ways to decrease disparities in healthcare from leading thinkers

in this area.

“It’s amazing what can be accomplished when you bring the right people to the table and you don’t care who gets the credit.”

- Dr. Frank Staggers, M.D., Chairman of the Ethnic Health Institute and California Medical Association Lifetime Achievement Award Recipient, 2009

Two additional tactical groups are responsible for taking action, executing

improvement projects, and gathering learning for future improvements.

ALAMEDA COUNTY TACTICAL GROUP This tactical group is made up of on-site leaders in our organization including

supervisors. This group meets weekly to focus on the execution of improvement projects

that are within Alameda County AMR’s domain. It is also the group that handles the

investigation of unusual occurrences and oversees the day-to-day gathering of data for

analysis. This tactical group conducts a brief daily meeting at 3 PM every day to assess

daily and month-to-date performance on critical areas like response time performance.

IMPROVEMENT PROJECT TEAMS Improvement Project teams are ad hoc groups that are brought together to

implement improvements. They may involve members from multiple agencies and

organizations, particularly in the case of system-wide improvement projects.

Inputs: What Informs Our Thinking, Strategy and Actions

There are several sources of data, information, and perspectives used by our quality

management system including key performance indicator results, customer feedback,

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clinical literature, strategic objectives from our annual community strategic planning

process, perspectives from community and system partners, and more. Our data collection

processes are facilitated by a number of advanced technologies including FirstWatch,

Computer Aided Dispatch (CAD), Multi-CAD Information System (MCIS), Multi-EMS

Data System (MEDS), Ninth Brain Suite, Business Objects, Optima Live, Optima Predict,

and Survey Monkey. Used together, these systems fully support our team’s performance

improvement as well as reporting and day-to-day management objectives. Our chronic

disease management and referral capabilities will also be enhanced by new technologies

from Microsoft Health Vault and Palantir by or before the new contract. We describe these

technologies in section D.2.5.6.

Outputs: The Results We Seek to Achieve

The results our system is designed to achieve focus on our patients and the

community. For patients we are committed to producing extraordinary clinical care that

provides them the optimal chance for survival along with decreased suffering from pain,

difficulty breathing, nausea, and fear. We are committed to producing these results with a

level of customer service that leaves patients feeling they were treated with kindness,

compassion, dignity, and respect in alignment with our STAR CARE values. These values

require our team’s actions be Safe, Team-based, Attentive to human needs, Respectful,

Customer-Accountable, and Appropriate.

Additionally our commitment is to measurably improve the health status of our

community. It’s not possible for an EMS system to execute this strategy in isolation, so

our approach is to become the best possible community partner for organizations like the

Alameda County Health Care Services Agency and the Ethnic Health Institute.

Measurable health improvement is challenging to produce; yet we are committed to

collaborating with other community health organizations to produce measurable outcomes

as we detail in this and the Commitment to EMS System and Community section.

Most EMS organizations limit their clinical objectives to the preservation of life.

Without question, our highest priority is to deliver life-saving care to the people whose life

hangs in the balance. But, we believe that we can and should do more. When we say “our

purpose is to reduce suffering”, we are referring to the suffering of our patients as well as

our community, our partners, employees, and organization.

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RELIEF OF SUFFERING NATURE OF SUFFERING ACTIONS TO RELIEVE SUFFERING

For our patients and community, we seek to reduce their suffering from pain, difficulty breathing, trauma, death, fear, poverty, and economic, cultural, linguistic, and other barriers to accessing and receiving the care they need. For patients’ loved ones, we seek to reduce the suffering or fearing for another.

We provide the best possible treatments to help them survive their illness or injury and ease their pain. The care is provided with compassion to reduce their fear, and with enlightened service to connect them with resources, information, and education to prevent further medical problems or better manage chronic diseases.

For our partners in hospitals, Fire Departments, law enforcement agencies, and other community health care groups aligned with our purpose, vision, and values, we work with them to reduce suffering from the current economic crisis, and from the confusion and polarization that can come from an insufficient connection with their EMS partner.

We partner with and support organizations that are already working at a grass roots level in the community to address problems. We are committed to being the best possible partner Alameda County’s EMS system participants could have including community organizations, the EMS Agency, Fire First Response agencies, law enforcement agencies, and hospitals.

For our organization and our employees, we seek to reduce suffering from fatigue, stress, work-related injury or illness, barriers to bringing one’s “whole self” to the workplace, and barriers to doing the best we can for our patients and communities.

We adhere to our purpose, vision, and values internally as well as externally. We provide them in a work environment that allows and encourages employees to do their very best. Our Community Health Partnership model for EMS encourages employees to follow their unique passion for service whether it is planting trees, teaching someone how to prevent asthma attacks, or helping a young person choose healthcare as a career. We compensate our employees for all their work described in this proposal.

One of the social determinants of a community's health is employment. We are

committed to providing good jobs for the people of our community, meaning jobs that are

well-paying, fully-benefitted, and meet the principles of “good work” we describe in the

Commitment to Employees section: Ethics, Engagement, Excellence, and Empathy. The

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Alameda County AMR

family includes many

employees who were born

and raised in Alameda

County. One of the results

we are committed to

producing is a thriving

workforce that finds joy in

the service they provide to our community. We also partner with local community

organizations focused on youth development like Youth Uprising, the Bay EMT Program

pictured here, and Satori’s Circle to make our organization an accessible and welcoming

career path for people in our community.

“This program was created to help our community’s young people meet the challenges of starting a career in EMS. Alameda County AMR has been a strong supporter and partner

in helping us educate, inform, and inspire our students to pursue this path.

- Wellington Jackson, Bay EMT Program Founder and Alameda County Fire Department Firefighter/Paramedic

It’s not possible to produce good results for patients and the community while

providing good jobs for employees without sound financial and resource management. Our

commitment is to produce these essential results for the people we serve, our partners, and

our team members in a way that’s sustainable long into the future.

Our ultimate results are encapsulated in our purpose and vision. Our quality and

strategic planning processes translate this purpose and vision into measurements,

monitoring, and improvement actions. Every KPI we track has an implied desired result of

ongoing performance improvement or maintaining current excellence.

Measuring, Monitoring, and Improving System Performance

One of the core elements of our quality management system is monitoring the

performance of processes. To organize the things we need to monitor, we recognize key

results areas that represent the macro core components of our system that must work

together to produce our intended results. Within each KRA, specific key performance

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indicators (KPI) are designed to enable statistically-valid analysis and evidence-based

decision making.

Charter Improvement Projects

Based on our KPI reports and other inputs, we identify improvement opportunities

and charter improvement projects using a modified Six Sigma template like the one in the

next chart, which incorporates the Institute for Healthcare Improvement (IHI) model for

improvement at its core. Improvement Projects are the actions designed to change the

results of a process to better reduce suffering and improve health.

IMPROVEMENT PROJECT CHARTER TEMPLATE Project Name:

Tie into the big picture of purpose, vision, and values:

Project description and AIM Statement:

Metrics:

Clinical/Business Case, why this matters:

Team Leader/Members:

Project Scope, What’s in/What’s not:

Resources:

Schedule:

Conduct Plan-Do-Study-Act (PDSA) Cycles

This model for improvement involves a three-part aim

statement followed by one or more Plan-Do-Study-Act (PDSA)

cycles.

The three-part aim statement answers the questions:

1. What are we trying to accomplish?

2. How will we know the change will be an improvement?

3. What action are we going to take to make the improvement?

As part of the PDSA cycle, performance improvement project

teams may use many of the traditional performance improvement

tools such as process mapping, value stream mapping, matrix

analysis, Pareto analysis, direct observation, statistical process control

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charts (SPC), capability analysis, force field analysis, and others.

Statistically-Valid, Easy to Read Progress Tracking

We generally track quantitative KPIs using statistical process control (SPC) charts

like the one in the next example:

Sample Statistical Process Control (SPC) Chart

We monitor qualitative indicators using qualitative coding and description. For

example, to qualitatively code our employee satisfaction survey comments section we read

all the comments, find common themes, create a coding system for the common themes

and then count the coded items by topic to determine what is most important. Regular KPI

performance analysis highlights where performance is strong and where opportunity for

improvement exists. We focus on system-wide performance analysis and improvements to

facilitate greater and more sustainable improvement. We use other tools like Pareto

analysis as displayed on the next chart as needed to identify the areas where improvement

activities can have the most positive impact on results.

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Sample Pareto Analysis Chart

When possible, before making a full-scale fundamental change in a process we will

use a series of small Plan-Do-Study-Act cycles and small experiments to refine our

understanding of the process and the results it produces. Different projects require

different levels of project design and involvement.

For improvement projects that can be designed and implemented by our

organization alone without significant difficulty, a company project charter is completed to

initiate improvement activities. For more complicated system-wide improvement projects,

a system-wide project charter is completed. Once an improvement project is chartered, we

use the following sample improvement project progress report for ongoing project

monitoring and reporting:

SAMPLE IMPROVEMENT PROJECT PROGRESS REPORT PROJECT DESCRIPTION METRICS TEAM LEADER STATUS

STEMI Shorten the time from 9-1-1 call to intervention in hospital.

Time from call to balloon inflation in cath lab.

Lee Siegel Next Steps: Process flow chart analysis for time delays.

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Results

All the structures, measurements, and activities we engage in related to the

leadership and management of our organization are aligned with our purpose, vision, and

values. The end results we seek are to reduce suffering, improve health, and measurably

improve the health of our community. Examples of this vision in action are described

throughout this proposal. They include creation of an Asthma Team, development of a

composite scoring system for airway management, and improving PCR printing

performance from 67% to 95% over a one-month period. Current improvement projects

under way include looking at backboard padding for a more comfortable way to

immobilize patients and decrease the chance of pressure ulcers, and the development of our

next Clinical Composite Score for patients with STEMI. Our research study to determine

the clinical impact of various ALS ambulance response times will also produce valuable

results for patients and the community.

✔ 1. QUALITY MANAGEMENT

In the majority of American EMS systems Quality Management is limited to a retrospective evaluation of patient care reports. A significant percentage of EMS systems have expanded the scope of their quality management efforts to include clinical performance indicators paired with an education system designed to make clinical improvements. Alameda County is committed to a comprehensive model of quality management that, while patient centered, encompasses all vital functions within the system. The County seeks a Contractor who shares this perspective.

We currently maintain a comprehensive, patient-centered quality program that

encompasses all vital functions in keeping with the County’s perspective described in the

requirement above and as outlined in the introduction to this Clinical Quality Improvement

section. We are committed to continuing to do so for ongoing improvements in the future.

Our proposed quality program is designed to address all key functions that help us

serve patients and the community. It is fully-integrated throughout our organization and

lead by our General Manager, with the support of the entire quality/leadership team. That

means our quality management program and our system of leadership and management are

indistinguishable from each other -- all aspects of our system are incorporated into a single

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seamless system for measurement, monitoring, performance improvement, and day-to-day

management.

Our quality management system translates these requirements for performance

results into measurements, both quantitative and qualitative. This information serves as the

basis of our discussions and efforts and lets us know how we are doing for our customers in

key areas and where there are opportunities to do more. Our primary quality review

processes occur at daily, weekly, monthly, quarterly, and annual intervals, as described

under the heading "Quality Structures" in the introduction to this Clinical Quality

Improvement section.

✔ 1.1 Proposers are required to document their commitment to have the senior members of their Alameda County operations actively participate in the leadership and oversight of the County quality management system. This commitment includes but not limited to:

✔ 1.1.1 Active participation of Proposer’s senior leadership in EMS groups or committees dealing with quality management;

We actively participate and will continue to actively participate in the Alameda

County EMS Agency Quality Council and the Alameda County EMS Advisory Committee,

as well as other County quality efforts. Our General Manager and clinical leaders will

continue to participate in the leadership and oversight of the County quality management

system. In addition to fulfilling required reporting mechanisms, we invite and will

continue to invite members of the County EMS Agency to participate in our monthly

Quality Steering Committee meetings that follow this standard agenda:

• Key performance indicator report review, analysis, and action,

• Performance improvement project list review, reports, and updates,

• Chartering of additional improvement projects, and

• Additional topics.

✔ 1.1.2 Designation of a Quality Manager to oversee Contractor’s quality program;

Our designated Quality Manager is Luis Diaz, RN. As described in the introduction

to this section, quality focus is hardwired throughout our organization. Our General

Manager, Mike Taigman, is responsible and accountable for overseeing overall quality and

performance, as well as quality and performance improvement. In this role, Mike is

supported by our entire quality/leadership team. Please see the Key Personnel section in

Required Form Exhibit J for more information and resumes.

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✔ 1.1.3 Submission of comprehensive key performance indicator reports to the County;

We submit and will continue to submit comprehensive key performance indicator

(KPI) reports to the County under a new contract. The following is a list of the KPIs we

currently track or will be tracking before the new contract begins. KPI definitions, data

sources, and goals can be found in the charts in section D.2.5.1. We anticipate that KPIs

and report contents will evolve over time as part of our ongoing collaboration with the

Alameda County EMS Agency and Medical Director.

CLINICAL KPIS 1. Scene and Pre-hospital Time for Life-Threatening Trauma

2. Scene and Pre-hospital Time for Cardiac Chest Pain

3. Scene and Pre-hospital Time for Stroke

4. Time to Intervention for STEMI

5. Time to Hospital for Stroke

6. Cardiac Arrest Resuscitation Rate

7. Airway Checklist Compliance - Composite Score compliance KPI for Cardiac

Arrest, STEMI/Acute Coronary Syndrome, Stroke, Major Trauma,

Unresponsiveness, and Pain will be added when applicable checklists and protocols

are approved by County Medical Director.

8. Protocol and Policy Compliance

9. Paramedic Skill Retention

10. Asthma Team Impact

11. Printing PCR Prior to Return to Service

RESPONSE TIME PERFORMANCE KPIS 12. Weekly Response Time Performance by Zone, Sub area, Priority, and the EOA

(the County also has near-real-time access to daily response time performance)

13. Late Call Analysis

14. Lost Unit Hours

15. Ratio of Mutual Aid Provided vs. Received

CUSTOMER SATISFACTION KPIS 16. Did the Paramedics Arrive Quickly?

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17. Did the Paramedics Act in a Concerned and Caring Manner?

18. Did the Paramedics Explain What They Were Doing and Why?

19. Pain, Difficulty Breathing, or Discomfort Improvement

20. Overall Care and Service Rating

HUMAN RESOURCES/EMPLOYEE SATISFACTION KPIS 21. Number of Shift Holdovers Per Week

22. Employee Morale

23. Turnover Factors

24. Turnover Rate

COMMUNITY HEALTH PARTNERSHIP KPIS 25. 9-1-1 Calls, ED Visits, Hospitalizations for Adults with Asthma Treated by

Asthma Team

26. Community Health Improvement Activities

FLEET KPIS 27. Critical Vehicle Failures

28. Late Preventive Maintenance

SAFETY KPIS 29. Employee Injuries

30. Severity of Employee Injuries

31. Vehicle Contacts

32. Cost of Crashes

UNUSUAL OCCURRENCES AND COMPLAINTS KPIS 33. Unusual Occurrences and Complaints

FINANCIAL SUSTAINABILITY KPIS 34. Unit Hour Utilization Ratio

35. Average Patient Bill

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✔ 1.1.4 Active participation in projects designed to improve the quality of EMS in the County of Alameda; and

We actively participate in projects to improve the quality of EMS in Alameda

County and will continue to in a new contract. For example, Medical Director Dr. Pointer

and the Alameda County EMS Agency recently initiated a project called Take Heart

Northern California, designed to improve cardiac arrest survival rates in the County.

Alameda County AMR was an active participant in the formation meeting and we took

immediate steps to implement some of the program guidelines, including training all our

employees to do high performance CPR using the Smart Man Mannequins. We attended

the Take Heart America

strategic planning session

in Minneapolis with our

colleagues from the EMS

Agency, and we’ve

organized all the AMR

operations in Northern

California, several of

whose General Managers are pictured here, to support and participate in this innovative

program. As this program moves forward we will work with the County EMS Agency and

Take Heart America to develop KPIs with which to monitor our progress on this initiative.

✔ 1.1.5 Description of the Proposer’s overall approach to comprehensive quality management. [Per Addendum I, Part II, #15:] At a minimum, the Contractor will be responsible for protocol compliance and data gathering. Ultimately EMS wants the Contractor to be not only a catalyst for research, but also a joint partner with EMS for other research projects.

Our comprehensive approach meets and exceeds this requirement. It is based on

our purpose and vision, aligned to all key goals by our quality and strategic planning

processes, implemented through action plans, and monitored by results. We participate

with other system stakeholders in many of these processes and we welcome the

participation of the Alameda County EMS Agency and Medical Director in these activities.

Our Community Health Partnership Model of EMS means that we integrate our community

health improvement activities into our quality and strategic planning processes.

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As described in this section’s introduction, our overall approach is to identify,

measure, and monitor performance in all aspects of our organization that contribute to our

purpose of relieving suffering and improving health to identify opportunities for

improvement activities that result in better care and service for our patients and

community. Our philosophy is that everything we do should help fulfill this purpose, and

that improvement projects and activities should be evidence-based to focus on areas where

a change can have the biggest potential to make a difference. That means our data is

collected, reported, and analyzed using statistically-valid methodology and thinking, a

significant advance from what most EMS organizations can offer from both an operational

and research perspective.

COMMITMENT TO RESEARCH

We welcome the opportunity to further contribute to research in EMS. Alameda

County AMR is engaged in a number of clinical research trials to further evidence-based

knowledge in our industry. We work with local hospitals, Medical Directors, the Alameda

County EMS Agency, partners, and our scientifically-trained team to design and conduct

these trials. Our current clinical research trials include:

Impact of EMS-Based Community Asthma Teams on Adults with Chronic

Asthma Study

This study examines the impact of intensive in-home coaching by EMT and

paramedics members of our Asthma Team on 9-1-1 calls, emergency department visits, and

hospital admissions for adults with chronic asthma. This prospective randomized study is

being conducted in collaboration with Highland Hospital’s Emergency Medicine

Residency Program.

Clinical Impact of Response Times Study Series

For this series of studies we will seek to determine what impact various response

times have on clinical severity and patient outcomes for Echo calls, as well as other time-

sensitive conditions such as STEMI, stroke, and major trauma. We propose this series of

studies be performed in collaboration with the County EMS Agency, our national clinical

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team, and EMS researchers at the University of Arizona. In compliance with RFP

Addendum I, Part IV, #2, an initial overview of this proposed study is in Attachment 6.

American Heart Association ACLS Education Retention Study

We are partnering with the University of Pittsburgh, Washington State University,

and Laerdal to study information retention levels for providers. This study compares

retention levels from the traditional approach to ACLS education of one 8-hour class every

two years versus those who receive a short course followed by 10-minute monthly

computer-based training sessions. All participants must hold a current ACLS card and be

certified in the initial training. Participants’ information retention levels will be tested at 3,

6, 9, and 12-month intervals. This study is sponsored by Laerdal Medical Corporation and

the American Heart Association in cooperation with AMR, the National League for

Nursing and the University of Pittsburgh Medical Center.

Completed research studies our organization has conducted include:

Carbon Footprinting in North American EMS Systems/Preliminary Emission

Benchmark Development Study

A healthier environment is essential to improving community health. Alameda

County AMR’s first study as part of the North American EMS Emissions Study Group,

Carbon Footprinting of North American EMS Systems, by Blanchard, I.E. and Brown, L.

H., was presented at the National Association of EMS Physicians meeting in January 2010.

This study characterized the carbon emissions from a broad sample of North American

EMS agencies, and begins the process of establishing EMS related emission benchmarks.

Alameda County AMR participated in this study and is an ongoing member of the North

American EMS Emissions Study Group, an international collaboration committed to

reducing the impact of EMS on the environment. This ongoing series of studies is being

conducted in association with Alberta Health Services Emergency Medical Services,

Calgary, Alberta, Canada, the Anton Breinl Center, James Cook University School of

Public Health, Tropical Medicine and Rehabilitation Sciences, Townsville, Queensland,

Australia, and the Department of Emergency Medicine, University of New Mexico Health

Sciences Center.

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Inspired by our participation in this study, Alameda County AMR has issued a

“biggest loser” challenge to sister organizations throughout the Bay Area to see which

operation can reduce its proportional carbon footprint the most over the next few years

while maintaining optimal care, service, and system sustainability.

EMS Impact based on Rapid Acute Physiology Score (RAPS) Study

For this study we looked at heart rate, respiratory rate, blood pressure, Glasgow

Coma Score, and oxygen saturation to calculate a RAPS score. We presented the first

EMS study on the validation of RAPS at the National Association of EMS Physicians

annual meeting held in January, 2010. More about RAPS can be found in Attachment 7.

King Tube Airway vs. Combitube Study

For this study, we partnered with Alameda County EMS Agency and Medical

Director to determine which airway device was better. Our results were that airway

success rate on both were about the same, but ease of use was better with the King Tube.

Based on these results, we switched to the King Tube, now in use.

Several members of our quality/leadership team have written grants that have been

funded. To further Alameda County research efforts we commit to provide grant writing

along with study management and implementation support.

Alameda County also benefits from the research functions of AMR’s larger

organization. AMR has been the originator and principal investigator for multiple

published research reports related to medications, protocols, and equipment. In 2000, The

Prehospital Care Research Forum presented the Best Research Award to AMR.

AMR has a National Equipment Evaluation Team comprised of clinicians,

operations leaders, senior managers, and purchasing managers who meet monthly to review

new clinical equipment. Because of AMR’s industry-leading presence, equipment makers,

researchers, and vendors offer us the opportunity to pre-view and evaluate new equipment.

Additionally, in cooperation with local EMS agencies, our multiple operations provide a

platform for evaluation of EMS innovations.

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Examples of this team’s research include:

• Nationwide trial of various ventilator and CPAP devices

• Evaluation of the King Airway

• Evaluation of the Stryer Power-PRO cots for injury reduction

• Evaluation of different oxygen tank lift devices designed to reduce injuries

• Validation study of carbon monoxide monitors that could be beneficial to support

the firefighter rehabilitation function

• Evaluation of hemolytic agent bandages

Some examples of the published research AMR and/or the Alameda County AMR

quality/leadership team has participated in include:

• “Bourn, S. (2005). How Patients Select Sites for Non-Emergent Acute Care:

University of Colorado.

• Foster, D., D’Acchioli, R. (2005). Prospective Service Integration: The Key to

Success

• Gorrell, M. (2005). A Retrospective Analysis of Paramedic Performance for

Advanced Airway Management: American Medical Response.

• Snider, J. B., Moreno, R., Fuller, D. J., & Schmidt, T. A. (2004). The Effect of

Simple Interventions on Paramedic Aspirin Administration Rates. Prehosp Emerg

Care, 8(1), 41-45.

• Harlan, K. (2002). Assessment of Trancutaneous Cardiac Pacing Use in Selected

Northern California Counties: Northern California Training Institute.

• Marly, CD, DO, Eitel, DR, MD, Koch, MF, Hess, DR, Taigman, MA, (1996)

Prehospital Use of a Prototype Esophageal Detection Device: A word of caution,

Prehospital and Disaster Medicine vol 11, no 3, pages 224-227

• Brown, LH, Learner, EB, Larmon, B, LeGassick, T, Taigman, M (2007) Are EMS

Call Volume Predictions Based on Demand Pattern Analysis Accurate? Prehospital

Emergency Care 2007; 11:199-203

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• Blanchard, IE, Brown, LH, and the North American EMS Emissions Study Group

(2010) Carbon Footprinting of North American EMS Systems, presented at the

National Association of EMS Physicians January 2010

✔ 1.2 Proposers are encouraged to incorporate the most current Baldrige National Quality Program: Health Care Criteria for Performance Excellence and the self analysis worksheet in their response. While the County will not be requiring the Contractor to apply for the Baldrige Award, it does believe that the core areas addressed by this process provide a solid foundation for a comprehensive quality management program.

As an enhancement and meaningful proof of our commitment, we will apply for the

Malcolm Baldrige National Quality Award by the third year following a new contract.

According to one of the founders of the quality movement in the United States,

Joseph Juran, “The most comprehensive list of actions to achieve world-class quality is

contained in the Malcolm Baldrige Criteria.” We incorporate the Malcolm Baldrige

National Quality Program: Healthcare Criteria for Performance Excellence in our

organization’s strategy and actions. As part of this enhancement our quality/leadership

team includes Diane Akers, former Alameda County EMS Director and Alumni Examiner

for the Malcolm Baldrige National Quality Award.

While we have been providing high quality care for decades, our commitment to

apply for both California's CAPE award and the Malcolm Baldrige National Quality Award

will facilitate significant improvements to our system. Our initial self-assessment results

on the next pages came from a survey of all of our employees last December, 2009. The

results of this survey highlight the areas we need to focus on to become application-ready.

Additionally a copy of our completed self-analysis worksheet that was driven by these

survey results is included in Attachment 8.

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✔ 2. QUALITY PROCESSES AND PRACTICES

The County is interested in a clear and concise set of processes and practices, designed to be feasible for implementation and produce tangible improvements for the patients and other customers served by our EMS system, the Contractor’s employees who serve Alameda County, and the other agencies involved in Alameda County EMS. At a minimum, Proposers should address the following in their proposal:

✔ 2.1 LEADERSHIP ✔ 2.1.1 Describe the Proposer’s leadership structure. Include purpose, vision, mission, and values.

Our purpose/mission is to relieve suffering and improve health. Our vision is to

measurably improve community health. Our values are the STAR CARE values detailed at

the beginning of this section, that require actions to be: Safe, Team-Based, Attentive to

Human Needs, Respectful, Customer-Accountable, Appropriate, Reasonable, and Ethical.

We believe true leadership requires setting a compelling vision, providing people with the

resources and training they need to achieve the vision, and encouraging and supporting

their work towards those goals. The next graphic shows how our leadership structure is

aligned with our purpose, vision, and values:

PATIENTS & COMMUNITY

PARAMEDICS, EMTS, DISPATCHERS

SUPERVISORS, FLEET, MATERIALS, HR, SCHEDULING,

CLINICAL, EDUCATION, IT

QUALITY/LEADERSHIP TEAM

AMR

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This approach to organizational structure aligns with our purpose, vision and

values. Our patients and the community we serve guide our decision making. The team

members who have regular direct contact with our customers are supported and served by

others in the organization.

At Alameda County AMR we are proud of the facilitative leadership style our

organization strives to use to resolve issues and move forward to achieve results. We

believe that each employee regardless of their title has a unique contribution to make

towards achieving our purpose of reducing suffering and improving health in our

communities. Our practices are designed to maximize each employee’s individual

contribution which leads to greater employee satisfaction and better performance.

Below are some of the hallmarks of our approach to leadership:

• Clear focus on results for patients and our community

• Purpose, vision, and values established in conversation with representatives of all

employees

• Ethical and compliant behavior required from the top down

• Commitment to running as a sustainable, viable organization including green

practices

• Two-way communication throughout the organization

• Quality processes in collaboration with members from beyond our organization

• Active leadership in the community

• Involvement with all EMS Agency committees and processes

• Ethnic Health Institute and other community partnerships, and

• Inclusive, system-wide orientation to enable the best possible service for patients

and the community.

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ASTHMA TEAM: PURPOSE, VISION, VALUES IN ACTION

One example of our purpose, vision, and values in action is the creation of our

Alameda County AMR Asthma Team. We used the 7-step process outlined below to

design this and our other interventions for measurably improving community health:

7-Step Process for Measurably Improving Community Health

1. IDENTIFY NEEDS: Identify community needs through epidemiological data and

strategic planning with our partners such as the Ethnic Health Institute which includes the

Alameda County Health Care Services Agency

2. IDENTIFY PARTNERS: Identify community partners already working to address

these needs

1. Identify Needs

2. Identify Partners

3. Determine Gaps

4. Determine How we can

Help

5. Plan Improvement

Project

6. Conduct PDSA Cycle

7. Improve/Hold Gains

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3. DETERMINE GAPS: Work with partners to identify gaps between current

resources and current and long term needs

4. DETERMINE HOW WE CAN HELP: Collaborate with partners and our team to

develop strategies for how our organization can help fill the gaps

5. PLAN IT: Charter improvement projects using the IHI Model for Improvement

using IHI strategies for every step from measurement methodology to beta testing

6. DO IT: Conduct Plan-Do-Study-Act (PDSA) cycles in collaboration with the

County Health Care Services Agency, the EMS Agency, first responders, community

groups, hospitals, and others to refine the program

7. IMPROVE IT/HOLD THE GAINS: Collect data and feedback on the intervention to

assess impact and to design sustainable improvement that holds the gains.

We work at the

intersection of the

community and the

health system

collaboratively creating

resources to better

inform patients which

helps improve their

outcomes. We strive to

follow the Chronic

Care Model of disease

management created by

MacColl Institute.

Here is how those steps resulted in creation of the Asthma Team, and what we are

doing currently to track our progress and impact:

1. IDENTIFY NEEDS: Alameda County is facing an asthma crisis. According to the

Alameda County Health Status Report 2003, asthma death rates exceed the Health People

2010 national objectives, the age-adjusted rate of asthma hospitalization among children

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under 15 is more than twice the California rate, and African American males under age 15

were hospitalized at four times the rate of Latinos and five times the rate of Whites or

Asians. According to a 2007 report called Select Health Indicators for Cities in Alameda

County, an average of 2,200 people with asthma are hospitalized each year in our County,

and the rate of hospitalizations for African Americans was several times higher than that

for other ethnic groups.

The following map shows the density of asthma cases in Alameda County and

indicates that Oakland has much higher rates than other parts of our service area.

2. IDENTIFY PARTNERS: In response to epidemiological data indicating that asthma

disproportionately affects Alameda County and Oakland, we identified community partners

working to address the needs for asthma management and support including the Ethnic

Health Institute and the Alameda County EMS Agency’s Asthma Start program.

3. DETERMINE GAPS: Working with our partners, we learned that more than 80

separate community groups already were working to improve asthma in our County.

Meeting with many of them to see how we could support and enhance these efforts, we

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learned that children under 18 in Alameda County have access to a variety of support

services through the County and other existing organizations, but that an opportunity

existed to help adults better manage their disease.

4. DETERMINE HOW WE CAN HELP: With existing community groups and EMS

Agency Fellow Senai Kidane, MD, we devised a strategy based on our partners’ experience

with successful strategies for community health outreach programs and our organizational

knowledge from decades of treating asthmatic patients whose symptoms rise to the level of

calling 9-1-1, some multiple times in one month. The result was the creation of the

Alameda County AMR Asthma Team, a team currently comprised of approximately 15 of

our Paramedics and EMTs who have indicated an interest in helping in this realm.

5. PLAN IT: We

determined that the Asthma

Team’s mission would be to

provide intensive case

management to asthmatics

in our community, to

conduct in-home visits to

create customized asthma

trigger-proofing plans as

well as personalized self-care plans for adults with asthma who have called 9-1-1 for

asthma-related issues or been referred to the team by other sources including hospitals.

Educational activities include teaching asthmatic patients to recognize the early warning

signs to help them manage their disease and learning how to identify personal asthma

triggers.

In keeping with our commitment to objectively measure the efficacy of our actions,

we worked with Highland Hospital to develop a research study related to our Asthma Team

activities. This study examines whether our interventions will decrease 9-1-1 calls,

emergency department visits, or hospitalizations for patients served by the Asthma Team,

and assesses their overall satisfaction with the service.

The Impact of EMS-Based Community Asthma Teams on Adults with Chronic

Asthma Study will be launching as soon as we finish the Institutional Review Board

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process which is required for all research studies that involve people. We will be tracking

KPIs associated with our Asthma Team activities for this study.

Our technology team is creating customized drop down menus for our Multi-EMS

Data System (MEDS) ePCR that will enable us to easily document, track, and monitor the

efficacy of our community education efforts while maintaining full HIPAA compliance.

The ability to offer this kind of community-driven customization is one of our ePCR

system’s key benefits over off-the-shelf, one-size-fits-all products. We are also looking at

technology-driven systems to help connect patients with community resources and

professional support including serving as a partner for Microsoft Health Vault. For more

about MEDS, see sections D.2.5.6 and I.3.

6. DO IT: The first Plan-Do-Study-Act (PDSA) cycle for this project will launch as

soon as the Institutional Review Board approves our study. It will involve five Asthma

Team home visits based on the initial protocol and checklist. The feedback from these

initial visits will be used to refine the protocol, checklist, and tracking. The second PDSA

cycle will roll the full study out to a randomized group of adults seen in the Emergency

Department of Highland Hospital for chronic asthma. The results of this study will be

evaluated scientifically and the results will determine if we should expand the program to

include all patients in the County. All of these cycles will be conducted in collaboration

with the Alameda County EMS Agency, the County Asthma Start Team, the Ethnic Health

Institute, and Highland Hospital.

7. IMPROVE IT/HOLD THE GAINS: The results of this research will determine if

there are measurable benefits for people with asthma. If the hypothesis proves true and

there are benefits we will hardwire the Asthma Team’s practices into our system in a

sustainable way.

In addition to the Asthma Team, our community partners helped us identify an

opportunity to convert all our front-line crews to stewards of asthma self-care and

management in addition to the traditional EMS role of emergency response. All our

ambulances are now supplied with asthma care literature approved by the County and

created by the Ethnic Health Institute. Our crews have been educated to distribute it to

patients who need it. This literature includes referral resources and tips on how to use a

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variety of asthma medications. We

also stock similar literature for other

diseases and risks that impact our

communities including diabetes,

hypertension, fall prevention, and

cancer. All information is currently

offered in English and Spanish, the

two most common languages spoken

by our patients. We are in the process

of translating this information to

additional languages. More about our extensive community health commitment can be

found in the Commitment to EMS System and Community section.

✔ 2.1.2 Describe the quality management competencies that members of the leadership team possess, including their ability to analyze performance data and conduct improvement projects.

The Proven Team Who Will Oversee and Implement our Quality Program

Our quality focus is supported by our entire quality/leadership team and workforce.

Our Quality Steering Committee members and most of our other quality/leadership team

members have received one-on-one training in quality management principles and practices

including data analysis and improvement projects by our General Manager, a Six Sigma

Black Belt and faculty in EMS Quality Management and Strategic Human Resources for

the University of Maryland Baltimore County’s Masters Degree program in Emergency

Health Service Management.

Additional training and ongoing coaching has been and will continue to be provided

by both Diane Akers and Davis Balestracci during our monthly Quality Steering

Committee meetings. These contracted consultants add to our team’s world-class quality

competencies. Diane Akers’ extensive background as trainer of Baldrige Examiners and

judge of the California Award for Performance Excellence (CAPE) based on Baldrige

Criteria, along with her history as former Director of the Alameda County EMS Agency,

helps our team develop processes that hold to the highest quality standards and address the

unique needs and priorities of our Alameda County community.

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Davis wrote the book, “Data Sanity: a Quantum Leap to Unprecedented Results,”

now in its second edition, and has earned an international reputation for adapting statistical

methods to healthcare improvement as well as organizational psychology and

transformation. He has earned multiple quality awards for demonstrating improvement,

innovative teaching of statistical

methods, educational program

improvement, and increasing

customer satisfaction.

Davis is a regular presenter

at the prestigious Institute for

Healthcare Improvement U.S. and

European annual forums. At the

invitation of Donald M. Berwick,

MD, MPP, FRCP, President and

CEO of the Institute for Healthcare

Improvement, Davis was a member of the faculty team sponsored by the Harvard Institute

for International Development that taught health care quality improvement methods to 80

health care leaders in the Middle East. He has given seminars and consulted in Canada,

Palestine, Israel, Norway, Australia, New Zealand, Scotland, Wales, and in more than 100

hospitals in England sponsored by the National Health Service’s Modernisation Agency.

Davis is a senior member of the American Society for Quality (ASQ) and former chair of

its Statistics Division. He is also past President of the Twin Cities Deming Forum. He is

known worldwide for a provocative, challenging, yet humorous and down-to-earth public

speaking style.

Our Clinical Education Services (CES) team is led by Elsie Kusel and Lee Siegel,

each of whom is a certified Alameda County Continuing Education provider with more

than two decades of service in this County. This history gives them a proven, long-

standing track record of effectively training our County’s paramedics and working with the

County Medical Director and others in our system to ensure clinical quality.

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Our Quality Steering Committee and team will be joined by Quality Manager Luis

Diaz, a registered nurse with more than fifteen years serving this County’s hospitals and

Fire First Response organizations in lead clinical and quality roles, should we be selected

in this RFP process. Luis’ strengths include database design, programming, and

management and several of our local Fire First Responder agencies continue to use his

systems. As part of our commitment to be the best possible partner for all system

participants, Luis will continue to provide database support to system partners as a member

of our team.

Additional Background about our Team’s Quality Competencies

Alameda County AMR General Manager, Mike Taigman, has been an

internationally-recognized industry leader in EMS quality and performance improvement

for the past thirty years. Mike’s reputation as a public advocate for patients and an

innovator in clinical quality and performance is well

documented through his publications, teaching, and

public speaking. Additionally, two of the EMS

quality management systems Mike designed,

implemented, and facilitated (EMSA in Oklahoma

and SunStar in Pinellas County Florida) have won

state level quality awards for excellence.

Before joining AMR, Mike founded the

company Paramedics Plus with a few colleagues who

shared his vision for radically improving the way

EMS cares for sick and injured people. One of his

co-founder colleagues was Tom Wagner, now Chief

Executive Officer for all of AMR West. They partnered with East Texas Medical Center

EMS (ETMC-EMS) for its analogous track record. Eventually ETMC-EMS purchased all

of the shares of the original founders.

During their tenure together building Paramedics Plus, these leaders initiated,

implemented, and guided radical improvements to benefit patients including:

• Winning the State Quality Award for Oklahoma, where Tom was General Manager,

while returning unprecedented profits to the EMS Authority to benefit patients;

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• Making significant improvements in cardiac arrest resuscitation rates in Tulsa and

Oklahoma City by working with EMSA and local Fire Departments;

• Improving response times from 90% to 92% in a six-month period in Pinellas

County, a service area with over 910,000 residents; and

• Designing, implementing, and for ten years leading, a cross-organizational quality

management system using statistical process control, which has become the model

for EMS systems across the U.S.

Glenn Leland, former COO for Paramedics Plus’ Oklahoma operation, picked up

where Tom and Mike left off and ran the EMSA operation with record performance before

re-joining AMR as Senior Vice President.

With their unparalleled track record of industry firsts and quality-oriented

innovation, these individuals could have chosen to stay where they were or join almost any

organization in healthcare. Each independently chose AMR for some common reasons:

• AMR is the leading provider of pre-hospital services in the world. That gives the

company access to the best technologies, products and people working in EMS

today, along with an unparalleled wealth of real-world expertise.

• AMR and its sister organizations touch a patient every 3 seconds. That means

quality improvements here benefit exponentially more people than through any

other company.

• AMR brings the benefits of a national company to the local level, while fostering

and supporting grass-roots level customized innovation. That provides Alameda

County the freedom to move beyond traditional approaches to EMS and the

managerial, financial, and clinical strength to make it happen.

Alameda County provides the ideal setting for ground-breaking, quality and

community health advances because of its perfect combination of pioneering EMS clinical

leadership, an abundance of serious community health issues, a lineage of grassroots

community action, and hundreds of Alameda County AMR employees who love this

community and are willing to engage in the transformation of EMS to better serve patients

and the community.

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The Alameda County AMR team offers an unparalleled combination of fiscal

strength, institutional know-how, innovation, and proven local team excellence to support

Alameda County’s patients and communities and to implement the County and our shared

vision of EMS as a quality-driven, fully-integrated community health partner.

✔ 2.1.3 Describe the methods used to communicate openly with the workforce and the methods used to assess the effectiveness of this communication. Include a description of how the organization communicates performance data to the members of the workforce involved in the process whose performance is being monitored.

Effective communication with the workforce is particularly important as well as

challenging in EMS, where employees work remotely and are often in motion throughout

the day. Our communication philosophy puts the burden on the quality/leadership team to

reach out to employees in ways that are as engaging and easy as possible for them to access

the information they need to know. We generally use a number of different channels for

communicating the same information to increase the probability that our crews will receive

the message.

Methods for Communicating with our Team

The methods used to communicate openly with the workforce include:

• Bi-directional email

• True open-door policy

• Regular town hall meetings

• Management ride-alongs in the field

• Posting on employee bulletin boards and break areas

• Cell phone

• Pager

• Podcasts available online, on iTunes, and via CD’s distributed by vehicle

service technicians

• Ninth Brain, a web-based platform that enables online message posting,

message read notification, and other features detailed in section D.2.5.6

• Twitter (currently in exploratory phase)

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Our podcasts are available online at http://public.me.com/mtaigman for free to the

public and other system participants. These audio programs provide brief, pertinent,

topical information in a format designed to make it easy for crews to listen to on post

between calls or during commute time. We have received positive feedback from our

crews on recent podcasts including those listed in the following table.

RECENT PODCASTS AT ALAMEDA COUNTY AMR

All podcasts are available to system participants and the public at no cost

SPEAKER / INTERVIEWEE TOPIC(S)

Josh English, EMT-P, Alameda County EMS Agency Asthma self-care

History of the Airway Checklist

Dr. Jim Pointer, Alameda County Medical Director H1N1 Flu Virus

Michael Moore, EMS Patient, Alameda County EMS patient perspective on

living with blindness and how guide dogs work

Dr. Ash Jain, Director of the Cardiovascular and Stroke Center, Washington Hospital

How doctors use pre-hospital data for diagnostic and

treatment decisions

Elsie Kusel, CES team leader and Leslie Simmons, Administrative Supervisor, Alameda County AMR

Self-care and stress management techniques for

EMS professionals

Dr. Frank Staggers and Joyce Gray of the Ethnic Health Institute

Community health improvement, ways you can

get involved.

Methods for Assessing Efficacy of Communications

We want our communications to be effective at furthering our purpose, vision, and

values. One of the methods we use for assessing our effectiveness is monitoring changes in

performance. For example, following Dr. Jain’s interview podcast on how doctors use pre-

hospital data for diagnostic and treatment decisions, we observed a dramatic, statistically-

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significant improvement in the percentage of PCRs printed and left at the hospital before

crews returned to service, from 67% to 95% over a one-month period.

We also measure the effectiveness of our communication techniques through

responses to our quarterly online employee survey and random live sampling of employees,

asking them, did you get this message? For example, we conducted mandatory training for

all our crews on the Airway Checklist last Fall.

In the next employee survey we asked for feedback on the training. We will use

that information to guide our communication techniques in the future.

Methods used to assess the effectiveness of our podcast and other communications

include those listed below:

• Quarterly employee satisfaction surveys including communication-related questions

such as, “Did you listen to the audio program? If not, why not?”

• Monitoring post-communication behavior and performance changes.

• Auto-alerts via Ninth Brain Suite notify our Clinical Education Services (CES)

team when personnel have opened or not opened a particular communication.

• Self-reporting by employees and Supervisors related to the effectiveness of the

communication.

Performance Data and Information We Communicate to Our Employees

We select the method to communicate performance data and information with our

team based on the urgency and/or time sensitivity of the information. We focus on

communicating performance information relevant for performance improvement,

workplace morale, and employee growth and education, as shown in the next chart:

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PERFORMANCE DATA COMMUNICATION

PERFORMANCE DATA TYPE OF INFORMATION FREQUENCY OF

COMMUNICATION

RESPONSE TIME PERFORMANCE

Month-to-date-response time compliance

• Paged every six hours to on-duty crews • Included monthly in Performance Digest for all crews

COMPOSITE CLINICAL SCORES

Percentage of patients treated in compliance with composite checklists

Included monthly in Performance Digest for all crews and on data display in deployment

TIME-TO-UNIT-ALERT

The time between when a 9-1-1 call appears in our CAD from either of the two fire dispatch centers, and the time when an ambulance is alerted

Ongoing real-time feedback on monitors for dispatchers

CUSTOMER

SURVEY Quantitative and qualitative information from survey

• Ongoing feedback to relevant personnel • Summarized quarterly in Performance Digest for all

EMPLOYEE SURVEY

Quantitative and qualitative information from survey

• Ongoing personal feedback to individual employees who so request

• Quarterly summary with detailed excerpts and data

UNUSUAL OCCURRENCES

Various including customer service-related and clinical

Immediate contact with relevant personnel and EMS Agency consistent with protocol

KEY PERFORMANCE

INDICATORS

Various of those listed in section D.2.5.1

Included monthly in Performance Digest for all crews

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✔ 2.1.4 Describe how the organization’s leadership team promotes legal and ethical behavior for themselves and the entire organization. Describe the organization’s process for handling breaches of ethical behavior.

Promotion of legal and ethical behavior is a top priority for our organization. It

begins with the hiring process, which includes peer-interviews and thorough background

checks. The E in STAR CARE stands for ethics. All our employees are educated about

the STAR CARE values. We also have an extensive ethics component to our orientation

program, along with online ethics classes and tests required for all employees. Our

organization has an ethics hotline 877-835-5267 available 24/7 where employees can call,

express concerns, and receive guidance. Alleged breaches of ethical behavior are fully

investigated. If a breach is found, then immediate corrective action including remediation

is taken up to and including termination if necessary.

✔ 2.1.5 Describe how the organization’s leadership promotes a culture focused on patient and employee safety.

Our core purpose, to reduce suffering and improve health, requires actions to

minimize risk to our patients and our employees. Our STAR CARE values begin with S,

for Safety. We have a comprehensive set of protocols and procedures along with a firm

commitment that our actions reflect our values.

Patient safety is hardwired into our practices, policies, and our County protocols.

This focus includes:

• A comprehensive set of Safety Policies that set the safety standards for the

ambulance industry.

• Driver training designed to decrease crashes and provide a smooth safe ride for

patients.

• Compliance with County clinical protocols to ensure that patients receive the care

they need.

• Infection control policies and practices designed to prevent cross contamination.

For example, we’ve replaced all of the traditional cloth straps on our stretchers with

strength-tested plastic ones that are much easier to clean and are much less likely to harbor

bacteria or virus colonies.

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Employee safety innovations for this proposal include the introduction of Stryker’s

Power-Pro cots. These cots feature a button-operated hydraulic lift system and built-in

pull handles.

In 2009, OSHA recommended that to reduce back injuries organizations should

reduce the size or weight of the object being lifted. Our safety team researched and

evaluated stretchers and found that the total weight lifted on an average shift at the head

end of a cot using a traditional stretcher was 2,440 lbs. Using a Power-PRO cot

significantly

reduced the weight

lifted, to 1,120 lbs.

Our sister

organization in San

Joaquin County has

tested the Power-

PRO cots. Their results include:

• 68% reduction in lost workdays from injury

• 69% reduction in injuries from raising cots

• 96% reduction in injuries from lowering cots

We also benchmarked with Austin

Travis County EMS in Austin, Texas, to

support this decision. In 2006 they

switched to the Power-PRO cot, and

reduced their average number of injuries

from 37 to 14 per year.

Another action we are taking to

improve safety for both our employees

and our community is the elimination of all 24-hour work shifts, which we have already

begun. This strategy is consistent with recommendations in the Alameda County EMS

Agency’s 2007 system review conducted by Fitch & Associates which observed that in our

busy system, 24-hour shifts are not safe.

EMPLOYEE SAFETY STRETCHER RESEARCH RESULTS

STRETCHER

POUNDS LIFTED ON AVERAGE SHIFT

HEAD END

POUNDS LIFTED ON AVERAGE SHIFT

FOOT END Traditional 2,440 2,640 Power-PRO 1,120 1,720 Lifting Reduction 1,320 920

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As we began to embark on this shift change process we met with employees and

listened to their concerns in a series of meetings with union representatives and other

employees who would be affected by this change. While we have not had fatigue-related

situations in this County, there is ample research to show the risks and dangers associated

with 24-hour shifts. Most of our employees have acknowledged that in a busy system like

ours, 24-hour shifts are not appropriate.

Some of the ongoing actions we take to promote safety include:

• Continual eye on safety improvement project opportunities

• Monitoring employee safety

related Key Performance

Indicators such as on-the-job

injuries and exposures, and

number of lost work hours

from primary job function due

to on-the-job injuries or

exposures

• Comprehensive safety training

and education

• Safety posters

• “What’s Wrong with this

Picture?” visual refresher

posters

• Safety newsletter

• Regular safety check

Our organization also seeks to promote a healthier workforce by encouraging

healthy behavior such as diet and exercise modification. Our new hires, led by our Clinical

Education Services staff conduct an end-of-day walk around our operation’s San Leandro

neighborhood to launch a practice of good self-care and stress management.

Pre-hire physical tests and post-hire physicals every two years also contribute to our

healthy workforce. Dr. Casey Terribilini, a noted chiropractor and former paramedic,

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created our pre-hire physical ability evaluation test to test functional areas of performance

typical for work as a Paramedic or EMT. We describe this test in the next chart.

DR. TERRIBILINI’S AMR PRE-HIRE PHYSICAL AGILITY TEST

• 3-MINUTE AEROBIC WARM-UP USING A STEP TEST. Candidates must complete 24 step-ups per minute. The candidate’s heart rate is monitored and may not exceed 85% of the maximum heart rate allowable for the person’s age group.

• LIFTING IN THE FOLLOWING SEQUENCE: 1. 40 lbs. from ground to fully lowered stretcher

2. 40 lbs. “sit pick” from chair to lowered stretcher 3. 90 lbs. from stretcher at mid-rolling position to high-rolling position

4. 90 lbs. from ground level to waist level 5. 120 lbs. from ground to fully lowered stretcher

6. 110 lbs. “sit pick” from chair to lowered stretcher 7. 140 lbs. from stretcher at mid-rolling position to high-rolling position

8. 120 lbs. from ground level to waist level

Once hired, all field employees also receive a physical exam from a local physician

every two years. This regular exam assesses employees for limb impairment, diabetes,

cardiovascular health, respiratory function, hypertension, rheumatic, arthritic, orthopedic,

muscular, neuromuscular, or vascular disease, epilepsy, mental disorders, hearing, vision,

drug use, and alcoholism. Our recruitment and screening processes are designed to hire

people who will have a long, healthy career in EMS.

✔ 2.1.6 Describe how the organization handles situations that have or may have had an adverse impact on patients or the public.

When situations that have or may have had an adverse impact occur we notify the

EMS Agency immediately and follow these additional steps:

• Take immediate action to minimize or stop any harm or risk;

• Apologize to the parties involved;

• Conduct a complete investigation seeking to discover the cause(s) and issue(s) of

the situation, with a primary focus on systems and processes first;

• Provide feedback and take action to prevent repeat occurrences if appropriate; and

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• Document all steps of the process in our Ninth Brain Suite on-line complaint

management system for ongoing monitoring and pattern detection.

We track unusual occurrences and complaints as a KPI using data collected through

Ninth Brain.

✔ 2.2 STRATEGIC PLANNING

✔ 2.2.1 Describe how the organization assesses its strategic challenges and opportunities.

We assess strategic challenges and opportunities on an ongoing basis at our Quality

Steering, Community Health Advisory Board, and regular County meetings. We are also

initiating a new community health-focused strategic planning process to enhance our

existing processes.

Our first Annual Community Health Summit is planned for the second half of 2010.

At the Annual Community Health Summit, our organization will meet with other

stakeholders such as hospitals, the Health Care Services Agency, the EMS Agency, Fire

First Responder partners, members of the Ethnic Health Institute, and other local

community health groups. Our General Manager will facilitate discussion to gather all

information from participants including:

• Strengths, Weaknesses, Opportunities, Threats (SWOT) analysis of the system

• Environmental scan of healthcare needs, reimbursement systems, call volumes,

community health resources, workforce issues, performance data, evolving

technologies, and other issues affecting our organization, industry, and community

Following a thorough discussion of needs and priorities, the group will identify:

• Strategic objectives

• Tactics/action plans to achieve the objectives typically including relevant measures,

responsible parties, and timelines

For us, a plan’s value lies in the results it helps to achieve for our patients and other

customers. Throughout the year, progress towards action items will be monitored and

adjusted as needed through our monthly Quality Steering Committee meetings and

quarterly Community Health Advisory Board meetings, which includes the Board of

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Directors of the Ethnic Health Institute. Members of the Alameda County EMS Agency

are invited to all our quality meetings. Our General Manager will also continue to provide

the EMS Agency Director and Medical Director updates in regular weekly meetings, along

with all KPI reports, for both reporting and collaboration purposes.

✔ 2.2.2 Describe how the organization creates strategic objectives and goals in response to the challenges and opportunities it faces.

We create strategic goals and objectives in response to challenges and opportunities

based on the most pressing community and system issues in collaboration with the

Alameda County EMS Agency, Medical Director, and our partners as described above.

One example of our collaborative goal-setting process is the 7-Step Plan for Measurably

Improving Community Health described earlier in section D.2.1.1.

✔ 2.2.3 Provide an example of the organization’s ability to execute its strategic plan and accomplish objectives.

Example of Ability to Execute: Community Partnerships

One example of our ability to execute our strategic plan and accomplish objectives

is our successful partnerships with local community groups and other stakeholders working

to promote community health. One of our strategic objectives was to become a partner in

community health. Our strategy was to avoid a “hero” model where our organization does

everything itself and instead seek out organizations that understand community health

needs and are already actively working to make a positive difference in the community.

Once we identified those groups, we met with them, discussed their goals and needs and

identified methods by which we could contribute to their success in achieving our shared

community health improvement goals.

We met with a number of groups including the Ethnic Health Institute, Alameda

County Health Care Services Agency, Youth Uprising, and Urban Releaf to discuss this

strategy. Those meetings and ongoing discussions have resulted in a variety of ongoing

tactics/actions including creating the Alameda County AMR Asthma Team, the Youth

Uprising/Alameda County AMR peer health advocate training and career pipeline program,

the support of Satori’s Circle, active involvement with the Bay EMT program, and others

described in the Commitment to EMS System and Community section. These tactics are

designed to further our vision of measurably improving community health and our purpose

of relieving suffering and improving health.

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✔ 2.2.4 Describe the process for creating action plans from the strategic objectives. Provide a sample of an action plan that’s aligned with one of the organization’s strategic objectives.

The process for creating action plans from strategic objectives is as follows:

1. Identify people relevant to achieving the strategic objectives

2. Meet with those people and elicit their input on actions needed to achieve objectives

3. Determine the gaps between today’s reality and the desired results

4. Charter projects using the modified Six Sigma charter template

5. Determine project leaders

6. Identify timelines for follow-up on each action and monitor progress on an ongoing

basis, making adjustments as needed.

7. Follow-up monitoring on an ongoing basis, making adjustments as needed.

Following this model, a sample action plan is provided in the following table:

SAMPLE ACTION PLAN TO ACHIEVE STRATEGIC OBJECTIVE

STRATEGIC OBJECTIVE: Become Partner in Community Health

RELEVANT PEOPLE INCLUDE:

Ethnic Health Institute leaders Joyce Grey and Dr. Frank Staggers,

Olis Simmons from Youth Uprising, Anita Siegel from the Alameda

County Health Care Services Agency, Emergency Medicine

Residents from Highland Hospital, and Dr. Senai Kidane, M.D.,

from the EMS Agency

DETERMINE THE GAPS:

There is a significant gap between the need for adult asthma self-

care competencies in the community and the ability of patients to

care for themselves to keep their asthma under control.

PROJECTS CHARTERED:

1. Education of Current Asthma Patients: For our current transport patients, we worked with EMS Fellow Dr. Senai Kidane, M.D. to create an assessment and education program for our Paramedics to use with patients we transport.

2. Home-based Interventions for Asthma Patients with Acute Need: For adults who need intensive help with asthma self-care, we chartered the creation of an Asthma Team whose members are trained by the Alameda County Asthma Start Program to teach a

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SAMPLE ACTION PLAN TO ACHIEVE STRATEGIC OBJECTIVE variety of self-care skills including home trigger minimization and medication use and compliance. We also chartered a prospective randomized study to determine the impact of this intervention.

LEADERS FOR THESE ACTIONS:

Education of Current Asthma Patients: Dr. Senai Kidane, M.D, Alameda County EMS Fellow

Asthma Team: Bruce Hagen, Alameda County AMR Operational Field Supervisor

Research Study: Dr. Gene Hern and Dr. Jenn Cyrkler of Highland Hospital

Co-Facilitators: The Ethnic Health Institute and Anita Siegel of the Alameda County Health Care Services Agency

Project Oversight: Mike Taigman, Alameda County AMR

TIMELINES:

These projects were launched in August 2009.

• Our goal for Education of Current Asthma Patients was to have materials completed and reviewed by relevant stakeholders by October, with training to begin in November.

These timelines have been met.

• Our goal for developing the Asthma Team’s home-based interventions was to meet with all relevant stakeholders and elicit additional input by October, and begin training team members in October/November. These timelines have been met.

• Going forward, we plan to conduct a small pilot test with a handful of patients in December and January to further develop logistics of referral and follow-up. Program is on track for full deployment March 2010.

FOLLOW-UP MONITORING:

Relevant KPIs to measure success of these programs include 9-1-1 calls for asthma, emergency department visits for asthma, and hospital visits for asthma.

We currently measure and monitor 9-1-1 calls for asthma and are conducting a study with Highland Hospital, the facility that sees the most adult asthma patients in the County, to access data on hospitalization and emergency department visits.

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✔ 2.3 CUSTOMER FOCUS

✔ 2.3.1 Describe how the organization determines the desires, needs, and expectations of patients and other customers. Include a list of key customer groups in addition to patients.

We determine how to meet patients’ clinical needs based on Alameda County

protocols along with ongoing best practices benchmarking. We determine patients’

customer service desires, needs, and expectations through regular patient satisfaction

surveys for all customers for whom we have an address, direct feedback via email, random

customer phone calls, hospital visits to solicit input, mail, and other processes.

Our website, www.alcoamr.net also has a user-friendly customer feedback form.

Forms from the site are automatically forwarded to our Operations Manager who reviews

them daily and notifies crews of commendations or investigates complaints/concerns. All

our quality and management processes are designed to maximize results for our customers

and let us know how we are doing at meeting their desires, needs, and expectations.

“The EMTs saved my life that night and I will be forever grateful.”

- Customer Survey Comment

Our customers are the patients and communities we serve. The Alameda County

EMS Agency and Alameda County Health Care Services Agency are customers as well as

partners whose purpose is aligned with ours. We focus on supporting our partners

including area Fire First Responder agencies, law enforcement agencies, hospitals,

community health organizations, and other groups who work with us to serve patients and

help our community.

We are committed to being the best possible partner for these system participants.

We meet regularly with all our partners to assess their desires, needs, and expectations and

we maintain close working relationships to have ongoing feedback and communication.

The chart on the next page shows some of the expectations and requirements of key

customer groups, patients, the community, and the Alameda County EMS Agency.

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CUSTOMER EXPECTATIONS AND REQUIREMENTS

Our goal is to meet and exceed these expectations and requirements.

KEY CUSTOMER

GROUP EXPECTATIONS/REQUIREMENTS

PATIENTS

• Arrive quickly after 9-1-1 is called

• Keep me alive • Make me feel better; take away my pain, difficulty breathing, etc.

• Tell me what you’re doing and why • Treat me with kindness, compassion, dignity, and respect

OUR

COMMUNITY

• Take care of our needs so we feel safe • Work well with partner public safety and healthcare agencies

• Be involved in improving our health and our community • Help us control costs and evolve our systems of care

COUNTY EMS

AGENCY

• Do what you say you’ll do

• Perform at or above the performance requirements in our contract • Actively participate in system improvement and innovation

• Be fully transparent and accountable for your actions • Be responsive to our requests

• Treat us with kindness, compassion, dignity, and respect

One example of meeting patients’ needs was our work with the County EMS

Agency to address nausea, a common complaint for patients calling 9-1-1. For many

people nausea is worse than pain. We worked with the County EMS Agency who helped

us add Zofran, a medication used to treat nausea. While we’ve only been using it for a few

months, the initial results show that more than 80% of people who receive IV Zofran have

significant relief of their nausea.

An example of working with our partners to better serve our community is when we

recently responded to a request from one of our local Fire First Responder partners to help

vaccinate members of the public at a series of flu clinics. Over the course of two months,

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we provided 14 crews at 9 clinics and were able to help vaccinate more than 7,000 people

in Alameda County. We are also exploring with Fire First Responder partners a pilot

program to develop Fire Station-based community health clinics that would meet the vision

of the Alameda County Health Care Services Agency Director.

An additional example of working

with partners to fulfill our patient and

community customer focus is our work with

the local community group Urban Releaf.

Urban Releaf’s sole mission is to increase the

number of trees planted in Oakland and

Richmond. Research studies by their team of

Ph.D.’s from UCSF, UC Berkeley, UC Davis,

and other leading research institutions show

that increasing trees can help improve air quality and contribute to better community

health. On December 11, 2009, we partnered with them to plant more than 40 trees at New

Highland Academy, an elementary school in Oakland.

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We commit to continued participation in and support for Urban Releaf tree

plantings throughout the course of the contract. Our latest collaboration on January 18,

2010, Martin Luther King Day focused on the area around the West Oakland BART station

where we helped plant dozens of trees.

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✔ 2.3.2 Describe the mechanisms that the organization uses to incorporate the “voice of the customer” in the strategic planning and quality management processes.

INTERVIEWS/PODCASTS: We incorporate the literal “voice of the customer” into

our day-to-day and long-term focus as much as possible. For example, we recently

distributed a podcast to all our crews of an interview with a patient who we treated to

enable our crews to hear the customer’s perspective and emotions.

CUSTOMER SATISFACTION SURVEYS: Our customer satisfaction surveys also are

designed to inform our strategic planning and quality management processes. We track

answers to several of our survey questions as KPIs. For example, one of the questions we

ask is, “The pain, difficulty breathing, or discomfort (the reason for calling) got better, got

worse, or stayed the same?” The returned surveys are matched with the patient care report

so that we are able to assess which categories of patients receive the most benefit from our

treatment and those for whom our intervention does little to relieve their suffering. We

incorporate the results of that analysis into our clinical strategic planning process and to

determine priorities for clinical quality improvement projects.

COMMUNITY GROUP MEETINGS: The voice of the community is heard through

our regular participation in community health meetings with the Ethnic Health Institute

(EHI) and other community health organizations detailed in the Commitment to EMS

System and Community section. We established our Community Health Advisory Board

with the EHI to have a formal process for soliciting input from their Board members.

ALAMEDA COUNTY EMS MEETINGS: The voice of the County EMS Agency is

heard through our weekly and monthly meetings and in our performance based contract, as

well as active participation in EMS Agency committees.

MEETINGS WITH PARTNERS: The voice of our partners is also important to us. We

hear our partners’ voice through participation in the Alameda County EMS Advisory

Committee, the Alameda County EMS Agency Quality Council, and regular, active

participation in all meetings where our involvement is invited including EMS Section of

the Fire Chiefs, Fire Chiefs, Bay Area Journal Club, and more.

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✔ 2.3.3 Other aspects of healthcare have documented inequalities in diagnosis and treatment based on age, ethnicity, and gender. Describe the organization’s system for assuring and monitoring equitable EMS care to traditionally underserved patients such as the elderly, substance abusers, and psychiatrics as well as to all patients based on neighborhood, age, gender, and ethnicity.

Alameda County AMR is committed to being part of the solution in overcoming

inequalities in patient care. We will not employ or continue to employ anyone who

demonstrates an inability or unwillingness to put patients first for any reason, including

discriminatory attitudes towards members of a protected class, traditionally underserved, or

non-dominant population.

Our community has a disproportionate number of traditionally underserved patients

including the elderly, substance abusers, psychiatric patients, people unable to pay, people

of color, people from other countries, and people whose first language is not English which

makes it particularly important for us to be vigilant with our actions as well as our

intentions. We have instituted a number of processes to support our commitment to serve

all patients with excellent care and service.

Our system for assuring and monitoring equitable EMS care to traditionally

underserved patients includes:

• Mandatory cultural competence training as part of our New Hire Academy

orientation

• Partnering with the Ethnic Health Institute as our Community Health Advisory

Board to inform ourselves about disparities in access, assessment, treatment, and

clinical research

• Assessing whether bias may have been a factor in any inadequacy identified in our

ongoing random chart audits of 10% of patient care charts; If so, we work to

understand the issues, address the causes, and take appropriate follow-up action.

• Auditing pain management and other treatments by ethnicity; This audit system

that was recently created by our Medical Director, Dr. Gene Hern will also be

conducted in our Contract Costa County sister organization for benchmarking and

comparison. We will share the results of this audit with our Community Health

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Advisory Board and we will seek their guidance on how to address any inequities

discovered.

• Including at least one person of color and one woman on every peer interview panel

for our hiring process

• Hiring based on clear and objective criteria

• Recruiting a diverse workforce including local organizations and schools

• Ongoing sharing of our patients’ perspectives through audio education, reporting of

survey data, and leadership prioritization/orientation of putting patients first

regardless of age, gender, color, ethnicity, sexual orientation, physical or mental

ability, medical condition, drug use, homelessness, neighborhood, income level,

languages spoken, or any other characteristic, and

• Training 100% of our field employees by Oakland based, Integral Trainings

(http://integraltrainings.com) on self-care, sustainability, diversity, and inclusion.

Through deep sharing, participants learned about themselves and the diversity of their team members’ life and work experiences, building stronger team bonds and a deeper

appreciation for multiple perspectives and experiences. It is our assessment that participants left the training with a deepened awareness of the importance of self-care for their own wellbeing and resilience; an enhanced understanding of how self-care supports their ability to care for patients; two concrete new tools to support their own wellness and encourage it in their colleagues; and ultimately, a deeper appreciation of themselves and

one another.

- Cherine Badawi Co-Founder and Lead Trainer Integral Trainings

Additionally, we do not tolerate discrimination in the workplace. AMR’s company

policy is provided to every employee in the Employee Handbook and prohibits

discrimination and harassment based on gender, race, color, religion, national origin,

ancestry, age, physical or mental disability, medical condition, pregnancy, sexual

orientation, marital status, retaliation, and any other protected status in accordance with all

applicable federal, state, and local laws. Further, the policy states that, “The Company’s

commitment to equality, understanding, and acceptance will be the foundation and

philosophy of Embracing Diversity Day. Embracing Diversity Day will be observed by the

Company as a paid holiday, to be celebrated on the third Monday of every February. This

holiday, which is specific to the Company, will serve as a memorial to Dr. Martin Luther

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King Jr., our U.S. Presidents, and all who have fought to make our world more sensitive

and open to diversity.”

✔ 2.3.4 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 the Proposer has learned by using these monitoring methods and the action the Proposer has taken to improve the service to patients and other customers.

Methods to Assess and Monitor Effectiveness of Meeting Customer Needs and Desires

As described in the introduction to this Clinical Quality Improvement section, we

have regular meetings and ongoing communications with our Alameda County EMS

Agency customer, along with ongoing performance monitoring, to ensure we are meeting

their needs and desires as well as those of our community. We also meet regularly with

members of the Ethnic Health Institute to determine how effectively we are meeting the

needs and desire of our community.

For patient customers, we have two primary methods for assessing and monitoring

our effectiveness at meeting their clinical and customer service needs, Patient Care Report

Audit and Customer Satisfaction Survey, described below.

Monitoring Patients’ Clinical Needs - Patient Care Report Audit

For patients’ clinical needs, we audit 100% of

our patient care reports for all cardiac arrest,

STEMIs, strokes, and trauma activations, and

randomly audit 10% of all patient care reports. In

these audits we look for 1) protocol compliance and

2) clinical improvement (objective and subjective).

This information enables us to know how we are

doing at providing good quality clinical care.

An example of information learned from

Patient Care Report Audit is when we found that our

clinicians were not documenting all the treatments

they were providing to patients on the Airway

Checklist. We provided education and coaching on

the importance of documentation including podcasts

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by a local physician and members of the Alameda County EMS Agency. Subsequently, the

number of patients who received a 1, the highest score, on the Airway Checklist increased.

Monitoring Patients’ Customer Service Needs - Customer Satisfaction Surveys

SAMPLE CUSTOMER SATISFACTION SURVEY

Sent to All Customers for whom we Have an Address

Dear Patient and Family, The paramedics from American Medical Response (AMR) recently cared for

you or a member of your family. We are very interested in improving our service and we would appreciate it if you would take a moment to complete this survey and send it back to us in the pre-paid envelope.

Sincerely, Mike Taigman, General Manager

How many minutes did you wait prior to calling once you began experiencing

your problem? _______

Did the paramedics arrive quickly? Yes No I don’t know

Did the paramedics act in a concerned and caring manner?

Yes No I don’t know

Did the paramedic crew explain what they were doing and why?

Yes No I don’t know

The pain, difficulty breathing, or discomfort (the reason for calling) _____ by the

time you got to the hospital Got better Got worse Stayed the same

Overall the care and service I received from the paramedics at American Medical

Response was: Wonderful Just fine Could have been better

Is there anything you’d like us to tell the crew that took care of you or anything

else you’d like to tell us? ________________________________

Would you like to speak with a member of our management team about your

service? Yes No

Your Name: __________________________________________

Your Phone Number: _______________________________

Your e-mail: __________________________________________

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In addition to our clinical care, there is also a need to have feedback on the

customer perception of the experience. Customer satisfaction surveys enable us to assess

the subjective qualitative experience of our patients. Surveys like the one on the previous

page are distributed to all patients for whom we have an address.

Out of 200 Random Customer Satisfaction Surveys:

88.06% said the paramedics arrived early. 99.00% said the paramedics acted in a concerned and caring manner.

93.53% said the paramedic crew explained what they were doing.

98.01% rate overall care as good or great.

Our customer survey was developed after benchmarking Sarasota Fire

Department’s customer survey. This award-winning EMS organization used a Ph.D.

organizational psychologist to guide over 300 individual hour-long interviews with patients

from their 9-1-1 system to find out what mattered most to them. They used the information

collected in those interviews as the basis for their written survey model questions.

Thus, the questions are designed to target information important to patients, not

what healthcare professionals think is important to patients. Generally, customers say they

want EMS service providers to:

• Get there fast

• Make me feel better

• Take away pain

• Tell me what they are doing and why before they do it.

Most EMS customer surveys are designed for public relations purposes. Our

surveys are designed to find out how we are doing on the issues that matter most to patients

and to collect performance improvement information, so the questions focus on our

customers’ experience and health.

Each survey has the questions in English and Spanish, the languages spoken by the

majority of our customers. Each survey has a self-addressed postage paid return envelope

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to increase the percentage we have returned. On these surveys, patients reinforce what’s

most important to them.

Here are a few quotes from recent surveys:

• “The crew was very attentive, explained everything and took good care of my son

(and Me!) Thank you so much!”

• “Because I was fighting to breathe and scared, I really don’t recall much – except

that both paramedics were very calm, reassuring, and efficient.”

• “They were very nice and understanding. They really did their best to make me feel

comfortable and safe.”

• “I could not have better care

or concern. They did all they

could to lessen pain with care

and concern. Very

knowledgeable.”

• “The crew was competent,

caring, compassionate and did

an excellent job of keeping my

wife informed. Thank you for

an outstanding job done by

true professionals.”

In addition to surveys, we also learn about patients and our County customers’

needs through a variety of other channels including regular quality meetings, feedback

from employees and supervisors, phone calls, and comments on our website or public

websites.

✔ 2.3.5 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.

Our mechanism for managing complaints is as follows:

Screen Shot of Alameda County AMR Yelp Review

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RECEIVING: Complaints reach us through a variety of channels including phone

calls, e-mails, website feedback form, supervisor personal report, and through regular

meetings with customers and employees.

INVESTIGATING: When a complaint is received, we log it into our Ninth Brain

Suite complaint management system. Our Clinical Education Services team leads clinical

complaint investigations. Other complaint investigations are led by our Operational Field

Supervisors. Investigations involve gathering all relevant information and identifying

causes.

RESOLVING: Methods to resolve complaints include meeting with relevant parties,

offering apologies, correcting any problems, and taking appropriate corrective action to

ensure they do not happen again.

TRACKING: Ninth Brain Suite software tracks issues and allows us to provide

analysis, reports and ongoing monitoring of any potential patterns.

ANALYZING COMPLAINT PATTERNS: With the incident tracking feature of Ninth

Brain Suite’s online database software, complaints are uploaded, and patterns are detected,

tracked and addressed. We follow up on all complaints that we receive.

EXAMPLES OF IMPROVEMENT ACTIVITIES RESULTING FROM ANALYSIS:

Improved PCR Printing and Dispatch Co-Location in ACRECC

One example of an improvement activity is our improved patient care report

printing performance. Area hospitals had been requesting that our crews leave a printed

patient care report with each patient before leaving the hospital and returning to service.

We worked with the hospitals and with our crews to develop a time-efficient plan

for printing at each hospital and to educate our crews about fulfilling this new deliverable.

Based on our intervention, patient care report printing increased from 67% to 95% over a

one-month period. This improvement has sustained at the 95% range since the

intervention.

Another example was when our Fire First Responder partner Livermore/Pleasanton

Fire Department let us know they felt our crews were taking too long to arrive at scene.

We met with them and learned they were measuring response time from when they

received the call in their dispatch center to when they saw the ambulance pull up on the

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scene. We worked with them to map the County 9-1-1 call process from the time they

received the call until it was delivered to our dispatch center.

Working together, we identified three or more steps in the process outside our

organization before our crews received a call. For example, if a person called 9-1-1 from a

cell phone in that area, first the call would likely go to California Highway Patrol, then to

the Livermore Police Department, then to the Livermore/Pleasanton Fire Dispatch, then to

Alameda County Regional Emergency Communications Center (ACRECC), then to our

dispatch center, and then to our crews.

When we looked at this potentially time-consuming, multi-step process together, it

was clear that significant portions of the process were outside our control. This analysis

helped inspire the plan to move our communications center from Burlingame into

ACRECC to improve call-processing time.

Additionally, even though our current average time-to-dispatch allows us to meet

response times, we are also working to improve the last step in the dispatch process which

is our internal time-to-dispatch by implementing new software technology called Optima

Live in our dispatch center. We will continue to work with this department and other

components of the system to refine the process to produce better results.

✔ 2.3.6 Describe the mechanism for providing infection control for employees, system partners in healthcare, and patients.

Infection control for our system

partners and patients begins with our infection

control practices within our own organization.

Our actions and philosophy about safety and

communicable disease prevention go above

and beyond industry norms because we think

of our employees’ 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

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providers from acquiring infections while at work. We 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 in our New Hire Academy 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 an aggressive set of ongoing practices to further reduce risk of infection and re-

infection including:

• Aggressive employee vaccinations including H1N1 flu to protect ourselves and our

patients

• Upgraded plastic cot straps designed for decontamination

• Alcohol-based hand sanitizer in all stations, ambulance cabs, and patient

compartments

• Hospital-quality disinfectant wipes and implementation of disinfection practices

designed to prevent colonization of infectious agents on ambulances, cots, and

durable equipment

• Universal precaution equipment and personal protective equipment (eg. masks)

• Aggressive hand-washing and glove use systems and protocols

• Provide stethoscope covers for clinicians to use and change between each patient

• Train clinicians to use infection control glove practices including putting on a new

set of clean gloves each time they touch their patient, and

• Notification of partner agencies as soon as we become aware of possible exposures.

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✔ 2.4 CUSTOMER SERVICE TELEPHONE LINE

✔ 2.4.1 [As amended by Addendum I, Part I, #4] Contractor shall establish and publish a Customer Service Telephone Line giving internal and external customers and system participants the ability to contact a designated liaison of the Contractor’s leadership team to discuss commendations or suggestions for service improvements. The telephone line shall be accessible without charge to all callers within the continental United States.

Our toll-free customer service line number, 877-524-2027, is answered 24/7 live by

our dispatch center. Those answering the phone are trained to address customer service

inquires as well as medical emergencies. This strategy avoids a potential problem where a

customer service phone number might be dialed in a situation where there is a true medical

emergency requiring immediate action. Our team members created and implemented the

first quality improvement phone line in the EMS industry as part of the BayStar leadership

team in San Mateo County in 1990.

For our customer service line, we have created a special customer feedback call-

taking screen in our computer aided dispatch (CAD) system. When a call comes in over

this feedback line a special “call”

is opened in the CAD and the

caller information is recorded.

The “customer feedback call” is

then dispatched to one of our field

supervisors for immediate follow-

up.

Commendations are delivered quickly to crews. Concerns and complaints are

investigated immediately and resolved as quickly as possible. We track unusual

occurrences and complaints as a KPI as described in subsection 2.5.1 of this Clinical

Quality Improvement section.

✔ 2.4.2 The number may be answered by a designated manager or provide an opportunity for the caller to leave a voicemail message. The number will be published in the local telephone directory, on the Contractor’s website, and publicized at local healthcare facilities, fire stations and public safety agencies.

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Our customer service line will meet and exceed these requirements. It is currently

answered live in our communications center by trained Emergency Medical Dispatchers. It

is published on our website www.alcoamr.net and has been sent to the local phone

directory for their next publication. It will be publicized at local healthcare facilities, fire

stations, and law enforcement agencies.

✔ 2.4.3Members of the Contractor’s Leadership Team are to be automatically notified via pager of any incoming calls. A management designee must return the call to the customer within 30 minutes, 90% of the time. Incidents that require follow up to the customer should be resolved by the end of the next business day from when the call was received, and if not possible a call should be made to the customer with the status of the request.

All calls on this line are answered live by our dispatchers. The information is

immediately routed to our Operational Field Supervisors for follow-up well within the 30

minute requirement. When possible we work to resolve issues the same day that we

become aware of them. If we are not able to resolve the issue by the end of business on the

next day we will call the person who made the complaint to update them on the status of

the investigation.

✔ 2.4.3b [Per Addendum I, Part I, #4] If the number is answered by an automatic greeting and/or menu selection, and should a caller inadvertently call the customer service line looking for emergency service, the initial message must immediately convey that this is a customer service line, if caller has an emergency hang up and dial 911.

Our callers will not face these potential problems because our customer service line

is answered live 24/7 by personnel qualified to handle medical emergency calls.

✔ 2.4.4 Handling Service Inquiries and Complaints: - Contractor shall log the date and time of each inquiry and service complaint. Contractor shall provide a prompt response and follow-up to each inquiry and complaint. Such responses shall be subject to the limitations imposed by patient confidentiality restrictions.

We log data and times of each inquiry and complaint in Ninth Brain Suite online

database software to ensure prompt response, an ability to analyze any patterns, and

seamless tracking and documentation process. All our practices are compliant with HIPAA

and other regulations.

✔ - Contractor shall, on a monthly basis, submit to the County a list of all complaints received and the disposition/resolution. Copies of any inquiries and resolutions of a clinical nature shall be referred to the EMS Medical Director using the EMS unusual occurrence procedure within twenty-four (24) hours of the initial inquiry.

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We will submit a list of complaints and their disposition as part of the Unusual

Occurrence/Complaint KPI that we review each month. We currently report all clinical

issues to the EMS Medical Director within the 24 hour period and will continue to do so.

✔ - Proposal shall include a description of the Proposer’s process for managing service complaints.

Complaints reach us through a variety of channels including phone calls, emails,

website feedback form, supervisor report, and through regular meetings with customers.

When a complaint is received, we log it into our Ninth Brain Suite complaint management

system. A member of our Clinical Education Services team leads clinical complaint

investigations, while Operational Field Supervisors lead other complaint investigations.

Investigations involve gathering all relevant information, identifying causes,

meeting with relevant parties, and working to correct any problems and take appropriate

actions to ensure they do not happen again. Ninth Brain Suite software tracks issues and

allows us to provide analysis, reports, and ongoing monitoring of any potential patterns.

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✔ 2.5 MEASUREMENT, ANALYSIS, AND KNOWLEDGE MANAGEMENT:

“In the simplest terms, [Measurement and Analysis] is the ‘brain center’ for the alignment of your organization’s health care and administrative operations with

its strategic objectives.”

- Baldrige National Quality Program Health Care Criteria for Performance Excellence

✔ Clinical error or compliance processes are deemed confidential, including proceedings, findings, and documents and are protected from disclosure, to the extent allowed by law. All system participants will be required to enter into privacy agreements as required by law and that compel individuals involved to adhere to the confidentiality requirements of the process. Clinical care error documents will not be released except as required by law or as required by individual regulatory monitoring agencies or fiscal intermediaries according to pre-established County policy and agreement.

We comply with and will continue to comply with this requirement.

✔ A comprehensive quality management system addresses all of the key areas in an organization that are essential for accomplishing the organization’s purpose, vision, values, and strategic objectives. Key Result Areas (KRA) are likely to include clinical performance, employees, fleet management, fiscal sustainability etc.

Our system complies with and will continue to comply with this requirement.

✔ The Proposer selected to provide emergency ambulance service to Alameda County will work with the EMS Director and the EMS Medical Director, and any relevant quality committees to define Key Performance Indicators (KPIs) that help define and measure progress toward accomplishing each KRA.

We currently meet these requirements and will continue to do so working with the

Alameda County EMS Agency Acting Director and Medical Director, their quality

committees, and our rigorous internal quality program.

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✔ 2.5.1 Proposers should list their Key Result Areas (include a definition and measurable performance indicator) along with a description of how that area contributes to the accomplishment of the organization’s purpose, vision, values, and strategic objectives.

KEY RESULTS AREAS / KEY PERFORMANCE INDICATORS The following numbered list of our key results areas (KRAs) and associated key

performance indicators (KPIs) is provided as an overview of the KRAs and KPIs we are

tracking now or will be tracking before the start of a new contract. This list also serves as a

guide to the subsequent charts that contain all requested information for each item.

In conversation with the Alameda County EMS Agency and the County Medical

Director we anticipate these KPIs will be modified and new KPIs will be added to address

the system’s evolving priorities and needs.

CLINICAL KPIS 1. Scene and Pre-hospital Time for Life-Threatening Trauma

2. Scene and Pre-hospital Time for Cardiac Chest Pain

3. Scene and Pre-hospital Time for Stroke

4. Time to Intervention for STEMI

5. Time to Hospital for Stroke

6. Cardiac Arrest Resuscitation Rate

7. Airway Checklist Compliance - Composite Score compliance KPI for Cardiac

Arrest, STEMI/Acute Coronary Syndrome, Stroke, Major Trauma,

Unresponsiveness, and Pain will be added when applicable checklists and protocols

are approved by County Medical Director.

8. Protocol and Policy Compliance

9. Paramedic Skill Retention

10. Asthma Team Impact

11. Printing PCR Prior to Return to Service

RESPONSE TIME PERFORMANCE KPIS 12. Weekly Response Time Performance by Zone, Sub area, Priority, and the EOA

(the County also has near-real-time access to daily response time performance)

13. Late Call Analysis

14. Lost Unit Hours

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15. Ratio of Mutual Aid Provided vs. Received

CUSTOMER SATISFACTION KPIS 16. Did the Paramedics Arrive Quickly?

17. Did the Paramedics Act in a Concerned and Caring Manner?

18. Did the Paramedics Explain What They Were Doing and Why?

19. Pain, Difficulty Breathing, or Discomfort Improvement

20. Overall Care and Service Rating

HUMAN RESOURCES/EMPLOYEE SATISFACTION KPIS 21. Number of Shift Holdovers Per Week

22. Employee Morale

23. Turnover Factors

24. Turnover Rate

COMMUNITY HEALTH PARTNERSHIP KPIS 25. 9-1-1 Calls, ED Visits, Hospitalizations for Adults with Asthma Treated by

Asthma Team

26. Community Health Improvement Activities

FLEET KPIS 27. Critical Vehicle Failures

28. Late Preventive Maintenance

SAFETY KPIS 29. Employee Injuries

30. Severity of Employee Injuries

31. Vehicle Contacts

32. Cost of Crashes

UNUSUAL OCCURRENCES AND COMPLAINTS KPIS 33. Unusual Occurrences and Complaints

FINANCIAL SUSTAINABILITY KPIS 34. Unit Hour Utilization Ratio

35. Average Patient Bill

At minimum, Proposers should describe KRAs that track:

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✔ • Response time performance by zone, sub area, priority, and the EOA.

See KPI #11 in the following chart for information responsive to this requirement.

✔ • Scene time and total prehospital time for time dependent clinical conditions like cardiac chest pain, stroke, and major trauma.

See KPIs #1, 2, 3, 4, and 5 in the following chart which fulfills this requirement.

✔ • Compliance with policies, procedures, timelines, and destinations for:

✔ ST-elevation myocardial infarction (STEMI) See KPI #8 in the following chart.

✔ Pulmonary edema and congestive heart failure See KPI #8 in the following chart.

✔ Asthma or seizures See KPI #8 in the following chart.

✔ Cardiac arrest See KPI #8 in the following chart.

✔ Trauma See KPI #8 in the following chart.

✔ Presumed stroke symptoms See KPI #8 in the following chart.

✔ Assessment of pain relief See KPI #8 in the following chart.

✔ Compliance with protocols, procedures, adjuncts, timelines for all patients who received, or should have received, an endotracheal tube, King tube, Combitube, or any other “advanced airway”

See KPI #7 in the following chart.

✔ Customer satisfaction See KPIs #16, 17, 18, 19, and 20 in the following chart.

✔ Complaint management See KPI #33 in the following chart.

✔ Employee satisfaction See KPIs #21, 22, 23, and 24 in the following chart.

✔ Paramedic skill retention See KPI #9 in the following chart.

✔ Use of mutual aid See KPI #15 in the following chart.

✔ Safety

See KPIs #29, 30, 31, and 32 in the following chart.

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KRA: CLINICAL

1. SCENE AND PRE-HOSPITAL TIME FOR LIFE-THREATENING TRAUMA

DEFINITIONS Pre-Hospital: Time from receipt of call to arrival at trauma center average per month. Scene: Time from arrival on scene to departure for trauma center average per month.

HOW CONTRIBUTES

Life threatening trauma often requires operating room intervention to stop internal bleeding, the less time spent in the field the faster the bleeding is stopped.

GOAL Short pre-hospital and scene times DATA SOURCE Computer Aided Dispatch system (CAD) DATA DISPLAY Statistical Process Control (SPC) Chart

2. SCENE AND PRE-HOSPITAL TIME FOR CARDIAC CHEST PAIN

DEFINITIONS Pre-Hospital: Time from receipt of call to arrival at hospital average per month. Scene: Time from arrival on scene to departure for hospital average per month.

HOW CONTRIBUTES

If the chest pain is caused by an occlusion of a coronary artery the faster flow is restored the better the patient’s chance of survival

GOAL Short scene and pre-hospital times DATA SOURCE CAD DATA DISPLAY SPC Chart

3. SCENE AND PRE-HOSPITAL TIME FOR STROKE

DEFINITIONS Pre-Hospital: Time from receipt of call to arrival at hospital average per month. Scene: Time from arrival on scene to departure for hospital average per month.

HOW CONTRIBUTES

The shorter the time from onset of symptoms until the bleed is stopped or the flow is restored the better chance of survival and the better chance that survival will be with good neurological function

GOAL Short time from receipt of call to arrival at hospital DATA SOURCE CAD DATA DISPLAY SPC Chart

4. TIME TO INTERVENTION FOR STEMI

DEFINITIONS Time of symptom onset to restoration of flow in the hospital. Time of call receipt to arrival at cardiac receiving facility Time of call receipt to restoration of flow in the hospital.

HOW CONTRIBUTES

The common phrase, “time is muscle” rings true for patients with occluded coronary arteries. The faster patients receive definitive care

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KRA: CLINICAL the better their chance of survival and the healthier their heart will be after the event.

GOAL Short E2B (9-1-1 call to balloon) time DATA SOURCE CAD, Multi-EMS Data System (MEDS), Cardiac Receiving

Hospitals DATA DISPLAY SPC Charts

5. TIME TO HOSPITAL FOR STROKE

DEFINITIONS Time last seen normal to arrival at Stroke Center Time of call receipt to arrival at Stroke Center

HOW CONTRIBUTES

The faster patients with a stroke receive in-hospital care the better their chance of survival and the better functioning they will have after the event.

GOAL Short time from last seen normal to arrival at Stroke Center DATA SOURCE CAD, MEDS DATA DISPLAY SPC Charts

6. CARDIAC ARREST RESUSCITATION RATE

DEFINITIONS Percentage of patients with witnessed ventricular defibrillation who are discharged alive from the hospital each month.

HOW CONTRIBUTES

Cardiac arrest survival is the gold standard of EMS system effectiveness.

GOAL Resuscitation rates equivalent to those in Seattle, widely regarded as the best in the world

DATA SOURCE Alameda County EMS Agency records DATA DISPLAY SPC Chart

7. AIRWAY CHECKLIST COMPLIANCE – COMPOSITE SCORE Composite clinical scores include protocol, policy, procedure, timelines, transport destination, assessment, and treatment. Additional composite checklists for other key clinical issues such as Cardiac Arrest, STEMI/Acute Coronary Syndrome, Stroke, Major Trauma, Unresponsiveness, and Pain will be developed collaboratively with the EMS Agency and other system stakeholders over time. As each one is developed, percentage compliance with that composite score will be added to the KPI list. DEFINITIONS If a patient is cared for with 100% of the components on the

composite checklist their score is 1. If any component is missing the score is 0. These indicators are measured by tracking the percentage of patients who score 1 reported monthly.

HOW These composite scores include all of the vital policies, procedures, timelines, transport destinations, assessments, and treatments that the

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KRA: CLINICAL CONTRIBUTES Alameda County EMS Agency and the Medical Director has

determined are essential to providing comprehensive exceptional care for the people we serve. Patients whose score is 1 are assured that they are receiving the most current evidence-based clinical care available.

GOAL 100 percent of patients receiving a score of 1 on the checklist DATA SOURCE MEDS, Bio-Key, CAD, FirstWatch DATA DISPLAY SPC Charts

8. PROTOCOL AND POLICY COMPLIANCE Including for STEMI, pulmonary edema and congestive heart failure, asthma, seizures, cardiac arrest, trauma, presumed stroke symptoms, pain relief assessment.

DEFINITION Percentage of audited PCRs with documentation of compliance with County protocols, policies, transport destinations, and timelines

HOW CONTRIBUTES

Protocols are the mechanism used to delegate physician practice of medicine to paramedics. Compliance with protocols is essential for performance improvement.

GOAL 100% of audited PCRs are compliant DATA SOURCE MEDS DATA DISPLAY SPC Chart

9. PARAMEDIC SKILL RETENTION

DEFINITION Percentage of paramedics who have demonstrated competency in vital and seldom used clinical skills each year.

HOW CONTRIBUTES

Certain critical clinical skills have the potential to erode without regular use. Ensuring that paramedics update their skill competency once a year assures patients that their paramedics will be able to perform vital skills when needed.

GOAL 100% of paramedics demonstrate competency in vital and seldom used clinical skills each year

DATA SOURCE Ninth Brain DATA DISPLAY SPC Chart

10. ASTHMA TEAM IMPACT

DEFINITION Number of patients visited by the Asthma Team each month and qualitative description of the activities.

HOW CONTRIBUTES

Key to building our capacity to measurably improve health and advance scientific knowledge about EMS’s involvement in

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KRA: CLINICAL community health through the asthma study.

GOAL See half of the adults seen for asthma at Highland’s Emergency Department

DATA SOURCE Highland and Team Records

DATA DISPLAY SPC Chart and Qualitative Description

11. PRINTING PCR PRIOR TO RETURN TO SERVICE

DEFINITION The percentage of PCRs printed between the time the unit arrives at the hospital and when it goes in service

HOW CONTRIBUTES

Provides the ability for in-hospital clinicians to have vital pre-hospital data available when making diagnostic and treatment decisions

GOAL All PCRs printed before the unit goes in service DATA SOURCE FirstWatch DATA DISPLAY SPC Chart

KRA: RESPONSE TIME PERFORMANCE

12. WEEKLY RESPONSE TIME PERFORMANCE BY ZONE, SUB AREA, PRIORITY, AND THE EOA

DEFINITION The percentage of 9-1-1 calls where the response time, measured from the time the call arrives from the FD PSAPs in our CAD until the unit arrives on scene, within contractual guidelines per week for each zone.

HOW CONTRIBUTES

Our purpose is to reduce suffering and improve health. Arriving on scene quickly helps us meet both of these criteria.

GOAL All responses in less than the required performance time frame by zone each month

DATA SOURCE CAD, Multi-CAD Information System (MCIS) DATA DISPLAY SPC Chart

13. LATE CALL ANALYSIS

DEFINITION Analysis of calls where the response time is longer than what is contractually required for the cause of the long response.

HOW CONTRIBUTES

Understanding the root causes and patterns behind late calls is essential to performance improvement. Reduction in the number of

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KRA: RESPONSE TIME PERFORMANCE late calls improves customer satisfaction and reduces suffering.

GOAL Understand and reduce the causes of late calls DATA SOURCE CAD DATA DISPLAY Pareto Chart

14. LOST UNIT HOURS

DEFINITION The number of unit hours paid for but not available to the system. HOW CONTRIBUTES

Lost unit hours represent system waste. Wasted resources increase system cost while decreasing performance which impairs the ability to reduce suffering and improve health.

GOAL Minimize lost unit hours DATA SOURCE MCIS DATA DISPLAY SPC Chart

15. RATIO OF MUTUAL AID PROVIDED VS. RECEIVED

DEFINITION The number of times we provide mutual aid compared with the number of times other agencies provide mutual aid for us each month.

HOW CONTRIBUTES

Being fair to our colleagues from other agencies is important

DATA SOURCE CAD and MCIS GOAL Ratio of mutual aid 1 to 1 for each transporting Fire Department DATA DISPLAY Data table

KRA: CUSTOMER SATISFACTION

16. DID THE PARAMEDICS ARRIVE QUICKLY?

DEFINITION The percent who answer yes on customer satisfaction surveys per month

HOW CONTRIBUTES

Getting there quickly is a key customer requirement

GOAL 100% of people surveyed answer yes DATA SOURCE Customer satisfaction surveys -- Youth Uprising is our preferred

vendor for customer survey data entry services. DATA DISPLAY SPC Chart

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KRA: CUSTOMER SATISFACTION

17. DID THE PARAMEDICS ACT IN A CONCERNED AND CARING MANNER?

DEFINITION The percent who answer yes on customer satisfaction surveys per month per month

HOW CONTRIBUTES

Acting in a concerned and caring manner is a key customer requirement

GOAL 100% of people answer yes DATA SOURCE Customer satisfaction surveys DATA DISPLAY SPC Chart

18. DID THE PARAMEDICS EXPLAIN WHAT THEY WERE DOING AND WHY?

DEFINITION The percent who answer yes on customer satisfaction surveys per month per month

HOW CONTRIBUTES

Explanation before action is a key customer requirement

GOAL 100% of people answer yes DATA SOURCE Customer satisfaction surveys DATA DISPLAY SPC Chart

19. PAIN, DIFFICULTY BREATHING, OR DISCOMFORT IMPROVEMENT

DEFINITION The percent of patients who report feeling better after pre-hospital care per month

HOW CONTRIBUTES

Relief of pain and suffering is a key customer requirement

GOAL 100% of people have relief of suffering DATA SOURCE Customer satisfaction surveys DATA DISPLAY SPC Chart

20. OVERALL CARE AND SERVICE RATING

DEFINITION The percentage of patients who rated overall service as good or great per month

HOW CONTRIBUTES

Overall assessment of our customer service performance

GOAL 100% of patients rate the overall service as good or great DATA SOURCE Customer satisfaction surveys DATA DISPLAY SPC Chart

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KRA: HUMAN RESOURCES/EMPLOYEE SATISFACTION

21. NUMBER OF SHIFT HOLDOVERS PER WEEK

DEFINITION Number of shifts where a crew is held past their end of shift time per week

HOW CONTRIBUTES

Ending shift’s on time has been identified by employees as a key requirement for employee satisfaction

GOAL Low number of holdovers per week DATA SOURCE Payroll System and Scheduling DATA DISPLAY SPC Chart

22. EMPLOYEE MORALE

Definition The percentage of employee satisfaction surveys that rate morale as “very happy” or most of the time “I have a good time at work”

How Contributes Morale of the workforce is believed to be one of the key ingredients in good performance and strong customer satisfaction.

Goal 100% of employees say that are very happy or most of the time they have a good time at work

Data Source Survey Monkey Database Data Display SPC Chart

23. TURNOVER FACTORS

Definition The percentage of employee satisfaction surveys that indicate yes on the 7 questions identified by the Gallop Organization as being predictive of turnover. 1. Do I know what is expected of me at work? 2. Do I have the right materials and equipment? 3. At work, do I have the opportunity to do what I do best every day? 4. Have I received recognition or praise for doing good work in the last seven days? 5. Does my supervisor or someone at work, seem to care about me as a person? 6. Is there someone at work who listens to my opinions? 7. Is there someone at work who encourages my growth and development?

How Contributes Retention of experienced employees increases our ability to deliver good quality service to our customers.

Goal 100% of employees answer yes to all 7 questions

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KRA: HUMAN RESOURCES/EMPLOYEE SATISFACTION Data Source Survey Monkey Data Display SPC Charts

24. TURNOVER RATE

Definition The number of employees who leave full time positions each month. How Contributes Retention of experienced employees increases our ability to deliver

good quality service to our customers. This is also a measure of employee satisfaction.

Goal Low turnover rate Data Source Human Resources Information System Data Display SPC Chart

KRA: COMMUNITY HEALTH PARTNERSHIPS

25. 9-1-1 CALLS, ED VISITS, HOSPITALIZATIONS FOR ADULTS WITH ASTHMA TREATED BY ASTHMA TEAM

DEFINITION Number of 9-1-1 calls, ED visits, and hospitalizations for adults with asthma treated by the Asthma Team

HOW CONTRIBUTES

Fewer 9-1-1 calls, ED visits, and hospitalizations decreases suffering

GOAL Reduced number of asthma attacks for people with asthma DATA SOURCE CAD, MEDS, Highland Hospital DATA DISPLAY SPC Chart

26. COMMUNITY HEALTH IMPROVEMENT ACTIVITIES

DEFINITION Qualitative description of the community health improvement activities engaged in each month.

HOW CONTRIBUTES

Our vision is to measurably improve the health of the community we serve and our partnership activities are a key component of that commitment.

GOAL Rich connected partnership activities engaged in health improvement each month.

DATA SOURCE Meeting and activity notes DATA DISPLAY Narrative description

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KRA: FLEET

27. CRITICAL VEHICLE FAILURES

DEFINITION The number of mechanical vehicle failures that occur while responding to, at the scene of, or while transporting a patient per month.

HOW CONTRIBUTES

Vehicle performance is an essential component of patient centered care.

GOAL Zero critical vehicle failures DATA SOURCE Fleet Management Software DATA DISPLAY SPC Chart

28. LATE PREVENTATIVE MAINTENANCE

DEFINITION The number of scheduled preventive maintenance services that are performed after the due date per month

HOW CONTRIBUTES

On-time preventative maintenance is a strategy to reduce critical vehicle failures

GOAL Zero late preventative maintenance services DATA SOURCE Fleet Management Software DATA DISPLAY SPC Chart

KRA: SAFETY

29. EMPLOYEE INJURIES

Definition Number of workers comp claims filed per month How Contributes This is a key measure of workplace safety Goal Zero employee injuries each month Data Source Corporate MSIP Report (national safety report) Data Display SPC Chart

30. SEVERITY OF EMPLOYEE INJURIES

DEFINITION The number of days that injured employees are unable to work in their primary job per month

HOW CONTRIBUTES

Our objective is to decrease the severity of employee injuries

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KRA: SAFETY GOAL Zero employee injuries each month DATA SOURCE Corporate MSIP Report DATA DISPLAY SPC Chart

31. VEHICLE CONTACTS

DEFINITION The number of times our vehicles come in contact with other vehicles or objects

HOW CONTRIBUTES

A low number of vehicle contacts is an essential measure of driver safety

GOAL Zero vehicle contacts DATA SOURCE Corporate MSIP Report DATA DISPLAY SPC Chart

32. COST OF CRASHES

DEFINITION Dollar amount spent on crashes each month HOW CONTRIBUTES

The cost of crashes is a measure of crash severity

GOAL Zero vehicle contacts DATA SOURCE Corporate MSIP Report DATA DISPLAY SPC Chart

KRA: UNUSUAL OCCURRENCES AND COMPLAINTS

33. UNUSUAL OCCURRENCES AND COMPLAINTS

DEFINITION Qualitative description and coding of unusual occurrences and complaints, along with count of incidents per month

HOW CONTRIBUTES

Addresses the things that our customers are concerned about

GOAL Reduce the number of unusual occurrences and complaints

DATA SOURCE Ninth Brain

DATA DISPLAY Qualitative Description and SPC

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KRA: FINANCIAL SUSTAINABILITY

34. UNIT HOUR UTILIZATION RATIO

DEFINITION The number of transports during a month divided by the number of unit hours produced.

HOW CONTRIBUTES

This is a key measure of productivity for the ambulance industry

GOAL Maintain unit hour utilization ratio in alignment with response time performance and task time

DATA SOURCE Daily SQL Reporting DATA DISPLAY SPC Chart

35. AVERAGE PATIENT BILL

DEFINITION Average patient bill per month HOW CONTRIBUTES

This is a key measure for accounts receivable and is important to our community for controlling healthcare costs

GOAL Control costs while maintaining excellent care and service DATA SOURCE Patient Billing Services DATA DISPLAY SPC Chart ✔ 2.5.2 Proposers should provide a list of suggested KPIs and goals (See Table 1) for each of the KRAs listed above. Include a specific data definition and data source for each KPI. Table 1: Example – Key Result Area (KRA) with associated Key Performance Indicators (KPI)

A list of the above-requested information including specific definitions, goals, and

data sources for each numbered KPI appears in the charts that immediately precede this

requirement. Our measurement, analysis, and knowledge management practices are

detailed in the introduction to this Clinical Quality Improvement section and as follows:

MEASUREMENT: At our monthly Quality Steering Committee meetings we

generate ideas on how to accurately measure and record relevant data for each area we

wish to improve. Our quality/leadership team works closely with the Alameda County

Key Result Area Key Performance Indicator Goal

Employee Retention Average tenure = 2 years Increase average length of tenure by 10% within 6 months

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EMS Agency, the Medical Director, community partners, and other relevant stakeholders

to ensure our ability to collect appropriate data in a scientifically-valid manner.

ANALYSIS: Once appropriate data for the relevant KPI has been collected, our

Quality Steering Committee including Health Care Statistician Davis Balestracci closely

examines the data using a variety of analytical tools to extract statistically-valid meaning

from the data.

KNOWLEDGE MANAGEMENT: Knowledge management relates to how the

information and understandings resulting from our data collection and analysis processes

are distributed and made useable by every person in our organization, our regulators, and

our partners. We use a variety of knowledge distribution methods including .mp3

downloads and CD’s, memos, emails, pages, texts, written and oral reports, and others

depending on the nature of the information and the County’s preference. We use a variety

of reporting methods described in the introduction to this section, using statistical process

control (SPC) charts as our primary method of communicating quantitative data. Samples

of reports required in section H.2.17.4 can be found in Attachment 9.

✔ 2.5.3 Proposers should describe their method for regularly assessing compliance with Alameda County EMS policies. Contractor will be required to produce a report that describes overall compliance with protocols and provide a statistical analysis, such as Pareto charts and/or process control charts, for protocols that have the most compliance problems. (See Figure 2)

We comply and will continue to comply with this requirement. The following is

our method for regularly assessing compliance with Alameda County EMS policies and

protocols:

• Conduct 100% chart audit for policy/protocol compliance on all cardiac arrest,

STEMIs, strokes, and trauma activations, 10% random chart audit for all others

• Document deficiencies and patterns of deficiency

• Analyze deficiencies and patterns

• Produce statistical process control charts as in Figure 2 of the RFP as well as Pareto

charts which help identify the most frequent deficiencies in policy/protocol

compliance

• Generate performance improvement projects based on information learned in the

above processes, and track project progress on an ongoing basis

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The above processes are designed in collaboration with representatives of the

Alameda County EMS Agency and Medical Director’s office with whom we meet formally

at weekly and monthly quality meetings in addition to regular contacts in our day-to-day

operations.

✔ 2.5.4 Describe how your organization makes performance data and analysis available to employees, customers, the County, and other system partners.

Our County customer receives detailed monthly performance reports in a variety of

areas and has near-real-time access to patient care and response time data every day. The

EMS Agency Acting Director and Medical Director also have regular weekly update

meetings with our General Manager. We are willing to provide the County with any

additional or follow up performance data or analysis at all times to further a transparent

working relationship.

Our system partners receive regular update reports on improvement projects with

which they are involved. We have regular meetings with individual partner organizations

like Fremont Fire, Oakland Fire, and Summit Hospital’s Emergency Department Staff to

gather feedback and share performance information. We also meet with them during

regular County meetings including the Fire Chiefs, the EMS Section of the Fire Chiefs, the

hospital STEMI Centers, and more. The County EMS Agency will have access to all of

KPIs we measure.

Our employees receive response time performance pages every six hours when on

duty, and other performance information including composite clinical score performance,

customer survey results, and employee survey results in a monthly performance digest.

More details can be found in section D.2.1.3.

As an enhancement for the new contract, we will prepare for our patient customers,

the County, employees, and other system partners an Annual System Performance Report

that includes performance information in all key areas. A copy of this report will be

available on our website at www.alcoamr.net.

✔ 2.5.5 Describe your organization’s approach to learning and performance improvement using industry and non-industry benchmarking.

Our organization’s approach to learning and performance improvement using

industry and non-industry benchmarking is to conduct both best practices and comparative

benchmarking.

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Best Practices Benchmarking

For best practices benchmarking we:

1. Identify areas we would like to improve,

2. Identify organizations that have best practices in those areas,

3. Read about, observe, visit, and interview members of those best practice

organizations to learn about how they do what they do,

4. Adapt practices for our organization by applying what we’ve learned, and

5. Enter a PDSA (Plan-Do-Study-Act) cycle for process improvement that

implements the change.

Recent best practice benchmarking that has influenced our organization and which

we detail in relevant sections of this proposal includes:

• Sarasota Fire Department and customer satisfaction surveys

• Seattle Medic One and cardiac arrest

resuscitation

• World Health Organization and their composite

approach to quality management scoring

• Alameda County Health Care Services Agency’s

Asthma Start Program and their approach to

adolescent self-care asthma management, and

• The Ethnic Health Institute, Youth Uprising,

Urban Releaf, and the California Health Endowment’s approach to

epidemiologically-driven collaborative community health improvement.

Comparative Benchmarking

Additionally, we do comparative benchmarking with MEDIC, the Charlotte N.C.,

Mecklenburg County EMS system, and our sister AMR operations across the Country on

areas of clinical and operational performance. We receive a Clinical Performance Indicator

monthly report from AMR’s national clinical quality team that provides a comprehensive

opportunity for comparative clinical benchmarking across dozens of EMS operations. This

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allows us to identify internal best practices that we can learn from to improve our

performance.

✔ 2.5.6 Describe your organization’s information technology system used to support the measurement, analysis, and reporting process. Include your approach to compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), data accuracy, timeliness, and security.

Our measurement, analysis and reporting processes are supported by a number of

core technologies described below including Computer Aided Dispatch (CAD), Multi-

CAD Information System (MCIS), Multi-EMS Data System (MEDS), Ninth Brain Suites

(Ninth Brain), Business Objects, FirstWatch, Optima, and Survey Monkey. Used together,

these systems fully support our team’s measurement, analysis, and reporting functions as

well as day-to-day system management and performance improvement objectives. We are

also partnering with Microsoft Health Vault and Palantir for some additional enhanced data

analysis capabilities.

“It’s not the tools you have it’s what you do with them that counts. My team and I are dedicated to ensuring Alameda County AMR has all the technical resources necessary to

be a shining star in information-driven clinical and operational EMS advances.”

- Phil Coco, National Director of Information Technology, AMR

We use some of the most advanced and sophisticated hardware and software

available anywhere and we have dozens of in-house technology experts both on and off-

site who are available to support these systems whose sole responsibility is to our

organization. The most important tool we have is the intelligence and experience of our

team members. Our on-site Information Technology Specialist, Louis Ho, is our liaison to

some of the most-respected technology experts in our industry through AMR’s national

information technology team. Our IT specialists throughout the Bay Area also can be

accessed for back-up support in the event of a major disaster.

Our organization has full-time compliance officers whose role is to ensure our

systems and technologies are always HIPAA-compliant. From a data security perspective,

our systems have the highest level of security equivalent to that used by the Federal

Government for top secret information and are fully HIPAA-compliant. The datasets we

use are gold-certified by the National EMS Information System (NEMSIS), the highest

level currently available.

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For us, technology is only as exciting as the results it helps achieve for patients and

the community. Below is a description of some of our core technologies:

PERFORMANCE, RESULTS, & REPORTING TECHNOLOGY

ENROUTE AMBULANCE COMPUTER AIDED DISPATCH The new EnRoute Ambulance Computer Aided Dispatch (CAD) system we will

provide as part of our

consolidation with the ACRECC

dispatch center is designed to

manage dynamic resources and is

the same brand that has reliably

dispatched ambulances throughout

Alameda County and the Bay Area

for several years.

This CAD already has an interface to both ACRECC and Oakland’s Fire CADs,

and is fully-integrated with Optima Predict, Optima Live, FirstWatch, MEDS, and MCIS.

The CAD facilitates management of the entire call from receipt of call, to unit selection, to

managing the response, to hospital transport, to return to service. It seamlessly facilitates

the dynamic posting of ambulances that is critical to good response time performance.

More can be found in Attachment 10, and at www.enroute911.com.

FIRSTWATCH REAL-TIME EARLY WARNING SYSTEM FirstWatch Real-Time Early Warning System (FirstWatch), is an independent

software and data mining and analysis company with more than 91 customers, including

public entities, governments, agencies, Fire Departments, law enforcement agencies,

communications centers, private ambulance services, and health departments. FirstWatch

is an internet-based system that collects data from numerous systems, pulls it all together,

and monitors it in real-time for user-defined issues, trends, or patterns. It works like a

smoke detector, always on in the background monitoring for issues that should be attended

to by humans. It also shares data and data analysis with agencies and individuals in a

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variety of forms such as e-mail, fax, text message, or other methods, with 99.999%

uptimes.

FirstWatch provides a data lockbox service which grabs and stores data before it

has been cleaned which allows regulators an extra level of assurance that they will be able

to perform their regulatory functions with confidence. Originally established as a

syndromic surveillance system, this software has the ability to monitor CAD and MEDS

ePCR data in real-time, provide alerts for situations that are defined by us as “unusual,”

provide real-time performance feedback on key processes, and provide macro analysis on

performance over time.

FirstWatch is compatible with a variety of data systems including Bio Key, the

patient care record data system used by most Fire First Responder agencies in Alameda

County. We are currently working with the County EMS Agency to integrate First

Responder partners’ Bio Key data and MEDS data to create system-wide, patient-centered

composite clinical scores for the Airway Checklist and other composite scores that will

evolve over time. The next picture shows PCR printing performance improvement as

monitored by FirstWatch. For more information, see www.firstwatch.net

FirstWatch Performance Monitoring

THE MULTI-CAD INFORMATION SYSTEM The Multi-CAD Information System (MCIS) is a proprietary tool that tracks and

analyzes response time performance data and all its sub-components. It allows for easy

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management of exemptions, providing regulators with a user-friendly mechanism to review

and audit response time compliance by zone. The following picture shows a portion of

MCIS that tracks month-to-date response time compliance by zone.

MCIS performance monitoring showing month-to-date performance as of January 17, 2010 9:30 PM

MEDS AND NEW MEDS VERSION 3.0 EPCR SOFTWARE

Our Multi-EMS Data System (MEDS) is the proprietary

software currently used in Alameda County for electronic patient

care reports (ePCRs). MEDS offers a highly functional end-to-

end EMS patient care record solution from data collection to

reporting and data analytics.

MEDS was originally developed by our company’s

national team of programmers in collaboration with San Mateo County EMS agency and

other Bay Area EMS Agencies to address the 9-1-1 industry’s need for software that could

interconnect multiple data systems and other reporting and analysis tools while providing

the rapid ease-of-use for day-to-day functioning EMS requires. For example, we have

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successfully integrated MEDS data into the hospital electronic medical records at Cottage

Hospital in Santa Barbara and Centura Health in Colorado. We have begun working with

Kaiser Oakland to achieve the same result.

MEDS has one of the strongest reporting capabilities in the industry and is also

customizable to enable collection of specific clinical and other data sets for research,

quality, and monitoring purposes. There are currently more than 3,000,000 patient care

records in AMR’s nationwide database, with an additional 90,000 patient care records

added each month, which gives us an unprecedented ability to benchmark and engage in

clinical research projects.

The new version of MEDS, MEDS 3.0 will be deployed in Alameda County in

2010. It features several enhancements that allow our system to gather information,

perform research, and execute performance improvement projects like never before. Some

of the new features of MEDS 3.0 include:

• Easy to add customizable drop down menus for composite checklists, County

specific protocols, or research studies.

• Interface with Fire House Records Management System

• Updates will be pushed to laptops used by our crews every three weeks. This

constant software improvement is a benefit over traditional version updates that are

done by most software companies.

• Touch-screen or keyboard data entry

• Reverse phone lookup built in

• Portable scanners to insert trailing documents or identification cards directly into

the ePCR. Images are sharpened and the file size is reduced for faster transmission

• Camera to take photos of patient medications

• Card reader to scan driver’s licenses for demographic information. Works with

licenses issued in any of the 50 states

• Interfaces with Lifepak-15

• Web version available

• Will be compatible with Cardiac Arrest Registry to Enhance Survival (CARES)

database by the end of 2010

• Instant insurance verification for improved accounts receivable

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• If AMR has previously treated a patient, MEDS 3.0 enables access to the prior PCR

so the provider can see past treatments and other clinical information

As an enhancement, before the new contract, we will develop an e-mail referral and patient information database for prevention or chronic disease management follow-up.

We will work with the County Medical Director to create a bank of e-mail instructions and then with the patient’s permission and email address, paramedics can send them

information designed to improve their self-care that will be waiting for them in their email box when they get home from the hospital.

The next MEDS screen shot shows how easy it is to document physical exam

findings.

MEDS 3.0 ePCR Screen Shot Physical Exam Documentation

More about our MEDS ePCR system can be found in Section I.3.

MICROSOFT HEALTH VAULT AND MEDS 3.0 Health Vault is Microsoft’s new internet-based health data storage and sharing

system. Microsoft invests approximately $35 Billion each year in research and

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development. Health Vault is their approach to use technology to help solve health

problems around the world.

It is a secure, web-based, free system that provides a place for patients to store their

health data -- all of it. The records are controlled by patients. Among the benefits for

patients is the ability for them to allow multiple treating physicians and care providers

access to their records, as shown in the next graphic. This capability is especially useful in

situations such as chronic disease management where multiple specialists may need access

to one patient’s information. AMR will have its own portal into Microsoft Health Vault. If

patients wish and with their permission we can register them for Health Vault, upload their

MEDS ePCR to their personal Health Vault account, and read information from their

Health Vault account in the field.

OPTIMA PREDICTTM AND OPTIMA LIVETM SOFTWARE SUITE ADVANCED PLANNING AND DECISION SUPPORT

Optima Predict and Optima Live Software Suite (Optima) is an operations research-

based suite of software products focused on optimizing resources and improving response

times. Optima Predict is an advanced planning support tool that uses simulation

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technology to allow any number of future scenarios to be assessed and evaluated, and a

working model that simulates real-life performance. Optima Live is an interactive real-

time decision making support tool for improving response time performance. It makes

dispatch and re-deployment recommendations to dispatchers based on current vehicle

locations and status, staff shift information, and call information. The following pictures

show samples of the kind of analysis done by Optima Live. The next screen shot is a real-

time view of Alameda County System from Optima Live:

Optima Live Real-Time System View

More about the ground-breaking Optima tools can be found in the Operations

Management Provisions section, Attachment 11, the Optima Live Movie CD included in

the Attachments binder, and at www.theoptimacorporation.com.

PALANTIR ADVANCED ANALYTICS AND DATA MINING

Alameda County AMR is currently collaborating with Palantir Technologies, a

leading Silicon Valley based technology firm, to deploy a revolutionary analytic and data

mining platform. The platform offers unparalleled capabilities for integrating, visualizing,

and analyzing information. The technology supports many kinds of data including

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structured, unstructured, relational, temporal, and geospatial. The platform has been built

for interactive analysis with a focus on security, scalability, ease of use, and collaboration.

Palantir Screen Shot of EMS Call - High Level Overview

The Palantir platform is broadly deployed in the intelligence, defense, law

enforcement, and financial communities. Now, Alameda County AMR is the first

organization in the world to apply this innovative technology to healthcare. We are

planning to deploy a comprehensive solution that will enable us to aggregate our numerous

data sources and provide a comprehensive view of our clinical, operational, and financial

performance.

Currently the technology has been utilized to aggregate Alameda County AMR

CAD and ePCR data. It is anticipated that future deployments will be used to aggregate,

visualize, and analyze data from numerous other clinical, operational, financial, and

external healthcare information systems. By breaking down traditional information silos

and aggregating both pre-hospital and hospital data, it will be possible to analyze and

measure what actually happens throughout the patient care continuum. This new

technology will support our ongoing efforts to improve our overall care, manage costs, and

ultimately improve patient outcomes.

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Palantir Screen Shot of Peak EMS Call Volume Analysis

Palantir’s headquarters are in downtown Palo Alto. For more information see

www.palantirtech.com. For videos displaying some of the current applications of the

technology please visit www.palantirtech.com/government/videos.

NINTH BRAIN SUITE Ninth Brain Suite (Ninth Brain), is web-based platform supports training and

education, quality management, complaint and incident tracking, safety, OSHA

compliance, licensure and certification tracking, and other vital processes. The program

was created by EMS professionals to improve EMS organizations’ ability to:

• Track work-related employee health issues and compliance with safety

requirements

• Provide high quality online education to help employees 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 for running an EMS system

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• Communicate vital and time sensitive information to employees

• 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 employees, first responders, supervisors, and administrators of pending and

expired certifications/licenses with automated alerts, and

• Create custom reports

The next picture shows a sample of the Credential Tracking System in Ninth Brain:

Ninth Brain Credentials Tracking Screen Shot

The next screen shot shows a sample of the AMR customized education courses

available online through Ninth Brain.

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Ninth Brain Custom Online Education

BUSINESS OBJECTS Business Objects is the business intelligence tool we use to analyze, understand,

and create meaningful reports from the information contained in our massive database of

clinical, system, and performance information.

For more, see: www.ondemand.com/businessintelligence.

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ISERA SCHEDULING SOFTWARE This scheduling program allows us to input the shift design rules in our union

contract along with the system’s historical demand for calls and it helps us produce a

schedule that maximizes coverage while minimizing waste. ISERA helps make sure that

our ambulances are fully staffed to meet the needs of the system.

ISERA Scheduling Software Screen Shot

SURVEY MONKEY Survey Monkey is a web-based survey tool that facilitates easy collection of

employee feedback online and via email and allows data to be exported to a variety of

formats for analysis and reporting purposes. Currently we use Survey Monkey for our

quarterly employee satisfaction surveys and other on-line surveys for various projects.

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Customer satisfaction surveys are mailed in paper and results are input to a database using

Youth Uprising’s social enterprise business for data entry services.

Survey Monkey Screen Shot of Employee Survey Question

✔ 2.5.7 Proposers shall provide sample checklists to improve clinical care for EMS patients and to improve the reliability of other key processes. An example is provided in Table 2.

In addition to clinical checklists, we use a number of checklists in our organization

to improve reliability of processes related to preventive fleet maintenance, equipment

maintenance, stocking, hiring, new employee orientation, tiered partnering decisions, and

other employee matters. Sample checklists can be found in Attachment 12 as well as in the

Minimum Clinical Levels and Staffing Requirements section.

COMPOSITE CLINICAL CHECKLISTS

For clinical matters, we collaboratively developed the Airway Checklist shown in

the next picture with the Alameda County EMS Agency, Alameda County’s Medical

Director, and system partners using the Institute for Healthcare Improvement’s Model for

Improvement. The Airway Checklist is based on a composite scoring system inspired by

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best practices benchmarking with the World Health Organization. We are in the process of

developing checklists for other clinical issues including Cardiac Arrest, STEMI, Stroke,

Unconsciousness, Pain Management, and Major Trauma. We recently completed phase 1

of the STEMI checklist with partners from Summit Hospital and anticipate its completion

before the start of a new contract. We currently measure Airway Checklist performance as

a KPI and will add others as they are approved for full deployment by the Alameda County

Medical Director.

The Airway Checklist represents a significant advance in EMS. All EMS providers

learn that Airway, Breathing, and Circulation, the ABC’s, should be the primary focus as

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they care for patients, and it is common for EMS systems to measure and report their

ability to manage airway. However, when one looks closely at what is being measured, the

vast majority of EMS systems that track and report airway management skills are really

looking at intubation skills. When viewed from the patient’s perspective, this approach is

inadequate. It focuses more on provider skill than on patient need and presumes that the

only important part of the airway to assess is from the neck up.

While intubation or other “advanced airway” skills make up an important

component of care for these patients, these people also need a proper assessment including

end-tidal carbon dioxide monitoring and a listen to their lung sounds. They need oxygen

and to be properly positioned for optimal air flow. The reality of good care is that patients

like these need a composite of assessment and treatment such as the one we use today to

ensure good comprehensive care.

Composite Clinical Checklist Inspiration

The Airway Checklist was inspired by benchmarking a quality improvement

initiative the World Health Organization presented at the Institute for Healthcare

Improvement’s Annual Forum in 2008. There,

Atul Gawande M.D, from the World Health

Organization described a multi-national research

study where they implemented a trial surgical

checklist in nine countries to decrease post-

surgical complications and death. The World

Health Organization adapted to surgical suite

safety the airline industry’s approach to using

checklists for every flight 100% of the time.

The checklist they created details critical

actions that should be taken in the operating room

before, during, and after surgery, such as marking

the surgical site, introducing oneself to the other providers, and providing the patient with

antibiotics. To track performance if all actions on the checklist are performed, the score is

one, if one item from the list is missing, the score is zero.

Dr. Donald Berwick, MD, IHI President and CEO

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Their data showed a significant decrease in post-surgical complications and deaths

with the use of the checklist, so they decided to roll out the checklist to all operating rooms

around the world. It is estimated that full implementation of will save approximately 2.2

million lives per year of those who otherwise would have died post-operatively.

Alameda County EMS, Medical Director, and Partners Checklist Collaboration

Inspired by the World Health Organization’s surgical suite checklist and hoping to

improve on the traditional approach, we invited the Alameda County EMS Agency, the

Medical Director, and several of our Alameda County Fire First Responder partners

including Fremont, Oakland, City of Alameda, and Alameda County, to collaborate in the

development of a novel approach to EMS airway management performance measurement.

We facilitated the project to create the new composite Airway Checklist following the

Institute for Healthcare Improvement’s Model for Improvement.

The approach the project team took is simple and patient-centered. We looked at

the airway as extending from the mouth and nose to the alveolar ducts in the lungs where

oxygen and carbon dioxide are exchanged with blood flowing through capillaries. We

included all patients who have or potentially have airway compromise such as asthma,

pneumonia, and cardiac arrest.

The resulting evidence-based checklist the team collaboratively designed has seven

assessment components and six treatment components. Consistent with the World Health

Organization’s scoring system, the patient’s Airway Checklist score is one if all of the

checklist components are documented. If one item is not performed and documented, the

score is zero.

INITIAL/PDSA CYCLE: Once an initial checklist was devised, we had two

members of our team, one Fire paramedic and one ambulance paramedic, try the checklist

with a handful of patients. Based on their experience we refined the checklist.

BETA TESTING/PDSA CYCLE 2: For beta-testing we sent the checklist out with a

small group of paramedics made up of 20 of our Field Training Officers and experienced

paramedics from four area Fire First Responder partner agencies. Feedback on the

checklist was gathered from these beta-testers using a web-based qualitative survey. The

checklist was revised again to incorporate feedback. We then met with the County Medical

Director for a final review and approval.

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IMPLEMENTATION/PDSA CYCLE 3: We rolled out the final checklist to all our

employees in Fall 2009 and created an Airway Checklist Performance Key Performance

Indicator (KPI). The KPI is defined as the percentage of patients by month who have or

potentially have airway compromise whose score is one. Consistent with our quality

practices, each month we review Airway Checklist Performance and take actions to

continually improve in this area. By using Airway Checklist Performance to monitor how

we manage airway we ensure our patients receive every possible chance of breathing easier

and staying alive.

Next Steps: Additional Composite Clinical Checklists Commitment

Going forward, we commit to leading the design and implementation of composite

checklists for the care of patients with STEMI, stroke, pain, cardiac arrest, major trauma,

and unconsciousness. Our objective is to have a small set of composite key performance

indicators designed from the patient’s perspective that will enable every EMS provider in

the system to know how well we are caring for our most serious patients. This system

makes it easy to educate, monitor, and provide performance feedback for both individual

EMS providers and the entire system.

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✔ 2.5.8 Include a team approach to the treatment of cardiac arrest, and other Echo calls where team members are assigned specific roles to improve the efficiency of EMS interventions. Include establishing and maintaining airway control, intubation, and establishing medication access. Table 2: Example - “Pit crew” positions and responsibilities (Subject to modification)

Position and Responsibilities Personnel Assigned

Pit Crew Leader: Overall team leader Assigns roles Monitors time intervals (2 min. CPR, drug intervals, etc.) Assures quality of CPR Assures use of proper equipment and adjuncts (e.g., EtCO2) Serves as scribe (field notes) Supervises and assigns crowd control Supervises DNR/POLST issues Performs NO patient care

Fire or transport EMT or paramedic (preferably Fire Captain or Lieutenant)

Airway Leader: Performs appropriate airway techniques, procedures Supervises airway decisions Uses confirmatory adjuncts Completes PCR at hospital (if appropriate) (with med leader) Communicates with law/family as needed Defibrillates if medication leader not available

Fire or transport paramedic

Medication Leader: Defibrillates Initiates IV or IO Administers (or supervises) medications Tracks and notifies team of all monitor changes Completes PCR (with airway leader) Communicates with family/law as needed Terminates resuscitative efforts (with team leader)

Fire or transport paramedic

CPR Chief: Supervises and performs CPR (with team leader) Assists with equipment/medication setup Performs communications

Fire or transport EMT

Team Assistant: Assists with CPR Assists with communications Assists with setup

Fire or transport EMT

Team Leader/Airway Assistant (optional) Serves at assistant to team leader Assists airway leader

Fire or transport EMT or paramedic

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We subscribe to the pit crew approach and are in the process of training our crews

to this standard. Cardiac arrest resuscitation is one of the few places in EMS where the

measurement is straightforward and unambiguous -- people either live or they die. With

the advancement of resuscitation science, in a small handful of EMS systems if a person

has a witnessed cardiac arrest with a ventricular arrhythmia such a person has a better

chance of living than dying. One of the many practices that these EMS systems point to as

contributing to their success is the “Pit Crew Concept.”

The pit crew concept comes from race car driving. When you are in a race car, one

of the keys to winning a race is to have as short as possible a pit-stop. An effective pit-stop

is complete, safe, and really fast. If your crew has a pit-stop of 16 seconds and your

competitor has a pit-stop of 17 seconds, you have a one-second lead to win the race.

We are competing against death from sudden cardiac arrest. In the course of our

benchmarking research visits with members of Seattle Medic One, the organization that

produces the best cardiac survival rates in the world, we asked their approach to pit-crew.

For Seattle Medic One, a “pit-stop” is any time CPR is interrupted for assessment or

treatment. They require pit-stops to be 10 seconds or less. Pit-crew choreography involves

one person standing back watching time intervals, one person managing airway, one person

managing EKG and defibrillation, and one person on compressions.

Our approach to the pit-crew concept is to work with our first response partners to

make sure each of these vital roles is filled and that our pit-stops (defined as breaks from

CPR), are 10 seconds or less, consistent with the industry’s best practice. We are actively

supporting the County’s spearheading of Take Heart Northern California a program that

includes the Pit Crew approach to cardiac arrest scene management with other modalities

like post resuscitation hypothermia and high performance CPR to measurably improve the

survival to hospital discharge rate for people with cardiac arrest.

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✔ 2.6 PROCESS MANAGEMENT

✔ 2.6.1 Describe the organization’s core competencies and how these were determined.

Our organization’s core competencies with respect to overall operations include the

production of solid response time performance and outstanding clinical care. These

competencies were determined by looking at our results on a daily, weekly, and monthly

basis. The “Fitch Report” on the Alameda County EMS system externally validated the

strong clinical care we provide in collaboration with our Fire First Responder partners.

We also have competencies in quality management systems, building health

corporate cultures, and sound fiscal management. Our organization’s core competencies

with respect to process management are process design, performance analysis, systems

thinking, collaboration, partnership, and patient-centered design. These core competencies

were determined based on feedback from customers and system partners including the

Alameda County Health Care Services Agency and EMS Agency.

✔ 2.6.2 Describe how the organization designs key processes with the involvement of patients, customers, front line employees, and system partners.

The way we design key processes is:

• Determine what result is hoped to be produced from the process

• Identify the inputs to the process

• Design a process map for each step of the process

• Identify key process performance measurements to monitor whether the

process is producing the desired result, and

• Conduct small beta trials to test the process before implementing changes

system-wide wherever possible.

We involve patients through their input via surveys and other contacts. Other

customers, front line employees, and system partners including the EMS Agency, Fire First

Responder agencies, and hospitals are involved in process design by being included on

tactical performance improvement teams. For example, to design and establish the Asthma

team, we met with employees, people who have asthma, the Ethnic Health Institute, other

community groups, the EMS Agency, and the County Medical Director.

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✔ 2.6.3 Describe the organization’s continuity of business plans for management of incidents or disasters, which disrupt the normal ability to provide EMS service.

In a disaster situation, we follow the County protocols for disaster response with

respect to our external activities. Internally, our continuity of business plan addresses:

• Concept of operations

• Disaster situations

• Planning assumptions

• Healthcare and EMS planning

• Alert levels

• Coordinators

• Essential functions, services, and skills

• Alternative work arrangements

• Essential contract and support services

• Delegation of authority

• Succession planning

• Alternate physical facilities

• Effective communications

• Business record keeping

• Training

• Devolution

• Recovery and reconstitution

• Logistics and supplies

• Financial continuity

• Triage and patient management

• Surge considerations

All our employees receive initial training in disaster response protocol and the ICS

structure. We maintain an Ambulance Strike Team and an extensive background in leading

the medical role within the ICS structure during disasters. For more on these capabilities,

see Commitment to EMS System and Community, Disaster Assistance and Response

subsection.

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✔ 2.6.4 Describe the organization’s experience with trials related to clinical innovation (new medications, equipment and clinical protocols).

Alameda County AMR is engaged in a number of studies to further evidence-based

knowledge in our industry. We work with local hospitals, Medical Directors, the Alameda

County EMS Agency, partners, and our scientifically trained team to design and conduct

these trials. Current clinical research trials include:

Impact of EMS-Based Community Asthma Teams on Adults with Chronic

Asthma Study

This study examines the impact of intensive in-home coaching by EMT and

paramedics members of our Asthma Team on 9-1-1 calls, emergency department visits, and

hospital admissions for adults with chronic asthma. This prospective randomized study is

being conducted in collaboration with Highland Hospital’s Emergency Medicine

Residency Program.

Clinical Impact of Response Times Study Series

For this series of studies we will seek to determine what impact various response

times have on clinical severity and patient outcomes for Echo calls, as well as other time-

sensitive conditions such as STEMI, stroke, and major trauma. We propose this series of

studies be performed in collaboration with the County EMS Agency, our national clinical

team, and EMS researchers at the University of Arizona. In compliance with RFP

Addendum I, Part IV, #2, an initial overview of this proposed study is in Attachment 6.

American Heart Association ACLS Education Retention Study

We are partnering with the University of Pittsburgh, Washington State University,

and Laerdal to study information retention levels for providers. This study compares

retention levels from the traditional approach to ACLS education of one 8-hour class every

two years versus those who receive a short course followed by 10-minute monthly

computer-based training sessions. All participants must hold a current ACLS card and be

certified in the initial training. Participants’ information retention levels will be tested at 3,

6, 9, and 12-month intervals. This study is sponsored by Laerdal Medical Corporation and

the American Heart Association in cooperation with AMR, the National League for

Nursing and the University of Pittsburgh Medical Center.

Completed research studies our organization has conducted include:

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Carbon Footprinting in North American EMS Systems/Preliminary Emission

Benchmark Development Study

A healthier environment is essential to improving community health. Alameda

County AMR’s first study as part of the North American EMS Emissions Study Group,

Carbon Footprinting of North American EMS Systems, by Blanchard, I.E. and Brown, L.

H., was presented at the National Association of EMS Physicians meeting in January 2010.

This study characterized the carbon emissions from a broad sample of North American

EMS agencies, and begins the process of establishing EMS related emission benchmarks.

Alameda County AMR participated in this study and is an ongoing member of the North

American EMS Emissions Study Group, an international collaboration committed to

reducing the impact of EMS on the environment. This ongoing series of studies is being

conducted in association with Alberta Health Services Emergency Medical Services,

Calgary, Alberta, Canada, the Anton Breinl Center, James Cook University School of

Public Health, Tropical Medicine and Rehabilitation Sciences, Townsville, Queensland,

Australia, and the Department of Emergency Medicine, University of New Mexico Health

Sciences Center. We have challenged our sister operations in the Bay Area to a “Biggest

Carbon Footprint Loser” contest.

EMS Impact based on Rapid Acute Physiology Score (RAPS) Study

For this study we looked at heart rate, respiratory rate, blood pressure, Glasgow

Coma Score and oxygen saturation to calculate a RAPS score. We presented the first EMS

study on the validation of RAPS at the National Association of EMS Physicians annual

meeting held in January, 2010.

King Tube Airway vs. Combitube Study

For this study, AMR partnered with the County to determine which airway device

was better. Our results were that airway success rates on both were about the same, but

ease of use was better with the King Tube. Based on these results, we now use the King

Tube.

Alameda County AMR also benefits from the research functions of our larger

organization. AMR has been the originator and principal investigator for multiple

published research reports related to medications, protocols, and equipment. In 2000, The

Prehospital Care Research Forum presented the “Best Research Award” to AMR. More

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about our national organization’s extensive research activities appears earlier in section

D.1.1.5.

✔ 2.6.5 Describe the organization’s approach to improvement of work processes and provide and example (e.g. the Six Sigma DMAIC model or the IHI Model for Improvement, found at the Institute for Healthcare Improvement).

Our approach to improvement of work processes is first to identify processes that

need improvement. We use key performance indicator (KPI) data to look for improvement

opportunities and we are in regular conversation with the Alameda County Medical

Director, the Alameda County EMS Agency, and other stakeholders and partners about

what improvements they would like to see. We use the IHI Model for Improvement paired

with a modified version of Six Sigma’s DMAIC model for improvement project

management. Our team includes a Six Sigma Black Belt.

Example of Improvement using IHI Model for Improvement

One example of a work process improvement we conducted using the Institute for

Healthcare Improvement (IHI) Model for improvement is our improved process for patient

care report printing.

As a result of the PCR printing improvement project, we achieved a statistically-significant improvement in printing prior to returning to service performance, improving from 67% to

95% in approximately two weeks, and sustaining the improvement since. - Lee Siegel, Alameda County AMR Quality/Leadership Team Member

The IHI model focuses on a three-part aim statement, followed by a number of

PDSA cycles. The following is a description of the three-part aim statement and PDSA

cycles we used for this improvement.

Aim Statement Part One: What are we trying to accomplish?

We are trying to ensure that in every hospital pre-hospital patient clinical data is

available to in-hospital clinicians who use it to make diagnostic and treatment decisions for

patients. Pre-hospital clinical data is necessary for vital treatment decisions for STEMI,

Stroke, and resuscitated cardiac arrest patients being treated with the hypothermia protocol.

Aim Statement Part Two: How will we know the change will be an improvement?

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There will be an increase in the percentage of printed, not faxed or computer-

accessible, patient care reports with complete patient care information left at the hospital

before the crew returns to service. The other way we will know the change is an

improvement is from customer feedback from key hospital customers.

Aim Statement Part Three: What action are we going to take to make the improvement?

The action we take is to conduct a Plan-Do-Study-Act (PDSA) cycle.

PLAN

1. Define a measurement system for performance in collaboration with our

customer the EMS Agency and the Medical Director.

2. Build a technology to make the measurement by hiring FirstWatch to map our

CAD data and ePCR data to create a customized report and alert system.

3. Provide education to crews and dispatchers on the data definition of a compliant

printed PCR, including the 19 necessary data elements to be completed prior to printing.

4. Develop method to provide feedback to crews about system-wide performance.

Consistent with W. Edwards Deming, the founder of modern quality improvement, and our

core philosophy of quality improvement, we focus on system-wide performance feedback

and improvement, rather than individual performance feedback.

5. Modify in-service process to include dispatcher asking the crew if they have

printed a compliant patient care record before they return to service.

DO: Implement the plan.

STUDY: Study the results by looking at the percentage of compliance over time.

Our study revealed that we had made a dramatic, statistically-significant

improvement in approximately two weeks, going from 67% to 95%.

ACT: Hardwire practices that resulted in the improvement into daily processes.

The blue line on the FirstWatch chart below shows the improvement. We’ve been

able to sustain the improvement around 95% since June of 2009 when the process changes

were implemented.

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PCR printing before returning to service performance

✔ 2.7 RESULTS:

✔ 2.7.1 Describe the results the organization intends to produce through effective management of its key result areas. Include descriptions of the results patients, stakeholder groups, market segments, and the County can expect from the organization’s provision of service. Include specific health outcomes if possible.

The results we seek to achieve are to meet and exceed the expectations and

requirements of our customers identified in section D.2.3. Everything we do is focused on

producing enhanced results. In our system, the focus is on producing enhanced results for

our patients and the community. These results fulfill our purpose of reducing suffering and

improving health and our vision of measurably improving community health.

CUSTOMER EXPECTATIONS AND REQUIREMENTS Our goal is to meet and exceed these expectations and requirements.

KEY CUSTOMER

GROUP EXPECTATIONS/REQUIREMENTS

PATIENTS

• Arrive quickly after 9-1-1 is called

• Keep me alive • Make me feel better; take away my pain, difficulty breathing, etc.

• Tell me what you’re doing and why • Treat me with kindness, compassion, dignity, and respect

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CUSTOMER EXPECTATIONS AND REQUIREMENTS Our goal is to meet and exceed these expectations and requirements.

OUR

COMMUNITY

• Take care of our needs so we feel safe • Work well with partner public safety and healthcare agencies

• Be involved in improving our health and our community • Help us control costs and evolve our systems of care

COUNTY

EMS AGENCY

• Do what you say you’ll do • Perform at or above the performance requirements in our contract

• Actively participate in system improvement and innovation • Be fully transparent and accountable for your actions

• Be responsive to our requests • Treat us with kindness, compassion, dignity, and respect

We have four core results that we seek to achieve every day:

• The best possible clinical outcomes to save lives and improve health

• Happy customers that feel good about the care and service they received

• A measurably healthier community

• Fast response times achieved safely

We seek to achieve enhanced results for a number of areas including:

For Patients and the Community

• Cardiac arrest survival rates

• Decreased pain as reported by patients

• Kindness, compassion, and comfort to make situations less scary for patients

• Reduce ongoing suffering and the number of avoidable repeat emergencies by

providing information and support systems to better care for chronic diseases

• Improved outcomes with short 9-1-1 call-to-intervention time for STEMI, Stroke,

and life-threatening trauma patients

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For other System Stakeholders

• A partner who shares the commitment to reduce suffering and improve health in our

community

• A partner with the expertise and resources to help weather difficult economic times

• A partner focused on producing shared outcomes not on taking credit

For the County

• A reliable provider whose performance matches our commitments

• The easy ability to audit performance to fulfill their regulatory responsibilities

• A fully transparent system that builds trust and confidence

• An innovative partnership to address healthcare challenges in our community that

lie beyond the boundaries of traditional EMS services

✔ 2.7.2 Describe the organization’s commitment to measurably improving the health status of our community through prevention, chronic disease management, or public education activities.

Our mission is to help measurably improve the health status of our community. As

detailed in the Commitment to EMS System and Community section of this proposal, we

follow an innovative, integrated Community Health Partnership Model for our

organization. That means we view community health

improvement activities as a core part of fulfilling our

organization’s purpose and mission.

Our goal is to be the best possible partner for

organizations aligned with our purpose and we

monitor our community health improvement

activities through our quality program and our

Community Health Advisory Board comprised of the

Ethnic Health Institute, which includes the Alameda

County Health Care Services Agency. We invite the EMS Agency and Medical Director to

participate in these and all our quality meetings. Some of the results we seek to achieve in

collaboration with our community health partners include:

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• For people with asthma: Decrease in the number of asthma attacks severe enough

to trigger a call to 9-1-1, emergency department admission, or hospital admission.

• For people with chest pain and stroke: Decrease the time between symptom

onset and call to 9-1-1, and increase the percentage of patients with chest pain or

stroke who call 9-1-1 rather than drive themselves to the hospital.

• For people with diabetes: Increase self-care capacity to decrease blood sugar

fluctuations (as measured by HbA1c) and associated long term complications from

diabetes including blindness, renal disease, heart attacks, limb amputations and

strokes.

• For people with pain management: Decrease pain as reported by patients with

pain.

• For cardiac arrest: Increase walk out of hospital cardiac resuscitation rate

• For nausea: Decrease nausea as reported by patients.

• For the elderly: Decrease in the number and severity of falls

✔ 2.7.3 Improvements results are often the result of focused improvement projects. Describe the approach to commissioning, managing, and tracking improvement projects. Contractor will be required to provide a report that updates progress on projects to the County’s performance improvement committee(s), as required.

Our Quality Steering Committee determines the improvement projects based on

analysis of performance data and other issues that arise in the system. We invite the

Alameda County EMS Agency and Medical Director to join these meetings and we report

progress to the County through weekly meetings and required reports.

Our approach to commissioning, or chartering in Six-Sigma terms, managing, and

tracking improvement projects uses the templates on the next page. Each month at our

Quality Steering Committee meeting there will be a report on the progress of each project.

A full description of our approach to these functions can be found in the introduction to this

Clinical Quality Improvement section.

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In keeping with our commitment to customized service for each community’s needs and priorities, AMR is pleased to offer Alameda County a team whose abilities and passion for

service match that of the system’s progressive, innovative health care leaders. I look forward to seeing what inspired results can be achieved in the next chapter.

- Mark Bruning, President of AMR

IMPROVEMENT PROJECT CHARTER TEMPLATE PROJECT NAME:

TIE INTO THE BIG PICTURE OF PURPOSE, VISION, AND VALUES:

PROJECT DESCRIPTION AND AIM STATEMENT:

METRICS:

CLINICAL/BUSINESS CASE, WHY THIS MATTERS:

TEAM LEADER/MEMBERS:

PROJECT SCOPE, WHAT’S IN/WHAT’S NOT:

RESOURCES:

SCHEDULE:

SAMPLE IMPROVEMENT PROJECT PROGRESS REPORT Project Description Metrics Team Leader Status

STEMI Shorten the time from 9-1-1 call to intervention in hospital.

Time from call to balloon inflation in cath lab

Lee Siegal Next Steps: Process flow chart analysis for time delays.

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COMMITMENT TO EMPLOYEES EXHIBIT A — SCOPE OF WORK — SECTION E

Employee satisfaction is one of our key results areas for ensuring quality

performance for our patients and communities, and because it is the right thing to do. We

track a number of KPIs to continue improving results in this area as identified in section

D.2.5.1. These include the percentage of employee satisfaction surveys that indicate yes on

the 7 questions identified by the Gallop Organization as being predictive of turnover:

1. Do I know what is expected of me at work?

2. Do I have the right materials and equipment?

3. At work, do I have the opportunity to do what I do best every day?

4. Have I received recognition or praise for doing good work in the last 7 days?

5. Does my supervisor or someone at work seem to care about me as a person?

6. Is there someone at work who listens to my opinions?

7. Is there someone at work who encourages my growth and development?

As the incumbent we are the only provider who can offer stability for the workforce

during this process. We will offer employment to and seek to retain 100% of the current

workforce. We will maintain all seniority levels and we will continue to provide excellent

wages, benefits, education, and career development opportunities that have contributed to

our currently high retention rates of more than 90% per year.

“I take pride in the fact that we are one of the busiest EMS systems in the Country. When people from other EMS areas outside the County we serve know you work for ALCO they take notice and show respect. Our collective reputation for being the best and the busiest

precedes us everywhere.”

- Donnie Fisi, EMT-P, August 2009 Employee Survey Comment

In addition to the inherent work satisfaction of helping those in need in our

community, we pay attention to the intangible components that make a difference in

workplace satisfaction to make Alameda County AMR a wonderful place to work.

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What is “Good Work”?

Harvard psychologist Howard Gardner Ph.D. says that “Good Work” involves four

components. Good work involves Ethics, Engagement, Excellence, and Empathy. Our

commitment to and treatment of our EMTs, paramedics, dispatchers, support staff, and

quality/leadership team members that serve and have served Alameda County is in

alignment with the principles of good work.

Ethics

The first principle of “Good Work” is Ethics. Our quality/leadership team engages

honestly and openly with employees even when the topic in uncomfortable. For example,

throughout this RFP process several employees have come to the quality/leadership team,

concerned that their family-like workplace might vanish if another provider wins the

competition.

While there’s an impulse to respond to difficult questions with placating responses

that are meant to soothe but don’t reveal the whole truth, that’s not the right thing to do.

We’ve answered their concerns by telling them everything we know about the competition

and encouraging them to talk with our competitors to find out for themselves what they are

like. We’ve promised to work very hard to retain this contract for them, their families, and

the members of this community. We’ve also invited them to help craft the content of this

proposal and they have accepted.

“I like the sense that leadership listens to us and considers our input -- and I like working for a company that has a strong business sense, especially these days.

- Louis Abaunza, EMT-P, caring for Alameda County’s patients since 1988

Engagement

Principle number two is Engagement. Our practice is to engage our employees in

all decisions that impact their work lives. For example, when we determined that it was

necessary to transition three 24-hour stations to 12-hour shifts, employees helped create a

smooth conversion process. Also, when it came time to create the Community Health

Improvement strategy that’s part of this proposal we asked the workforce to participate.

Our employees have come through with dozens of ideas for active community involvement

and with the help of our team we’ve implemented many of them and will continue to do so.

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Our employees’ employee survey results indicate a strong sense of engagement in our

organization and our shared purpose, vision, and values.

Excellence

Excellence is principle number three. People who are ill and injured in our

community rely on our ability to provide excellent clinical care and they appreciate the

excellent customer service they receive from our dispatchers, EMTs, and paramedics. One

of the perspectives we subscribe to is that employees tend to treat customers the same way

that supervisors and managers treat them. Our practice is to treat our employees with the

same kind of compassion, dignity, and respect with which we expect and require them to

treat our customers in alignment with our STAR CARE values.

Empathy

Empathy is the last principle of Good Work. It is the ability to recognize people’s

emotional state, their fear,

joy, anger, love, suffering

and more. Our

quality/leadership team has

deep connected

relationships with most of

our employees. Many of

them of them were born,

raised, and have worked

most or all of their EMS career in this community. We know what’s going on in each

others’ lives and we actively support each other and each other’s families in times of need.

We treat our employees like family with the kind of empathy and compassion that they use

when caring for the sick and injured.

Family

We added family to the list of Good Work criteria based on overwhelming feedback

from our employees about what is important to them and why they love working here.

Even though we are one of the larger EMS operations in the Country the people that work

here say it really feels like a family. As the incumbent provider we currently employ 100%

of the workforce, we will continue to employ 100% of the workforce and the transition to a

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new contract will be seamless for all concerned. We are the only provider who can ensure

there is no disruption to our employees or other system stakeholders during the transition

for the new contract. As the incumbent provider, we will be able to provide continuity of

benefits, including health, dental, and vision plans, Family and Medical Leave Act, and

others as outlined in the benefits chart that begins on the next page.

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ALAMEDA COUNTY AMR EMPLOYEE BENEFITS SUMMARY

BENEFIT DESCRIPTION

MEDICAL

Three Medical Options through Anthem Blue Cross Blue Shield and Kaiser Permanente AMR provides employees significantly subsidized medical insurance coverage. Specifically, employees have the ability to select from three (3) medical plan options which include: Anthem Blue Cross Blue Shield PPO Plan Kaiser Deductible HMO Plan Kaiser HMO $20 Plan

DENTAL

Aetna Employees have the ability to select from three (3) Aetna dental options which include: Aetna DMO Aetna PPO Dental Aetna Open Choice Dental

VISION

Vision Services Plan (VSP) Employees have the ability to select from two (2) VSP vision plans. In both options, the vision plan has significant vision care benefits and eye glasses benefits.

LIFE INSURANCE AND ACCIDENTAL DEATH &

DISMEMBERMENT (AD&D)

Prudential The company provided life and AD&D insurance, at no charge, equal to two times their scheduled annual earnings.

SUPPLEMENTAL LIFE & AD&D INSURANCE DEPENDENT LIFE

INSURANCE

Prudential Eligible employees have the ability to purchase additional life and AD&D insurance coverage. Additionally, employees also have the ability to purchase dependent life insurance coverage.

SHORT TERM DISABILITY

(STATE/SUPPLEMENTAL)

California/Prudential Employees are eligible for additional coverage in addition to the California State provided short term disability coverage. Short term disability is intended to cover the first 90 days of disability.

LONG TERM DISABILITY

Prudential After 90 days of disability and being confirmed as disabled, the company provides a long term disability benefits that will replace up to 60% of their base earnings. This benefit is paid for completely by the company.

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ALAMEDA COUNTY AMR EMPLOYEE BENEFITS SUMMARY

EMPLOYEE ASSISTANCE PROGRAM

MHM All employees and their immediate family members are entitled to use this assistance program. The 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 twenty-four (24) hours a day, seven (7) days a week.

FLEXIBLE SPENDING

ACCOUNTS

Aon Consulting We provide our employees the ability to establish a health flexible account and/or dependent care spending account. We further provide employees the convenience of a debit card that is linked with their flexible spending account election, at no cost.

AMR 401(K) PLAN (UNION PLAN)

Fidelity Investments Eligible employees are able to defer up to 40% of their earnings, subject to the annual IRS maximum 401(k) limits. The company provides 100% match up to 5% of their compensation subject to a four (4) year vesting schedule. Employees have the flexibility to select from up to twenty-one (21) mutual fund options to invest their contributions that are consistent with their short and long term retirement goals.

EMSC EMPLOYEE STOCK PURCHASE PLAN

(ESPP)

Computer Share In 2008 EMSC, the parent company of AMR, implemented a qualified Employee Stock Purchase Plan. Employees were able to elect to purchase up to $25,000 of EMSC class A common stock at a 5% discount. Future offerings have not been confirmed by the EMSC Board of Directors. Employees who purchased shares in September of 2008 and sold in December of 2009 made a 51% return on their investment.

PARAMEDIC SCHOOL

SCHOLARSHIP

AMR Tuition and books are provided to qualified candidates under AMR’s Northern California Paramedic School Scholarship Program.

* In general, benefits are available to full-time employees. If there is a discrepancy with the above information, the plan document and insurance policy will govern. The above information is based upon benefit offerings as of December 1, 2009. These benefit programs and rate information are subject to change. ** As an additional benefit, union employees enrolled in AMR’s health insurance plan will be receiving employer funded flexible spending account in the amount of $750 for 2010.

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Alameda County AMR has one of the lowest turnover rates in the ambulance

industry (less than 10%), which reflects our competitive wages, generous benefits package,

and our ability to offer EMS professionals a fulfilling, long-term career.

Also, our national size affords us the ability to provide more time off under the

Family and Medical Leave Act (FMLA) than companies that do not have our financial and

human resource strengths. One of our practices to help pregnant employees be able to

spend as much time as possible with their newborn is to place them on light duty when they

are no longer able to work their normal field shift. This practice allows them to keep their

hours and not use up their FMLA until the birth of their child.

AMR offers domestic partner benefits as one of the additional benefits for

California employees. One of the employee benefits to awarding the contract to Alameda

County AMR is that FMLA benefits stay intact with the new contract, which allows

employees to take the leave they have earned anytime before, during, or after the start of

the new contract. Another provider would not be required to offer FMLA until a year after

the start of the new contract. Additionally if Alameda County AMR is selected those

employees who have taken 401K loans would be able to maintain their current monthly

loan payment, which would not be the case with another provider.

✔ 1. WORKFORCE ENGAGEMENT ✔ Alameda County believes that an experienced, highly skilled, well rested, and satisfied workforce is essential to the provision of high quality EMS services. Describe 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, which includes but not limited to: ✔ 1.1 Describe the organization’s two-way communications process between front line employees and the leadership team.

One ongoing process we have for assessing the engagement and satisfaction level of

employees is to include statistically-valid KPIs related to employee satisfaction in our

monthly Quality Steering Committee meetings which guide our day-to-day actions and

decision making. Initial KPIs are identified in section D.2.5.1. We receive ongoing

feedback from employees using the following two-way communications methods:

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LIVE TOWN HALL MEETINGS: These open forums for employee and

quality/leadership team dialogue are held as needed at least quarterly at times convenient

for employees.

OPEN DOOR POLICY AND CULTURE: On a daily basis, leaders visit informally with

crews coming on or going off duty. Employees freely and frequently drop into the

quality/leadership team offices with questions, concerns, comments, and ideas. This

approach extends to e-mail, cell phone calls, and Facebook communications. Members of

our quality/leadership team are open and easily accessible to employees 24 x 7.

QUARTERLY EMPLOYEE SATISFACTION SURVEY: We conduct a quarterly web-

based survey deployed using Survey Monkey. Each survey includes a mix of Likert style

rating questions, yes/no questions, and open-ended questions. Surveys can be completed

anonymously or employees who would like feedback can provide their names and contact

information. Each employee who provides contact information receives personalized

feedback on their survey via e-mail from our General Manager.

Some foundational questions gleaned from the Gallop Organization’s research on

employee turnover are replicated on each quarter’s survey. For example:

• Is there someone at work who supports your growth and development? Yes or No

• At work do I have the

opportunity to do what I do best every

day? (Yes or No)

The remaining questions are

custom designed each quarter based

on feedback from the previous survey

and the leadership actions that have

been taken to address past concerns.

Here are some examples:

• Over the last four months has

your morale improved, stayed the same, or gotten worse? (Improved, Stayed the

same, Gotten worse)

• We’ve been told that when people call out sick on the weekends it causes lots of

stress for other crews. What thoughts do you have about how we can address this

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problem as a team so that all of our units are filled every day? (Open ended

question)

Based on the answers to these survey questions we’ve taken several improvement

actions. One example is that in the first round of employee surveys people mentioned

difficult and uncomfortable interactions with Operational Field Supervisors. We met with

all of our Operational Field Supervisors and even though it was uncomfortable shared the

results with them. Then we worked together to craft a strategy to improve interactions. On

the next survey we asked specifically about interactions with our Operational Field

Supervisors and 46.9% of employees said that their interactions with supervisors had

improved.

Each survey produces quantitative results which are tracked on an SPC chart as part

of our key performance indicators. They also produce qualitative data that are categorized

using qualitative labeling followed by Pareto analysis to identify the most talked about

issues.

In addition to the two-way communication methods above, we also communicate

with employees through the following mechanisms:

AUDIO PODCAST ON CD AND ONLINE DOWNLOAD: These regular podcasts include

various topics and speakers. Some highlights include an interview with County Medical

Director James Pointer MD on the H1N1 flu, an interview with one of our regular

customers who described what it is like to be an EMS patient who can’t see, and an

interview with the founders of the Ethnic Health Institute describing our collaborative work

to address healthcare disparities in Alameda County.

MEMO: Posted in crew areas and e-mailed to personal e-mail addresses.

PAGERS: Each field employee is issued an alpha/numeric pager. Short messages

about response time performance are paged every six hours to those on duty. Open shifts

and group commendations are paged out to all employees.

SUGGESTION BOX: This box is available in the crew areas and is checked daily by

the Operational Field Supervisors.

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MONTHLY PERFORMANCE DIGEST: Employees receive a monthly performance

digest e-mail that includes an overview and feedback on important KPIs including a

discussion of what actions we plan to take for ongoing future improvement.

NINTH BRAIN SUITE: Employees receive education and memos posted to our Ninth

Brain website.

For more about how we communicate with employees, please see D.2.1.3.

✔ 1.2 Describe the organization’s mechanism for encouraging, gathering, providing feedback on, and acting on employee improvement suggestions.

We maintain a number of channels for employee communication described above

and a culture that welcomes everyone’s input. We encourage employee improvement

suggestions by regularly soliciting them and responding to them through action. By

integrating employee feedback into our operation-wide quality process we maintain a

formal ongoing mechanism for reviewing and acting on employee improvement

suggestions, in addition to day-to-day input.

For example, an employee recently suggested that it causes crews stress to have an

automatic notification come across their pager 20 minutes after arrival at the hospital,

because it takes longer than that to print a copy of their PCR. Based on that observation we

changed the computer aided dispatch system’s auto-alert from 20 to 30 minutes. Another

employee recently suggested we conduct a Winter coat drive and we have scheduled coat

collection for January 2010, and distribution in February.

Our quarterly employee satisfaction survey process is our primary mechanism for

gathering and providing feedback on employee improvement suggestions. Our General

Manager responds personally to all employees who include contact information with their

submission. Employee improvement suggestions are included in quality meeting

discussions and considered for implementation based feasibility, system impact, strategic

alignment, and cost/benefit analysis.

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For example, a recent survey asked employees the following:

After we asked this question on the survey our employees who smoke took it upon

themselves to change their practices to solve the problem. As a bonus one of our

employees with a 25+ year smoking habit quit and has been smoke-free for the last four

months.

✔ 1.3 Describe the organization’s method for providing system and individual performance feedback to employees.

We subscribe to the prevailing quality management belief that more significant and

more sustainable improvements come from focusing on system performance. Some of the

methods we use to provide system performance feedback to our team include:

For response time performance, on duty crews receive pages every six hours with

month-to-date response time compliance. Our quality/leadership team has near-real-time

access to this data 24x7 through our Multi CAD Information System (MCIS).

For dispatch time, the time between when a 9-1-1 call appears in our CAD from

either of the two fire dispatch centers, and the time when an ambulance is alerted, our

dispatchers get real-time feedback via a gauge created by FirstWatch that’s displayed on a

monitor in the communications center.

For overall system performance and compliance, crews receive a monthly

performance digest summarizing KRA’s and KPIs via email, online, and posted. We offer

all our team members basic education on how to read a statistical process control chart and

analyze data. All employees, as well as other system stakeholders and partners are invited

to attend our educational offerings. Recently we held a day-long seminar with our

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Healthcare Statistician Davis Balestracci that several members of our team and community

attended.

System performance focus has enabled us to effectively make improvements such

as improving PCR printing performance from 60% to over 95%. Our Clinical Education

Services team provides individual performance feedback on documentation completeness,

protocol compliance, unusual occurrences, and customer satisfaction survey results. More

about how and what we communicate with employees appears in sections D.2.1.3 and

E.1.1.

✔ 1.4 Describe the organization’s mechanism for involving front line employees in quality and performance improvement projects.

Each improvement project has different requirements for employee participation.

In some cases where specialized skill or knowledge is required, specific employees will be

recruited to participate. For example, for our project to improve asthma care in the

community we recruited one of our Operational

Field Supervisors, Bruce Hagan, to lead the effort

because he had performed home asthma proofing

for people in the community during the late 1980s.

Another example is when we decided to

partner with Urban Releaf after a presentation at

one of our Ethnic Health Institute Asthma

Committee meetings about the impact of trees on

air pollution and asthma rates. Our paramedic

Travis Correl who was an arborist for 15 years

before joining our team leads our urban tree

planting efforts with Urban Releaf.

For other projects we will conduct open

recruiting from the entire workforce. For

example, during the H1N1 flu season last Fall, one of the County Health Care Services

Agency performance improvement projects involved community flu clinics for citizens at

high risk of complications from H1N1. We put out an open invitation to EMTs and

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paramedics to help staff the flu clinics and dozens of employees signed up for this work,

helping to vaccinate over 7,000 high risk residents.

When we needed to create a mechanism to assess our performance on the new

Airway Checklist we asked one of our best paramedics, Patrick Lickiss for his thoughts.

Patrick designed and implemented our process with our Clinical Education Services team

and the County Medical Director.

“I would like to express my personal thanks and appreciation to you and your crews. They performed professionally and were key in the successful operation of the Ira Jenkins Flu Clinic from start to finish. They willingly accepted varied assignments in the command

structure and support the operation from start to completion ... Together with our volunteers ... [we] provided prompt and seamless emergency medical prophylaxis to over a

thousand underserved County residents in five hours.”

- Luis Diaz, Incident Commander IRA Jenkins POD, Oakland Fire EMS Division

✔ 1.5 Describe the credentialing requirements for the employees including but not limited to EMTs, paramedics, dispatchers, and mechanics.

Our employees are required to fulfill all County and State credentialing

requirements and to maintain them at all times to be eligible to work. We help employees

maintain their required licenses and certifications by providing ongoing training as well as

certification and licensure tracking and reminders through Ninth Brain Suite online

software (Ninth Brain).

As a system enhancement, we will offer to track County and State licensure and

certification requirements for any of our Alameda County Fire First Responder partner

agencies using Ninth Brain. We will also make Ninth Brain accounts available for the

administration of each Fire First Responder agency before the start of the contract so they

have the ability to run their own reports if they choose.

Credentials Maintenance Tracking

Our Clinical Education Services (CES) team retains copies of current training and

documentation of valid certifications for our Paramedics and EMTs in our Ninth Brain

Suite web-based program. Ninth Brain allows us to track upcoming certification

expirations so we can notify employees well in advance of the need to update their

certifications and ensure that our field personnel hold all required certifications. The Ninth

Brain Suite also allows us to track course completion and compliance with annual refresher

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training requirements. It gives us the ability to scan copies of credentials to provide

archival evidence of certification and training.

In addition, it facilitates communication with our employees, 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, they receive automatic email alerts regarding certification expirations, as well as

reminders regarding upcoming courses that they need to complete or take other action to

maintain their required licensure or certification.

Our CES team follows up with employees ensure they maintain licensing and

certification requirements that we require to be current for an employee to work. The

following screen shot shows how to build a Credential Status Report:

Ninth Brain Screen Shot

In addition to credentials tracking, Ninth Brain supports training and education,

quality management, complaint and incident tracking, safety, OSHA compliance, and other

vital processes. This program was created by EMS professionals to improve EMS

organizations’ ability to:

• Track work-related employee health issues and compliance with safety

requirements

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• Provide high quality online education to help employees 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 employees

• 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 employees, first responders, supervisors, and administrators of pending and

expired certifications/licenses with automated alerts

• Create custom reports

More on Ninth Brain can be found in section D.2.5.6.

Required Credentials

Emergency Medical Technicians must have valid and up-to-date California Drivers

License, California Ambulance Drivers License, CPR Card (American Heart Association

or American Safety and Health Institute), Medical Examiner’s Card, and EMT certification

from a California county. Paramedics must have valid and up-to-date California Drivers

License, California Ambulance Drivers License, CPR Card (American Heart Association

or American Safety and Health Institute), Medical Examiner’s Card, California Paramedics

license, as well as have completed ACLS, PALS or PEPP, and BTLS or PHTLS. EMTs

and paramedics also must complete Alameda County EMS orientation and our New Hire

Academy orientation and training program before they are eligible for work. Dispatchers

must be EMD-certified by the National Academies of Emergency Medical Dispatch.

Mechanics must attend Diesel and Automotive School LTD, Ford Training Seminars on

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transmissions, gas and diesel engines, differential and electrical, FMC Automotive front-

end alignment, MAC’s air conditioners, and Wyotech Institute training.

✔ 1.6 Describe the career ladder and professional development process for members of the workforce. Include a description of the succession plan for key positions.

Our organization’s career ladder offers employees a wide range of clinical, support,

middle management, senior leadership, regional, and national opportunities. The basic

framework for our career ladder is:

• Vehicle Stocking Technician • EMT

• EMT/FTO • Paramedic

• Paramedic-FTO • Alternate Supervisor

• Clinical Supervisor/Specialist • Supervisor

• Administrative Supervisor • Director of Operations and/or other Leadership Positions within Education,

Scheduling, Fleet Management, Materials Management, Data Analysis, Human Resources

• General Manager • Regional CEO

• President • Chairman and CEO

Succession Planning

We offer a wide variety of programs and scholarships to help employees advance

their careers including scholarships for EMT and Paramedic training to mentoring and

leadership development. We provide tuition assistance for employees who wish to further

their education. Our succession plan for key positions includes a focus on our purpose,

vision, values, and strategic direction. Our plan is designed with the intention of creating a

team that is well positioned to deliver results for our customers in the future.

We work with our community partners Mentoring in Medicine, Youth Uprising,

and the Bay EMT program to develop a steady stream of new EMTs who match the ethnic

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make up of our community. As our current EMTs move on in their careers we have a

group of trained and credentialed new EMTs waiting to take their place.

Our succession plan for paramedics is focused on identifying and assisting our best

EMTs to go to paramedic school. We provide scholarships and help with scheduling to

prepare our EMTs for the next step on their career path. For key leadership positions we

identify likely candidates for promotion, create a plan to develop their competencies for the

job they would be stepping into, and create opportunities for early exposure to the actual

work associated with that job.

For example, our Operations Manager has been identified as the likely successor for

the General Manager position. Her development plan includes reading and course work,

participation in regional General

Manager meetings, direct

involvement in contract

negotiations, strategy meetings,

and other activities that fall into

the General Manager job duties.

Each member of our

quality/leadership team has the

opportunity to engage in one-on-

one coaching sessions to create and execute custom personalized leadership development

plans. Formal professional development programs we offer include:

PASSPORT TO SUCCESS: A customizable, employee driven program that includes

self-assessment, mentoring, job specific internships, and more.

LEADERSHIP EDUCATION AND DEVELOPMENT UNIVERSITY (LEAD U): This is a

combination of leadership development workshops and company-specific courses. Our

talent development partner for LEAD U is Development Dimensions International (DDI).

DDI has worked with some of the world’s most successful organizations to achieve

superior business results by building engaged, high-performing workforces. Alameda

County AMR is fortunate to have a DDI master trainer as part of its local quality/leadership

team. LEAD U programs are described in detail later in this section. Many of these courses

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fulfill the requirements for the Ambulance Service Manager certificate provided by the

American Ambulance Association.

ACCELERATED DEVELOPMENT PROGRAM (ADP): This program focuses on

developing the next generation of senior leaders. Over the course of 24-36 months ADP

participants create individual development plans that may include the completion of formal

academic education. Each leadership position within Alameda County offers courses to be

completed for not only proposed personnel but also newly promoted leaders to ensure that

they have the fundamental tools to be successful. encompasses these positional educational

requirements. This program is The following chart summarizes AMR’s Leadership

Succession Planning Program which offers tiered learning specific to each leadership level

— Supervisor, Manager, Director, General Manager, and Chief Executive Officer.

LEADERSHIP EDUCATIONAL ELEMENTS - FOR EACH TIER

SUPERVISORY LEVEL • Interdepartmental/cross-program exposure • Local leadership/professional development seminars • Development Dimensions International (DDI)

management courses • Leadership Development Program (LEAD U)

MANAGER LEVEL • Seminars • Community college courses (such as finance for non-

financial professionals • DDI Intermediate Interactive Management Program • LEAD U (including didactic modules/sessions)

DIRECTOR LEVEL • Industry-wide conferences • Continuing education courses, such as DDI • Seminars • Business development/sales/negotiation training • Finance for non-finance professionals • LEAD U (including didactic modules/sessions)

GENERAL MANAGER LEVEL

• Executive education programs at business schools/colleges

• Industry-wide conferences • DDI courses • LEAD U (including didactic modules/sessions)

CEO LEVEL • Executive education programs at business schools/colleges

• Personal development and advancement seminars • DDI Interactive Management Program • LEAD U (including didactic modules/sessions)

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More details about these programs are in the Investing in Your Success brochure in

Attachment 13, as well as below:

PASSPORT TO SUCCESS Passport to Success is a career growth program designed to help employees prepare

themselves to take on new roles in the organization, in both leadership and non-leadership

positions. This is an opportunity for team members to explore additional career paths and

enhance their skills for advancement. Depending on which passport is selected, the

employee is paired with a mentor who has demonstrated technical expertise in one of the

following areas:

• Business Development

• Compliance

• Clinical & Education Services

• Dispatch

• Accounting

• Fleet Services

• Human Resources

• Information Technology

• Operations

• Patient Services

Participants graduate from the program once all developmental activities for their

chosen passport have been completed.

LEAD U AND DEVELOPMENT DIMENSIONS INTERNATIONAL (DDI) Lead U is designed as a framework to house leadership development for AMR’s

local leadership teams. The concept is to foster and promote AMR’s leadership values,

philosophy, mission, policies, and practices for the organization, the team, and the

individuals. It provides the direction and structure for ongoing leadership development.

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Training strategies within LEAD U include instructor-led seminars, self-directed

CD learning modules, self-directed on-line training, and workshops taught by DDI-certified

Instructors. The LEAD U CD learning curriculum includes:

The Supervisor 100 Series

All new supervisors must complete within the first six months in their position.

- History of EMS

- Overview of AMR and the Supervisor Role

- Communication

- Key Performance Indicators (KPIs)

- Conflict resolution

- Decision making

- Performance management

- Building trust

- Employment law

- Financial Accounting

- Business Development

- Clinical Education Services

- Human Resources

- Government Relations

- Safety and Risk

- Patient Services

- Operations

The LEAD U workshop curriculum includes:

The AMR Leadership Foundation Series 110

All new supervisors must complete within the first year in their position.

ESSENTIALS OF LEADERSHIP: This foundation course teaches leaders to get results

through people skills. During the course, they gain the tools necessary for a successful

leadership journey. Learners acquire a set of proven interaction skills, discover seven

Leadership Imperatives key to meeting today’s challenges, and realize their roles as a

catalyst to inspire others to act.

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BUILDING AN ENVIRONMENT OF TRUST: There is a crucial link between trust and

operational success. Leaders must realize the power of trust as a tool. Leaders learn how to

avoid the trust traps and take action to create an environment in which people take risks,

identify and solve problems, and work together to sustain a high level of trust.

RESOLVING CONFLICT: Leaders will learn how to recognize when a conflict is

escalating and minimize the damage by using the most appropriate resolution tactic –

regardless of which stage a conflict is in. Leaders also learn the true cost of conflict to an

organization and techniques for handling even the most challenging discussion.

The AMR Strategic Leadership Series 210

All leaders must complete within the first two years in their position.

BOOSTING BUSINESS RESULTS: In this course leaders learn a proactive strategic

process to apply and leverage their leadership skills to realize business objectives. Leaders

will identify a project or task that requires the effective use of newly learned leadership

skills to achieve or enhance success. Leaders also determine goals and measurement

methods that help track and demonstrate the results of their leadership.

RETAINING TALENT: This course helps leaders understand their critical role in

retaining organizational talent. They identify what it takes to keep employees engaged and

how to conduct “quick check” discussions for retaining these valuable employees. By

taking a proactive approach to retaining people and encouraging open and honest

discussion, leaders can create an environment in which people will feel valued and satisfied

in their jobs.

MAKING EFFECTIVE DECISIONS: This course helps leaders master a systemic

approach to making better and faster decisions that will result in improved performance.

The LEAD U on-line eLearning curriculum includes:

The AMR Leadership Self-Development Series 910

All leaders must complete within the first two year’s in their position.

DELEGATING FOR PRODUCTIVITY AND GROWTH: To maintain a motivated

workforce leaders must become catalysts who transfer responsibility and authority. Leaders

learn skills for successfully matching people, responsibility, and authority to maximize

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involvement, productivity, motivation, and growth for individuals, groups, and the

organization.

INTERACTION SKILLS FOR SUCCESS: This course presents the basics of working

well together, reduce wasted time, lessen conflict, and influence interactions in a positive

way. The leader will gain skills to manage both business and personal interactions.

ADAPTING TO CHANGE: This course develops the confidence and skills needed to

face change and welcome it as an opportunity to grow and learn. When employees adapt

quickly, the entire organization becomes faster, more flexible, and better able to answer the

demands of an increasingly competitive marketplace.

ACCELERATED DEVELOPMENT PROGRAM (ADP) Developing the next generation of leaders is critical for the long-term success of

any organization, especially one such as AMR, which is labor intensive and strives to

promote from within whenever possible. The practice of promotion from within and

growing our own leaders has many benefits, including eliminating the steep learning curve

experienced by outside hires, providing a career path for our employees, and improving

employee morale. The purpose of the Accelerated Development Program is to provide a

vehicle for employees to more rapidly gain the skills and experience they need to be ready

to accept promotions, and to provide a pool of qualified internal applicants for openings

that occur in the leadership ranks.

ADP participants take part in a professional assessment intended to identify their

leadership strength areas, as well as developmental needs. They are then paired with

another tenured leader in the company, often a vice president or higher, who can mentor

the participant in their targeted growth areas.

Over the course of 24-36 months, the ADP participant creates and completes an

individual development plan that contains educational and experiential activities targeted at

developing gap areas where additional knowledge and training is beneficial. The individual

graduates from the program once they are ready to assume the next leadership role.

Additionally we are working with the University of Phoenix to develop an EMS Degree

program that is anticipated to go live in 2010.

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✔ 1.7 Describe a mechanism that utilizes experienced clinicians to mentor, monitor and assist paramedics and EMTs contemporaneously in the field.

Clinical Supervisor/Specialists and Field Training Officers (FTOs) provide clinical

performance education and feedback in the field. Last Fall we conducted a pilot test of the

Clinical Field Supervisor concept. Our trial was designed with the help of the County

Medical Director, our Clinical Education Services team, our General Manager, and one of

our local Fire First Responder partner agencies’ Clinical Managers. We benchmarked the

Clinical Supervisor program that’s been operational with the San Francisco Fire

Department’s EMS division for the last decade.

We learned several things from our trial that we’ve incorporated into our Clinical

Supervisor/Specialist program. It is possible to provide focused education and

performance feedback in real time with crews while on-duty and working in the field.

Additionally, crew feedback has been positive about the value of having additional

coaching and performance feedback on critical calls and other clinical situations. The test

Clinical Supervisor/Specialists were also able to notice system issues and work with the

quality/leadership team to make improvements. Our Clinical Supervisor/Specialist

program incorporates what we’ve learned from this trial.

In addition to the Clinical Supervisor/Specialists we are adding for this contract, our

team of full-time and alternate Operational Field Supervisors, along with our team of

nearly 40 FTOs, work daily with our crews to mentor, monitor, and develop both clinical

and customer service acumen. All new employees spend time with FTOs as part of their

orientation. The employees we identify as having opportunities for improvement are

assigned to work with an FTO to improve their skills, and the FTOs informally mentor

other employees through their daily interactions.

✔ 1.8 Describe the methods to assess, maintain, and develop new skills for employees in the workforce.

FTOs, Operational Field Specialists, and Clinical Supervisor/Specialists coordinate

the assessment, development, and maintenance of new skills for employees in the

workforce under the direction of the County Medical Director, our Medical Director, and

our Clinical Education Services team. Methods of assessment include direct observation

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and patient care report audit. Methods of development include formal training and

one-on-one coaching.

In our busy system, maintaining new skills is aided by using them in the field and

receiving feedback on performance through a variety of mechanisms including system

performance feedback on clinical composite scores such as the Airway Checklist and other

relevant KPIs and individual performance feedback as appropriate. As an enhancement for

this contract we will be adding our

Training In Motion mobile patient

simulation laboratory to the

system for skill development,

maintenance, and documentation.

This experiential learning

opportunity like all our

educational offerings will be

shared with our Fire First

Responder partners in Alameda County. More about this collaboration is in the

Commitment to EMS System and Community section.

✔ 1.9 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.

ALAMEDA COUNTY DEMOGRAPHIC PROFILE CATEGORY

ALAMEDA COUNTY OVERALL

DEMOGRAPHICS

ALAMEDA AMR WORKFORCE

DEMOGRAPHICS

WHITE 40.9% 64.0%

ASIAN 20.3% 9.0%

HISPANIC/LATINO 19.0% 16.0%

BLACK/AFRICAN AMERICAN 14.6% 9.2%

AMERICAN INDIAN/ALASKA NATIVE 0.4% 0.9%

NATIVE HAWAIIAN/PACIFIC ISLANDER 0.6% 0.9%

TOTAL (EXCLUDING “WHITE”) 54.9% 36%

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DIVERSITY ALIGNMENT IN ALAMEDA COUNTY

AMR began in Alameda County and we embraced diversity from our inception.

Our current workforce is rich in diverse ethnicity, national origin, gender, sexual

orientation, and age. According to the 2000 Alameda County Demographic Profile, we

have one of the most ethnically diverse populations in the nation. Our team reflects the

rich diversity of our community, with 36% of us identifying as other than “white”

compared to 15% for EMS organizations in the U.S.

Our Alameda County AMR team of employees is made up of people from all over

the world. Our team members speak Spanish, Cantonese, Japanese, German, Tagalog,

Mandarin, American Sign Language, Portuguese, Russian, French, Dutch, Kapampangan,

Italian, Ilocano, and Farsi, in addition to English.

Our practices to ensure diversity and to further align the ethnic make up of our

workforce with the communities we serve include partnering with local organizations that

are working to develop young people from our community and encouraging their members

to join the medical professions. These groups include:

Mentoring in Medicine

This program is led by local emergency physician Dr. Jocelyn Freeman Garrick. Its

mission is, “To diversify the healthcare workforce by mentoring and exposing

underrepresented students to health careers.” We present at Mentoring in Medicine

conferences and provide ride along opportunities to students in this program, encouraging

them to consider the EMS career path.

The Bay EMT program

This program is led by local Alameda County Fire paramedic Wellington Jackson,

who founded the program. This EMT program is free to the community and is designed to

provide opportunities for people who otherwise could not afford school to become medical

professionals. Alameda County AMR supports this program with equipment, supplies,

instructors, and clinical internships. We also host recruitment evenings for students in this

program, encouraging them to apply with us when they graduate.

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Satori’s Circle

Led by Bree Brooks, Satori’s Circle is a new non-profit organization that works

with at-risk teenage girls in the Bay Area. They offer mentoring, one-on-one/family

counseling sessions, workshops and presentations. We learned about this program from

one of our EMTs who learned about them from a friend. Alameda County AMR presents

education programs for Satori’s Circle on the EMS profession and we will be working with

them to encourage participation in the Bay EMT program as part of our career pipeline.

Our General Manager also serves as Vice President of their Board of Directors.

Youth Uprising

Led by longtime community leader Olis Simmons, Youth Uprising is a community

center located in one of the most challenged neighborhoods in Alameda County. They are

dedicated to advancing youth leadership development as a means of affecting positive

community change by ensuring that youth and young adults are supported in actualizing

their potential. Alameda County AMR works with Youth Uprising in a number of different

ways.

• They created the artwork for the cover of this proposal.

• They provide the data entry for our Customer Satisfaction Surveys.

• Their Corner Café caters many of the meals we provide during meetings at our

operation, as well as the holiday dinner we served our crews this year.

• We are working with them and the Bay EMT program to create a health career

pipeline for young people who are being trained as EMTs.

• We are also working with Youth Uprising to create a peer health advocate program.

This program has two objectives, to improve the health status of people in the

community at a grass-roots level, and to attract young people from the community

to join our family of EMS professionals.

The peer health advocate program teaches young people about self-care for chronic

diseases like asthma, sickle cell anemia, and diabetes. It teaches them how to recognize the

early signs of stroke and heart attack so that can call 9-1-1 early in the course of these time-

dependent emergencies.

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We also teach them how to do CPR. In addition to these skills for helping other

people, participants in this program are taught how to prevent the acquisition and

transmission of sexual diseases, how to avoid substance abuse, how to prevent violence,

how to cope with stress and depression, and how to process grief. The initial results of our

collaborative process with the Youth Uprising Education Staff and a group of young people

from the community is displayed in next graphic.

Cultural Competence Training

We pay particular attention to the needs of underserved and racial/ethnic groups and

we provide education and training to avoid the potential impact of uninformed cultural

attitudes, beliefs, and practices on diagnosis and treatment as well as workplace

environments. We will continuously promote skills, practices, and interactions to ensure

that the services we provide and our workplace are culturally responsive and competent

and free from discrimination.

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Last Fall we trained 100% employees in Cultural Competence using a custom-

designed experiential program created by two former senior Challenge Day facilitators.

Our Cultural Competence training develops skills for living with and working to serve

diverse individuals and communities. Cultural Competence is the willingness and ability

of an EMS system to value the importance of culture in the delivery of services to all

segments of the population.

It focuses on valuing differences and is responsive to diversity at all levels of our

organization including policy, leadership, administration, provider, patient and other

customers. One of the major concerns in healthcare is disparate treatment based on gender,

ethnicity, girth, literacy, and other factors. Our Medical Director, Dr. Gene Hern MA, MD

conducted a study on EMS disparities in treatment for Contra Costa County. Dr. Hern will

be replicating that study in early 2010 in Alameda County. We will use the results of his

work to guide any needed improvements to ensure equal treatment.

✔ 1.10 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.

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. Consistent with our

STAR CARE values, we are committed to a fostering actions that are Safe, Team-based,

Attentive to Human Needs, Respectful, Customer-Accountable, and Ethical, at every level

of our organization.

We promote workforce harmony and prevent discrimination based on these and

other characteristics through mandatory cultural competence training, recruiting from

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traditionally underrepresented groups, and ensuring our employee interview panel always

includes at least one person of color and woman.

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.

Our mandatory cultural competency training is conducted by Oakland-based

Integral Trainings. The cousins that run this training have more than 10 years of

experience facilitating intercultural, interpersonal, and diversity workshops in a multitude

of contexts around the US and the world. Their website is http://integraltrainings.com.

All quality/leadership team members are also required to engage in mandatory

diversity training. Our Ethnic Health Institute (EHI) mentors provide regular coaching to

our quality/leadership team on strategies to improve diversity in our workforce and prevent

disparities in healthcare in our community. Recently, one of our paramedics who is also a

filmmaker worked with EHI to create a version of their Stroke Awareness film in

Cantonese to improve access to vital health information to this population.

✔ 1.11 Describe the organization’s commitment to ensuring that providers are free from the influence of alcohol and intoxicating drugs. Impaired providers present a significant safety risk for patients, partners, and others in the community.

We have an alcohol and drug-free workplace policy and set of practices that

includes drug and alcohol testing for applicants and regular employees for anything on our

reasonable suspicion criteria list. A full copy of our policy is available on request.

✔ 2. DEDICATED PERSONNEL

✔ 2.1 [Per Addendum III, #1] The County recognizes the Contractor’s need to ensure adequate supervision of its personnel and the delegation of authority to address day-to-day operational needs. Personnel in leadership positions (as described in 2.4 - 2.6) are subject to approval by the Contract Administrator. An Operations Manager, Operational Field Supervisors, Clinical Field Supervisors, and the Quality Manager must be distinct and separate positions from each other.

Please refer to the Key Personnel section of Required Form Exhibit J, for a

complete list and description of our personnel and their qualifications, along with resumes

for the personnel we propose for the roles described in 2.4-2.6:

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• Mike Taigman, General Manager

• Dr. Gene Hern, Medical Director

• Luis Diaz, RN, Quality Manager

• Diane Akers, National Malcolm Baldrige Quality Award Consultant


These personnel are core members of the Alameda County AMR Quality Steering

Committee described in the introduction to section D, Clinical Quality Improvement.

✔ 2.2 The Contractor’s quality management program shall be incorporated into every layer of management and not be assigned to the responsibility of a single frontline or middle management position. A Quality Manager (see 2.6) shall be responsible for oversight and management of the key performance indicators and ongoing organization-wide quality management.

While we will add a highly-qualified member of the Alameda County EMS

community to our team as Quality Manager for this proposal, our General Manager, the

most senior member of our Alameda County team, has ultimate responsibility for oversight

and management of the key performance indicators and ongoing organization-wide quality

management. As detailed in Mike’s resume, he brings an extensive set of qualifications to

this role including a Lean Six Sigma Black Belt, DDI Master Trainer, and a track record of

training EMS leaders worldwide in the principles of quality management.

Our quality management program is incorporated into every layer of management

through monthly meetings of the Alameda County AMR Quality Steering Committee.

This team includes the people who have helped shape the criteria by which our industry is

judged and who have won industry quality awards for consistently meeting and exceeding

those standards.

The group meets the first Thursday of every month and is focused on

comprehensive data analysis from all KPIs and leadership for improvement projects.

Improvement projects are then implemented by tactical teams. Progress on improvements

is monitored through processes appropriate to the scope and needs of the project. Most

improvement projects involve project-specific KPIs for evidence-based and statistically-

valid monthly monitoring. We will provide all KPI reports to the County during these

meetings and on request.

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Our quality expert Diane Akers helps us align our KPIs and actions to the intense

requirements of State and National quality awards based on Baldrige criteria to which

we’ve committed to apply. Davis Balestracci enables our team to conduct world-class,

complex statistical analysis for quality improvement as well as research projects. He also

helps us identify datasets most relevant for making statistically-valid, measurable

improvements in community health.

The Quality Steering Committee meeting is chaired by General Manager, Mike

Taigman, and is made up of Alameda County AMR leaders with particular expertise and

involvement in implementing improvements in addition to these personnel. Members of

the EMS Agency and office of the Medical Director are invited to attend and we welcome

their input to this collaborative process.

✔ 2.3 The Proposers shall specifically explain how the Clinical Field Supervisors (2.8) and Operational Field Supervisors (2.9) 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.

Our Clinical Supervisor/Specialists function as an extension of our Clinical

Education Services team and they work under the supervision of the County Medical

Director. Clinical Supervisor/Specialists monitor, evaluate, and improve the clinical care

provided by our personnel by providing topic-specific in the field education and coaching,

responding to calls and providing feedback/support, and by reviewing patient care reports

on critical calls as defined by the County Medical Director.

The monitoring, evaluation, and improvement aspects of their work blend together

seamlessly as they work with crews on calls and at the hospital. One of their first

improvement projects focused in the implementation of the Airway Checklist composite

scoring system described in section D.2.5.7. Their objective was to measurably improve

the percentage of patients who have or have the potential to have airway compromise who

were cared for with all 13 elements of the Airway Checklist. We are currently tracking

performance in this area as a KPI which will be used for further improvements.

Our Operational Field Supervisors are all seasoned paramedics. While they do

handle administrative and system issues, their focus is on the execution of our

organization’s purpose, vision, and values which are all aligned with the provision of

wonderful clinical care and service for our customers. Like our Clinical

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Supervisor/Specialists, the Operational Field Supervisors regularly run calls with crews and

visit with them at the hospital as they deliver patients. They provide monitoring,

evaluation, and feedback for improvement throughout their entire shift and supplement the

ongoing feedback from our team of approximately 40 Field Training Officers. More about

our Clinical Field Supervisors and Operational Field Supervisors can be found in the Key

Personnel section of Required Form Exhibit J.

✔ 2.4 Operations Manager: Contractor shall provide a full-time Operations Manager to oversee and be responsible for the overall functioning of the Alameda County operation. This person shall have prior experience managing a large, high-performance EMS system and be approved by the EMS Director and EMS Medical Director. This person shall be a champion of quality management, and ensure all upper-level management positions are trained and participate.

Our General Manager, Mike Taigman, is responsible for the overall functioning of

Alameda County AMR and has been in this role over the past ten months. Mike has been

an EMS quality and management leader for more than 30 years. Mike’s prior experience

includes as co-founder and ongoing senior leadership team member of Paramedics Plus,

designing, implementing, and leading the award-winning quality programs at Oklahoma’s

Emergency Medical Services Authority (EMSA) and SunStar in Pinellas County, Florida.

He has worked with most of the highest performing EMS systems in the Country as

employee, educator, or consultant. More about Mike can be found in the Key Personnel

section of Required Form Exhibit J.

✔ 2.5 Medical Director: Contractor shall provide a 0.5 FTE physician, experienced in emergency medical services, to oversee clinical areas.

Dr. Gene Hern brings to our team

more than a decade serving patients in

Alameda County, including as Program and

Residency Director for Alameda County

Medical Center, Highland Hospital Campus,

where he continues to work as emergency

physician. Dr. Hern has lectured on a wide

range of clinical topics as well as medical

ethics and cross-cultural ethics and been

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Assistant Clinical Professor at UCSF for more than a decade.

He is an active participant in our clinical quality initiatives as well as monthly

quality/leadership team meetings, and teaches our employees at our “Hot Topics” lecture

series. Dr. Hern’s medical leadership will be supplemented by the EMS Fellow Physician

as part of our ongoing collaborations with Highland Hospital. As an enhancement,

Alameda County AMR commits to fund one quarter of the Fellow who will participate in

quality improvement, research, and clinical education projects. More about Dr. Hern can

be found in the Key Personnel section of Required Form Exhibit J.

✔ 2.6 Quality Manager: Contractor shall provide a physician, a Registered Nurse, or highly qualified and experienced paramedic to implement and oversee Contractor’s on-going quality management. This individual shall be responsible for the medical quality assurance evaluation of all services provided pursuant to this Agreement.

Our team has selected Luis Diaz, RN, longtime pre-hospital care coordinator for the

Oakland Fire Department, to join us in fulfilling our purpose, vision, and values if we are

selected in this RFP process. Our goal is to enable Luis to further his demonstrated

commitment to patients in this County while continuing to support our Fire First Responder

partners. Luis brings a complementary set of unique capabilities to our team, as detailed in

his resume in the Key Personnel section of Required Form Exhibit J.

Our entire quality/leadership team actively participates in our quality processes

along with our experts. Management responsibilities for particular improvement projects

are determined on a case-by-case basis, falling to leadership or members of our field staff

who volunteer to take on a leadership role for a particular project relevant to them. In this

way, field crew members are able to learn more about quality processes and get a different

perspective on our operations that can fuel further involvement or professional growth if

they choose.

✔ 2.7 Clinical/Education Staff: At a minimum, in addition to the above positions the Contractor shall provide and maintain two full-time clinical and educational staff positions (these are in addition to the Quality Manager position responsible for overall oversight of quality management).

Our Clinical/Education staff includes Elsie Kusel and Lee Siegel, each of whom is

an Alameda County-Certified CE provider and each of whom has more than two decades

of experience in Alameda County EMS. Elsie and Lee were involved in selecting Luis

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Diaz, RN, to join our Clinical Education Services team as Quality Manager based on their

past experience working together as some of the most dedicated, longstanding members of

our community’s EMS system. Elsie and Lee are responsible for ensuring our education,

training, and investigations are aligned with our purpose, vision, and values. Their role

includes participation in Quality Steering Committee meetings and all other activities

related to maintaining and improving the high quality of our crews’ clinical performance

and will continue to for the new contract. More about Elsie and Lee can be found in the

Key Personnel section of Required Form Exhibit J.

✔ 2.8 Clinical Field Supervisors: At minimum, the Contractor shall provide two Clinical Field Supervisors for each shift, approved by the EMS Medical Director, who are experienced, clinically and administratively competent paramedics with prior teaching/training experience who serve in the following responsibilities:

✔ 2.8.1 [Per Addendum I, Part I, #5] Respond to as many ECHO calls as possible as a first priority to assist and provide oversight.

Our Clinical Field Supervisors/Specialists are all experienced paramedics with

many years of field and teaching experience. Through our pilot program of this concept

working with the County Medical Director we were able to further refine the qualities and

capabilities that candidates for this new role in the system should possess. Our proposed

personnel for these roles identified in the Key Personnel section of Required Form Exhibit

J possess those qualifications and we anticipate they will be approved by the Medical

Director following this RFP process.

These personnel have fully-equipped emergency response vehicles to respond to as

many Echo calls as possible as a first priority to assist and provide oversight, as well as

responding to other calls, and meeting crews at the hospital to provide feedback and

education.

✔ 2.8.2 Provide direct, case-by-case oversight of clinical personnel

Clinical Supervisor/Specialists provide oversight, review, and feedback for the

clinical personnel handling the case on each call where they arrive in time to observe field

care.

✔ 2.8.3 Coordination of data collection for ongoing compliance in collection and reporting of cardiac arrest, airway, 12-lead data

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Data collection for ongoing compliance and reporting of cardiac arrest, Airway

Checklist, 12-lead, and other vital clinical data is coordinated by our Clinical Education

Services team and the Clinical Supervisor/Specialists. Before the start of a new contract,

new MEDS 3.0 will enable us to collect a host of easily customizable data fields for

ongoing reporting as well as quality improvement and research functions so our

improvement strategies and interventions are evidence-based and most likely to produce

results for patients. MEDS 3.0 is described in sections D.2.5.6 and I.3 of this proposal.

✔ 2.8.4 Direction and assistance with research and compliance for research in trial studies, focused audits, and state-directed demonstration projects

Our Clinical Supervisor/Specialists assist with research, compliance for research

studies, focused audits, and state-directed demonstration projects.

✔ 2.8.5 Teaching and reinforcement of clinical policies and procedures

Our Clinical Supervisor/Specialists are often described by our field crews as the in-

field extension of our Clinical Education Services team. They actively teach and reinforce

clinical policies, practices, and procedures.

✔ 2.8.6 Introduction of new techniques and procedures

Our Clinical Supervisor/Specialists are the primary vehicle for the introduction of

new techniques and procedures. Last Fall they supported Airway Checklist education in

the field.

✔ 2.8.7 Facilitate the use of PemSoft and other educational software

We currently use PemSoft and other educational software at Alameda County

AMR. Our Clinical Supervisor/Specialists are early adopters and testers of educational

software including PemSoft. Once they have learned how to use a new tool themselves

they help field crews learn how to use it.

✔ 2.8.8 Collaboration with County EMS Leadership and Prehospital Care Coordinators

Our Clinical Supervisor/Specialists program was created in collaboration with the

County EMS leadership, County EMS Medical Directors, and Prehospital Care

Coordinators. We commit to continuing full collaboration with County EMS leadership.

✔ 2.8.9 Resource persons for difficult clinical issues

Our crews regularly seek advice from our Clinical Supervisor/Specialists on

difficult clinical issues.

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