Fire Commission Response to Grand Jury Report
The merger of the Fire and Emergency Medical Services (EMS) functions into one department has been a matter of critical importance to the Fire Commission. The merger process began in 1996, at the time when three of the current commissioners were appointed by Mayor Brown. At the inception of this process, the Fire and Health Commissions met jointly and established that it was the policy of both Commissions that a fire-based EMS delivery system was in the best interest of San Francisco's residents and visitors. The merger of the Advanced Life Support (ALS) capability of the Department of Public Health ambulance system into the Fire Department, which was already providing Basic Life Support (BLS) emergency medical service, was perceived to be a natural and efficient combination of existing resources, while enhancing the quality of pre-hospital medical care. The Fire Commission appreciates the Grand Jury's work on this important issue and herewith responds to the Grand Jury Report on the Merger of Emergency Medical Services and the San Francisco Fire Department (hereinafter referred to as "Report").
Preliminarily, the Fire Commission notes the merger's progress since it was initiated in 1996:
Before the merger, the Public Health ambulance system consisted of an average of fourteen ambulances deployed dynamically, each staffed by two paramedics, providing service to the entire City. There are now twenty ambulances, each staffed by at least one paramedic and one Emergency Medical Technician (EMT), four Rescue Captains in vehicles, and additional H1-paramedic staffed ambulances deployed strategically throughout the City. For the past two and one half years, there have been a minimum of 21 and, during the past year, an average of 25 ALS engines deployed throughout the City, each staffed with one paramedic and one EMT. All Firefighter/paramedics now rotate between assigned ALS engines and ambulances, establishing continuity and rounding out the engine company's provision of services. With four Paramedic Rescue Captains in vehicles, there are, at any given time, more than 45 to 50 ALS-staffed Fire Department units responding to medical emergencies throughout the City. The number of paramedics-staffed units capable of responding at any given time has increased 200% from fourteen to more than forty-five. The number of individual ALS responses that are possible at a given time have increased more than 200% from fourteen to fifty.
Before the merger, the entire paramedic staff was supervised by one field supervisor. There are now four field supervisors, an increase of 300%. The ratio of field supervisors to paramedics has been improved from one to twenty-eight (1:28) to one to eleven (1:11).
Before the merger, the 90th percentile ALS response time1 for a paramedic to reach the scene was over nine minutes. The 90th percentile ALS response time for the first paramedic to the scene is now four minutes and forty seconds, cutting the response time in half.
Since the merger, paramedics, firefighters and Firefighters/Paramedics have been quartered together and have worked side by side in the delivery of emergency services to the City. These emergency services consist not only of emergency medical services and fire suppression2, but also water, surf and cliff rescue, hazardous materials response and weapons of mass destruction response which are all provided by firefighters and Firefighter/paramedics. During the past two years EMS and suppression administrative staffs have been integrated into the same headquarters. EMS and suppression training now takes place in the same facilities. There are now two California Medical Board Certified Emergency Room physicians who serve as Medical Directors of the Department.
In late 2003, the Commission revised its Annual Statement of Purpose by eliminating the statement that one of the Commission's purposes is to advocate for the realization of the merger. This was done in recognition that, in the Commission's view, the merger has been accomplished. Although the merger is accomplished, the manner and method by which the Department provides emergency medical services is continuing to undergo refinement. One role of the Commission is to provide ongoing support of the administration's efforts to enhance and support the collaborative work of the department membership and public stakeholders in the delivery of (1) fire suppression, (2) fire prevention and (3) emergency medical services with the focus upon the common public good. There is no priority given to one service over another. All are critical and integral components designed to effectively serve the public.
Since Chief Joanne Hayes-White took office in January of this year, she has taken swift and deliberate action to further improve upon the system. The Chief has named a new Director of Training who is the first Director trained as both a paramedic and firefighter. The new EMS Division Chief, appointed by Chief Hayes-White, is the first EMS Chief with extensive experience in the field as both a firefighter and paramedic. There is now a physician assigned to the in-service medical training for EMTs and paramedics. There is now an ongoing Quality Improvement Program designed to enhance the quality of medical care overseen by a physician.
Early this year, Chief Hayes-White convened an EMS configuration study involving all employee and work group organizations, including the Firefighter/paramedic association, the EMS Officers Association, Local 790 (representing the paramedics), the Director of the San Francisco County EMS Agency, Local 798 and other stakeholders in the process in an effort to refine the delivery of EMS services, taking into account quality of service, cost and the retention of Firefighter/ Paramedic personnel.
At the same time, Chief Hayes-White announced a goal of deploying each of the Department's 42 engines companies as ALS engines, further reducing response time and further integrating paramedics and firefighters into a unified response to a range of emergencies.
While there have been difficulties encountered along the way, perhaps not surprising given the breadth of the undertaking, the merger has resulted in a far more effective emergency medical services delivery system - to the great benefit of San Francisco's residents and visitors. The San Francisco Fire Department is viewed nationally as a model EMS provider in the areas of medical training, quality improvement and dispatch.
In view of this substantial progress, it is with dismay that we read the Grand Jury Report, with the offensive sub-title Match Made in Heaven or Shotgun Wedding?
The Report states that the majority of the Department Members "are dedicated to protecting the lives and property of the citizens of San Francisco." It is the Commission's view, based on its observance of and interaction with the Department's membership that, with the exception of the few individuals encountered in disciplinary proceedings, all of the members, uniformed and civilian, are dedicated to the Department's mission.
Contrary to the statements made in the Report, medical oversight of EMS is not weak, but, as pointed out above, it is stronger than ever before. The statement that "No one in authority is watching out for the EMS needs of San Franciscans or the EMS providers" has no support in fact and is contrary to the truth. In fact, the EMS needs of San Franciscans, through the merger and the continuing enhancement of the methods and quality of service, are significantly better provided for than prior to the merger. In fact, the EMS providers are better supported and supervised than prior to the merger. This is due to the efforts of the prior and current Mayoral administrations, the Public Health Commission and Director of Public Health, the Director of the San Francisco County Emergency Medical Services Agency, the Fire Commission, the Chief of the Fire Department and her administration, all of whom are looking out for the well being of the residents and visitors to San Francisco and the firefighters, EMTs, paramedics and Firefighter/Paramedics who help them. The Commission is dedicated to fostering a Department which will continue its progress toward becoming a model fire-based EMS delivery system in all facets of EMS delivery.
The Commission agrees that a very serious problem within the Department is the lack of promotions. This delay is related in part to the circumstances surrounding the Consent Decree and is due in large part to differences over the certification rule for the Captain's promotional examination. The Department is currently endeavoring to resolve this issue before the Civil Service Commission.
The Commission is responsible for overseeing the Department and working with the Chief, but does not "rubber-stamp" the Chief's decisions. The Commission independently evaluates recommendations and operates by consensus where appropriate. This Chief has brought a new openness to the deliberative process that fosters open debate during consideration of issues confronting the Department. The Commission does not hesitate to challenge and question the Chief.
The Commission does not tolerate on-duty alcohol or drug ingestion or intoxication. Members who have been found in violation of Department Rules and Regulations regarding drugs and alcohol have been appropriately disciplined by the Commission pursuant to its Charter mandate. The Chief of Department is in the process of initiating a program of random testing for on-duty drugs and alcohol. The random testing should enable further enforcement and provide deterrence.
RESPONSE TO FINDINGS AND RECOMMENDATIONS
The Commission notes that most of the "Findings" contained within Sections I, III and V of the Report, to which it has been asked to respond, are not true factual findings. The Report's findings are largely references to statements made in the Controller's April 28, 2004 review of the Fire-EMS System, to which the Department has already responded separately. Additional findings are arguments posited as facts. In addition to the specific responses below, the Commission refers to the other sections of this response in answer to the findings.
I. MERGER OF THE DEPARTMENT OF PUBLIC HEALTH EMERGENCY MEDICAL SERVICES AND THE SAN FRANCISCO FIRE DEPARTMENT
1.3 Agree in part. SFFD is also responsible for the effectiveness of EMS.
1.4 Disagree. The Report is engaging in semantics with the terms "merger" and "complete". The merger is complete by every measure, from the lettering on the ambulances to the integration of EMS services, training and administration into the Department. The Department, as with every successful organization, will continue to refine the method and quality of the services it provides.
1.5 Disagree. The SFFD Medical Director's salary is paid in part by the SFFD and in part by the Department of Public Health. The SFFD Medical Director has, and exercises, a policy advisory role in the SFFD regarding the provision of medical care and quality improvement.
1.6 Agree. There is a direct reporting relationship between the SFFD Medical Director and the Director of Public Health. There is also a direct reporting relationship between the Director of EMSA and the Director of Public Health.
1.7 Disagree. The SFFD Chief of EMS is one of three Assistant Deputy Chiefs who reports to the Chief of Department through the Deputy Chief of Operations.
1.8 Disagree. The Department responded to BLS medical calls before the merger and continues to respond, with added ALS capability, since the merger. The EMS mission is considered to be an integral part of the Department's mission.
1.9 Disagree. This statement does not make a fair comparison between all EMS calls, regardless of the true medical condition of the patient, and those fire calls which only involve actual structure fires. Call volume alone, without reference to the nature or severity of the incident as well as other factors, should not be relied upon in determining the appropriate deployment of resources.
1.10 Disagree. There is no basis, factual or otherwise, to support a conclusion that the number of fire suppression calls are "inflated" or are otherwise misrepresented. SFFD incident response data is available to the public through a number of sources.
1.12 Agree that street box alarms are typically responded to by an ALS or BLS engine and a truck, which are prepared to provide fire suppression or medical response. Disagree that this is excessive, given the importance of a fast medical response and the risk of fire spread posed by the construction type and density in San Francisco.
1.13 Disagree. Refer to Response to Findings and Recommendations in Section V and the Introduction, Overview and Conclusion sections of this Response.
1a. Agree. The Commission agrees with this recommendation to the extent that it suggests the establishment of specific criteria for measuring the success of the Department's provision of Emergency Medical Services. This recommendation will be implemented, understanding that the Commission views the merger as having already been "completed", but with the view that goals and timelines for further improvement should be established and articulated and accomplishment of these goals measured.
1b. Agree, as noted in 1a, above. The Commission is accountable to the Mayor and agrees that it should be accountable for all goals established for the Fire Department.
1c. The Mayor appoints Commissioners, pursuant to the San Francisco Charter, Sections 3.100 and 4.108., and, therefore, the Commission cannot implement this recommendation.
1d. The Commission disagrees with this recommendation. Medical oversight is provided by: The Department of Public Health Director; the Director of the San Francisco County Emergency Medical Services Agency (EMSA); the Department's two Medical Directors, all in communication with one another. The Department's Medical Directors and the EMS Division Chief and the EMS Operations Chief report to the Chief of Department and through her, report directly to the Fire Commission at regularly scheduled Commission meetings. Individual Commissioners recommended in November, 2003 that greater communication occur between the Chief of Department and the EMSA Director. There has been significant improvement in this area since the inception of Chief Hayes-White's administration, to the benefit of the Department's provision of EMS services.
The Commission believes that there may be occasions in the future when both the Fire Commission and the Public Health Commission would find it beneficial to meet jointly with respect to specific policies or procedures, as appropriate.
1e. The Commission agrees with this recommendation, which has already been implemented. The Commission, in its Annual Statement of Purpose posted on the Commission web site, recites that the provision of emergency medical services, together with fire suppression and fire prevention is an integral part of the Department's mission. The Commission has also communicated the importance of the Department's EMS mission in public statements during both regular and special Commission meetings.
In addition, at a special meeting convened by the Commission on August 12, 2003 specifically for the purpose of considering steps to take to improve the progress of the merger and to respond to complaints from Firefighter/paramedics, the Commission sought and obtained public comment from members. Following this meeting, two Commissioners undertook a series of individual meetings with all stakeholders in regards to the merger and the complaints since reiterated in the Report. These Commissioners publicly announced and repeated the importance of the EMS mission during the November 25, 2004 Commission meeting. (See minutes of August 12, 2003 Special Meeting and November 25, 2003 Regular Meeting.) Additionally, in communications with Department membership and administration, Commissioners have stressed the importance of a team approach of all segments of the Department in carrying out its mission to provide fire prevention, emergency medical services, fire suppression, rescue and hazardous materials response. The Chief of Department has clearly and unequivocally communicated the same message.
1f. This recommendation has already been implemented. Additionally, the EMS configuration study is currently underway to refine the Department's delivery of EMS services and ensure that the most effective and efficient combination of resources is brought to bear on medical and other emergencies. The Commission does not agree with the inference that there has been a disproportionate emphasis on fire suppression, but agrees with the recommendation that the Department should respond with appropriate staff and equipment.
III. RESOURCE ALLOCATION AND POLITICS
3.1 Disagree. Among other omissions, this statement does not account for the Firefighter-EMTs in the Department who provide important BLS services, in addition to their other services. This statement does not recognize the pre-merger and continuing demand for fire and other emergency response that is not eliminated by the addition of ALS responsibilities.
3.2 Disagree. The merger is complete. A goal has been expressed of achieving all ALS engines. Some recruits with paramedic licenses have been hired into the current academy and will be encouraged to work for the Department as Firefighter/Paramedics. The Department is currently reviewing its hiring plan to increase the number of paramedics.
3.3 Agree that an entrance level Firefighter/Paramedic provides firefighting and ALS services at a 15% higher cost than a fifth year firefighter.
3.5 This finding does not specify the criteria being utilized for this conclusion. Unable to agree or disagree because it is unclear in which situations the patients actually received or required ALS services.
3.6 Agree that twenty-one ALS engines is the minimum number of ALS engines that the Department will deploy. However this year, on average, twenty-five ALS engines have been staffed.
3.7 Disagree in part and agree in part. The merger has progressed under the administration of three short-term Chiefs and the merger was accomplished, in the view of the Commission, during the tenure of the previous Chief. Agree that the new Chief is charged with further enhancing the Department's provision of Emergency Medical Services. Agree that the new Chief should be, and is, supported in her efforts
3.8 Disagree. There has been significant change for the better in the Department, particularly as it relates to the provision of EMS services. Local 798 leadership has expressed support for the Department's provision of EMS services. This is consistent with the International Association of Firefighter's endorsement of a Fire-based EMS provider system model. All stakeholders have worked collaboratively during the Department's recent EMS Reconfiguration process.
3.9 Agree that Local 798 effectively advocates for its membership, which is open to all uniformed members of the Department from the rank of H-2 Firefighter to H-50 Assistant Chief.
3.10 This finding is so replete with argument that it is not capable of response.
3.11 Agree that this is the conclusion of the Controller's report. However, the volume of calls in the SFFD is far greater than "comparable" departments, resulting in a heavier work load and the exposure of members to greater risk.
3.12 Agree. This conclusion of the Controller's Report, however, omits the fact that San Francisco has greater population density and greater housing stock density than the other jurisdictions to which it was compared. Factoring in density, San Francisco has fewer fire stations per structure requiring fire protection than "comparable" United States jurisdictions referenced in the Controller's Report. This comparison also omits other factors, such as: the challenging topography of San Francisco; the limited availability of mutual aid from other jurisdictions due to the fact that the City is on a peninsula; the prevalence of older wood frame structures and the risk of earthquake.
3a. Agree. This recommendation has already been implemented and is also undergoing further evaluation through the EMS Configuration process. It should be pointed out that although the medical dispatches amount to approximately 70% of the current dispatch volume, this medical workload has been layered on top of the Department's pre-merger fire and emergency response. These additional calls do not obviate the need to respond to suppression and other emergencies. Given the age and density of San Francisco's predominantly wood frame structures, quick and aggressive response by a sufficient number of personnel and apparatus is necessary to extinguish fires before they spread, which could otherwise result in conflagration. Resources cannot be allocated based solely on the daily series of dispatches, but must also be ready to respond to the regular occurrence of fire and the risk of earthquake, conflagration and other anticipated major events.
3b. Agree. This recommendation has already been implemented and is continuing. The Commission has overseen the deployment of Department resources to carry out the EMS mission of the Department since the inception of the merger as noted in the Introduction to this response.
3c. This is a recommendation to the Board of Supervisors. The previous and current Presidents of the Commission have met with the Controller and his staff concerning the Controller's recommendations. The Department has responded in those meetings and during the public meeting conducted by the Finance Committee of the Board of Supervisors. Under the City Charter, it is the Fire Commission that sets objectives, programs and policies and prescribes and enforces rules and regulations for the Fire Department.
5.1 There have been generalized anecdotal accounts of harassment, such as are contained in the Report itself. Information concerning the date, station, identity of the harasser and/or identity of the victim has not been received by the Commission. Many of the complaints were apparently in reference to incidents that had occurred years previously, but were reported as if they had recently occurred. The Commission has been frustrated by the lack of specifics in these complaints, which reduces the complaints to the status of rumors - that cannot be proved or disproved. The Commission is, therefore, not aware of facts which would either support or refute that this is currently or has recently occurred. The Commission has also been advised that Firefighter/paramedics have given up their H-3 status because of workload, a factor being addressed by the EMS Reconfiguration process. Another factor may have been the long term assignment to an ambulance, addressed in part by the deployment of Firefighter/paramedic-staffed ALS engines.
5.2 Disagree for the reasons stated in response to 5.1. Agree that the EEO complaint process does not afford recourse to a complainant who is not in a protected status under anti-discrimination laws. The process available to Firefighter/paramedics who complain of harassment because of their job function or title is through the chain of command. Agree that the chain of command is less effective currently, given the lack of promotions and the resulting temporary officer assignments. Commissioners have also been advised that conditions for paramedics and Firefighter/paramedics have improved.
5.3 This statement is of the type referred to in response to 5.1. The Commission is not aware of facts to support a statement that this is occurring or has occurred during this or the previous Chief's administration.
5.4 Agree that there have been specific complaints made during the past year through the chain of command concerning incidents of claimed harassment. Members found to have engaged in this conduct have been appropriately disciplined. Two further disciplinary matters are pending and are currently before the Commission for determination.
5.5 This statement is of the type referred to in response to 5.1. The Commission is not aware that this is occurring, recently occurred or ever occurred.
5.6 The first sentence touches upon a matter that is currently before the Commission with respect to one station and cannot be commented upon. Other than that claim, the Commission is not aware of facts to support this statement with respect to other stations. The Commission agrees that removal of a perpetrator of harassment or discrimination from a station may be one of the appropriate methods of correcting the situation.
5.8 Disagree that the Department has weak leadership or that the Department has a hostile work environment. Complaints of harassment that are brought through the chain of command are appropriately handled.
5.9 Disagree. This is a vague and generalized statement that is unsubstantiated and amounts to rumor.
5.10 Agree. This section of the Charter was amended November 2003.
5.11 Disagree. The Commission has appropriately dealt with all claims of harassment or other misconduct that have been brought before it. Where violation of Department rules and regulations has been demonstrated, the Commission has imposed the appropriate discipline, including suspension, fine and termination. The Commission cannot act upon rumor, as the spreaders of such rumors are well aware. The Commission has clearly communicated to the Department that harassment of any kind will not be tolerated. The Chief of Department has demonstrated her own unequivocal determination to effectively deal with any specific claims of harassment. The Commission has directed, encouraged and supported the completion of the merger and the continuing improvement of the quality of service, including EMS service, provided by the Department.
5a. The Commission agrees with, and has already implemented and pursued a policy that harassment of any type, including harassment of Firefighter/paramedics, will not be tolerated. The Department should continue to investigate specific claims of harassment and, if verified, impose appropriate discipline, up to and including potential termination. The Department should take steps to eliminate structural impediments that are perceived as preventing enforcement of the Department policy that harassment will not be tolerated. The Commission recently terminated a member it found guilty of harassment.
5b. The Commission agrees with this recommendation, which has already been implemented.
5c. The Commission agrees with this recommendation, which has already been implemented.
The Commission views the merger as having accomplished a substantial and dramatic improvement in the quality of emergency medical services provided to the residents and visitors of San Francisco. There have been significant increases in the number of paramedics and in the number of paramedic-staffed units. The response time for medical emergencies is half what the response time was before the merger. There has been an increase in the degree of direct medical oversight and a further integration of EMS and Fire administration and training.
The Commission recognizes and continues to stress the importance and equal role of the EMS component of the Department. Although the Commission views the merger as having been completed, it supports the Chief of Department's continuing efforts to refine a balanced and efficient delivery of EMS, Fire Suppression and other emergency and prevention services in an environment that is free from harassment and discrimination in any respect.
The Commission continues to communicate, consistent with what has been articulated by the Chief of Department, that harassment of any member for any reason will not be tolerated. Members who have committed harassment have been disciplined by the Department administration and the Fire Commission. It appears that the working conditions of Firefighter/paramedics have improved due to the efforts of all members to work together. Many of the complaints which the Commission has heard, which have also been repeated in the Report, concern reports of incidents that occurred years ago. Members of the Department who feel that they have been harassed or discriminated against based upon their Paramedic or Firefighter/paramedic status are encouraged to bring their complaints through the chain of command without fear of retribution.
In conclusion, it is this Commissions' strongly held belief that the snapshot presented by the Grand Jury report does not accurately reflect the Department yesterday or today. The Department is more than a fire department. Its members offer the public a diverse set of skills and services and work collaboratively to achieve a selfless mission. The merger has been a broad undertaking in scope and has significantly improved the effective delivery of a full panoply of emergency services to the public.
The path is not always without conflict. The merger brought distinct working cultures together into a new organization that has taken time to mature. The Department consists of different employee groups, which, at times, have competing interests, particularly when there is a diminishing pie and serious financial and budgetary concerns facing the City. Yet, overwhelmingly, the members are united in their dedication to this City and to the delivery of effective suppression, prevention and emergency medical services in an environment that values cultural diversity and is free of harassment and discrimination.
The Department has taken great strides over the past eight years. The merger has been complex, yet, successful. Admittedly, there have been trying times. Admittedly, there is more to do - there will always be more to do. Yet, the Department is committed to excellence and no less a standard. The Members would no doubt agree.
Adopted at the Regular Meeting of the San Francisco Fire Commission on August 12, 2004.
Ayes: Conroy, Nakajo, Roeca, and Clarke
Tania Bauer, Commission Secretary
1 "90th percentile" means that in nine out of ten responses, the responding vehicle arrives within the required time. This is a national statistical methodology utilized by Emergency Response Agencies to measure and compare emergency response times.
2 "Suppression" in the SFFD includes all field personnel, including Special Operations, extinguishment of fires, emergency medical response, surf and cliff rescue, Airport operations and arson investigation.