Consultant Report Medstar EMS Fort Worth, TX System Review

AMR 04656

Consultant Report

MedStar EMS Fort Worth, TX

System Review

May 23, 2008

303 Marshall Road, Box 170 Platte City, MO 64079 (816) 431-2600 www.fitchassoc.com AMR 04657

Consultant Report

MedStar EMS System Analysis Fort Worth, Texas

Table of Contents

EXECUTIVE SUMMARY______1 SYSTEM OVERVIEW ______2 STUDY SCOPE & METHODOLOGY______4 SCOPE OF WORK ______4 PROJECT METHODOLOGY ______5 REPORT STRUCTURE ______7 ORDINANCES & INTERLOCAL AGREEMENT ______8 STATE REGULATIONS, UNIFORM ORDINANCE AND INTERLOCAL AGREEMENTS______8 STATE OF TEXAS REGULATIONS ______8 UNIFORM ORDINANCE ______8 AMENDED AND RESTATED INTERLOCAL AGREEMENT AND THE 2006 AMENDMENT TO THE INTERLOCAL AGREEMENT ______9 Price Subsidy Option ______9 Special Events ______9 ALL ALS, FULL SERVICE VS. TIERED ______10 Ordinances & Interlocal Agreement Recommendations:______11 EMERGENCY COMMUNICATIONS______12 COMMUNICATION CENTER OPERATIONS ______12 SUMMARY OF COMMUNICATIONS ______14 Communications Recommendations ______14 SYSTEM STATUS MANAGEMENT ______15 DEPLOYMENT ANALYSIS ASSUMPTIONS ______16 EXECUTIVE SUMMARY OF DEPLOYMENT ANALYSIS ______17 DAILY OPERATION OF SSM ______19 SYSTEM PERFORMANCE REPORT______19 AFTER ACTION REVIEW ______20 FRONTLINE INPUT ______21 LACK OF SENSE OF URGENCY ______21 System Status Management Recommendations ______22 FIRST RESPONSE ______24 RESPONSE TIMES ______24 FIRST RESPONDER CREDENTIALING ______25

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First Response Recommendations: ______25 CLINICAL CARE & MEDICAL OVERSIGHT ______26 EMERGENCY PHYSICIANS ADVISORY BOARD (EPAB)______26 MEDSTAR CLINICAL DEPARTMENT ______26 EPAB/CLINICAL WORKING RELATIONSHIP ______27 EPCR ______27 KEY PERFORMANCE INDICATOR DATA TRACKING______27 CLINICAL CARE ______28 EPAB BOUNDARIES ______28 SUMMARY OF CLINICAL AND MEDICAL OVERSIGHT ______29 Clinical and Medical Oversight Recommendations ______29 DEPLOYMENT CENTER - SUPPLY & FLEET ______30 CENTRALIZED DEPLOYMENT CENTER______30 SUPPLY MANAGEMENT ______31 SUMMARY OF SUPPLY______32 Supply Recommendations ______32 FLEET MANAGEMENT ______32 Vehicle Safety ______33 Reporting______34 Shop Work Area ______34 SUMMARY OF FLEET SERVICES ______34 Fleet Services Recommendation ______34 STRATEGIC HUMAN RESOURCES______35 THE PROBLEM OF PEOPLE ______35 EMPLOYEE SATISFACTION – THE WHITNEY SMITH COMPANY______36 FITCH SURVEY RESULTS______37 Demographic Data______37 What’s Working Well at MedStar? ______38 Improving Response Time Compliance ______38 Frustration: 80/20 Rule______39 Retention______39 The Whitney Smith Company Survey ______40 Results of Fitch Report ______40 Gallup 12______41 SUMMARY OF THE SURVEY ______42 COMPENSATION ______42 SUMMARY OF COMPENSATION ______44 RETENTION ______44 SUMMARY OF STRATEGIC HUMAN RESOURCES ______46 Strategic Human Resources Recommendations ______46 MANAGEMENT TEAM ______47 EXECUTIVE DIRECTOR ______47

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ASSOCIATE DIRECTOR POSITION ______48 EXISTING MANAGEMENT DEVELOPMENT ______49 Management Specific Training ______49 Academic Preparation ______49 Conference Attendance ______49 CURRENT MANAGEMENT PRACTICE ______50 OPERATIONS MANAGER CONFIDENCE ______50 CYCLE OF IMPROVEMENT ______51 PROCESS COACHING ______53 SUMMARY OF MANAGEMENT FINDINGS ______54 Management Team Recommendations ______54 SYSTEM FINANCE ______55 BACKGROUND ______55 Payer Mix______55 Self Paying Patients______57 SUMMARY OF PAYERS ______58 REVENUE______58 EXPENSE ______63 SUMMARY OF SYSTEM FINANCE ______64 Business Management Recommendations ______65 LATERAL INDUSTRY BENCHMARKING______66 RESPONSE TIME RELIABILITY ______66 CLINICAL CAPABILITY ______66 ECONOMIC EFFICIENCY ______67 CAEMS SOURCES OF REVENUE______68 LATERAL BENCHMARK SUMMARY ______68 Lateral Benchmark Recommendation ______68 FUTURE SCENARIOS ______69 STATUS QUO ______69 COMPETITIVE BID FOR AN AMBULANCE CONTRACTOR ______70 THIRD-SERVICE GOVERNMENTAL OR FIRE DEPARTMENT______70 AUTHORITY MANAGES OPERATIONS ______71 SUMMARY OF FUTURE SCENARIOS ______72 Future Scenarios Recommendations ______72 SUMMARY OF REPORT______73 RECOMMENDATIONS______74 Ordinances & Interlocal Agreement Recommendations:______74 Communications Recommendations ______74 System Status Management Recommendations ______74 First Response Recommendations: ______75 Clinical and Medical Oversight Recommendations ______75 Supply Recommendations ______76

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Fleet Services Recommendation ______76 Strategic Human Resources Recommendations ______76 Management Team Recommendations ______76 Business Management Recommendations ______77 Lateral Benchmark Recommendation ______77 Future Scenarios Recommendations ______77

FIGURE 1: NINE-PHASE CONSULTANT PROJECT METHODOLOGY ______5 FIGURE 2: APRIL 2008: SCHEDULED VS. ACTUAL UNIT HOURS ______36 FIGURE 3: INSTITUTE FOR HEALTHCARE IMPROVEMENT – DEMING’S SYSTEM OF PROFOUND KNOWLEDGE MODEL. ______51 FIGURE 4: SAMPLE STATISTICAL PROCESS CONTROL CHART ______52 FIGURE 5: IHI MODEL FOR IMPROVEMENT ______53 FIGURE 6: MEDSTAR PAYER MIX ______56 FIGURE 7: TOTAL POPULATION SERVED BY MEDSTAR (1989 TO PRESENT )______59 FIGURE 8: MEDSTAR MEAN SUBSIDY PER CAPITA (1989 TO PRESENT)______60 FIGURE 9: MEDSTAR MEAN BILL (1995 TO 2008) ______60 FIGURE 10: SUBSIDY PER CAPITA OF CAEMS MEMBER CITIES (2006) ______61 FIGURE 11: MEDSTAR GROSS CHARGES, CONTRACTUAL ALLOWANCES, AND PAYMENTS______62 FIGURE 12: CAEMS BENCHMARK OF COST PER TRANSPORT (2006) ______64 FIGURE 13: CAEMS BENCHMARK OF COST PER CAPITA (2006)______64

TABLE 1: THE GALLUP 12 QUESTIONS ______41 TABLE 2: SALARY BENCHMARKS ______43 TABLE 3: COMPARISON OF THE AVERAGE OF THE SALARY BENCHMARKS WITH PROPOSED MEDSTAR 2008 SALARIES.______43

Appendix A: Demand Analysis Appendix B: MedStar Employee Survey Results

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Executive Summary

Fitch & Associates conducted a comprehensive system review of the MedStar EMS system. This report includes the consultant’s findings and list of recommendations for improvement. The following executive summary shares an overview of the consultant’s findings.

! EMS system performance is less than desired by the Authority and member communities, but remains more reliable than most major Cities in the State and nationwide. ! The MedStar organization was patched together following the termination of the contractor and failing performance. It has been attempting to get back on track ever since and has not adequately developed as an organization and team. ! A proposed deployment plan, with stakeholder input, can achieve response time compliance, but still requires increased staffing. ! Staffing remains a significant issue tied to achieving performance and is heav- ily affecting management efforts. ! Employee frustration is high with three primary concerns: 1) pay, 2) scheduling convenience, and 3) existing management team issues. ! Nearly 70% of employees report, in the Fitch survey, that they are sticking with MedStar for the long haul. Turnover in 2007, however, was higher than the national average and industry average attrition rates. ! Current and proposed pay rates for controllers, EMTs, and paramedics are lower than the average of four separate benchmarks. ! Funding will need to increase to maintain sustainable performance and a minimum per capita should be established for member Cities. Reimburse- ment has gone down; volume has gone up, while subsidy has remained un- changed. ! MedStar is comparable with peer Cities that are members of the Coalition of Advanced Emergency Medical System (CAEMS) benchmark study. ! The management team and EPAB are currently functioning in a siloed, non- integrated fashion. No methodology for process improvement is in use. ! The Authority needs to assess the effectiveness of personnel in key leadership roles, clarify responsibilities, and establish boundaries. Management training would benefit the team.

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System Overview

The Area Metropolitan Ambulance Authority (d/b/a MedStar) is the exclusive emergency medical services provider for the Fort Worth, Texas metropolitan area. Known locally as MedStar, the EMS system serves emergency and non-emergency prehospital response and transportation for 15 Cities located in Tarrant, Johnson, Parker, Denton, and Dallas counties. MedStar serves a community of more than 830,000 citizens residing in an area of approximately 415 square miles located in the Dallas- Fort Worth Metroplex in North Texas. Fort Worth is the fifth largest city in the state and eighteenth largest in the United States. It is home to many major businesses and educational institutions and serves as the Tarrant County seat.

The Area Metropolitan Ambulance Authority was established in 1986. The original system model was a fail-safe franchise model, but the system was designed so that it could convert to a Public Utility Model, which it did in 1988.1 A Public Utility Model (PUM) is best described as “a highly defined business structure in which a public agency provides oversight but contracts with a provider for day-to-day operations. Elected officials appoint the leadership of the agency and approve the agency’s funding levels.”2 For nearly 20 years, MedStar contracted with private-for-profit contractors to provide day-to-day operational management through competitive-based contracting. The Authority administered the contract, managed accounts receivable, and managed the system infrastructure including the primary facilities and communications center.

In the spring of 2005, the Authority terminated its contract with its most recent operations contractor after consecutive months of failing to meet the performance expectations. The Authority immediately stepped in and assumed all responsibility for management of the day-to-day operations of the EMS system. Under the existing Interlocal Cooperative Agreement, in the event of the default of a contractor, the Au- thority was permitted to operate the EMS system while it conducted a competitive bid process to select and award the contract to a new private provider. In 2006, the member Cities of the Authority amended the Interlocal Agreement removing the eighteen-month operating restriction and the requirement that the system be put out to bid.

1 Stout, J.L. (1985, October). The failsafe franchise model. Journal of Emergency Medical Services, 10(10), 56-60. 2 Fitch, JJ, Keller, RA, Williams, DM (2005). EMS in critical condition: Meeting the challenge, ICMA IQ Re- port. Washington, DC: International City/County Management Association.

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In the time since the Authority terminated the contract with the private provider in the spring of 2005, it has continued to maintain responsibility for day-to-day operations. The Authority continues to struggle with meeting the performance expectations related to response time compliance and has experienced ongoing staffing shortages. In 2007, member Cities and the Emergency Physicians Advisory Board (EPAB) requested the Authority commission an expert assessment of the EMS system with specific emphasis on the issues resulting in the failure to meet performance compliance. In the fall of 2007, Fitch & Associates was engaged to provide an expert review audit and present to the Authority this report of the findings.

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Study Scope & Methodology

The Authority engaged Fitch & Associates to conduct a review of the system. The Firm has nearly 26 years of industry-specific expertise and knowledge from reviewing EMS systems around the world and across North America. In addition, the Firm has unparalleled experience in reviewing and designing high performance EMS systems including Public Utility Model and Failsafe Franchise Models.

Scope of Work The Authority outlined an eight part scope of work for the consultant team. It included:

1. Assessing MedStar’s operational performance, including scheduling and deployment, staffing levels, and organizational structure. In addition, identify alternatives and the cost of those alternatives. 2. Assess the financial status of the system and funding of the system with an analysis of the long-term implications of continuing the current funding policies. Identify alternatives to the current funding policies. 3. Assess the pay and benefits of MedStar personnel and develop recommendations designed to attract and retain a high quality work force. 4. Assess the management of the work force, including leadership, recognition, training, communication, and other factors necessary to secure a reliable, committed, and high quality work force. 5. Review the Uniform EMS Ordinance and the Interlocal Cooperative Agreement and identify changes which may be necessary or recommended to provide the structure for a state-of-the-art, high performance, high quality, pre-hospital emergency medical system. 6. Conduct meetings and interviews as necessary with stakeholders in the system to perform the tasks above. 7. Provide a detailed timeline of the work effort including proposed interim reports that keep the Authority and other stakeholders informed of the progress of the work. 8. Conduct a presentation of the findings and recommendations of the review.

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Project Methodology The methodology used to achieve the scope of work was very comprehensive and included significant input opportunities for internal and external stakeholders. To meet the goals of the project, Fitch & Associates used a multi-facetted approach, which included nine phases. An overview of each phase is described briefly.

Figure 1: Nine-Phase Consultant Project Methodology

Phase 1 – Project Initiation – To facilitate data collection and collaboration between the consultants and the EMS system, Jack Eades, the Executive Director of MedStar was designated as the project liaison. Key senior leaders were identified and scheduled for initial interviews. These included members of the MedStar management team, the Authority Board, City of Fort Worth Fire Chief, and the Medical Director. The consultant team met on-site with each person in short individual and small group interviews. The goal of the interviews was to gain clear perspective on the systems needs and expectation of the process and develop a collaborative relationship that would facilitate later data collection.

Phase 2 – Materials and Data Collection – With a foundational understanding of the scope of the project and to prepare for a more in-depth site visit and interviews, the consultant team forwarded a comprehensive information data request (IDR) to Mr. Eades. The IDR asked targeted questions about different areas of the system and requested key data to assist in understanding and evaluating the EMS system. Mr. Eades, working closely with his colleagues, compiled the data and forwarded it to the consultant team. The consultants reviewed the data.

Phase 3 – On-Site Interviews and Observations – After review of the comprehensive data, the consultant team returned to Fort Worth for another round of more detailed interviews with EMS personnel and internal and external stakeholder groups. The consultants followed up on information in the IDR and mined deeper into key processes and practices. After the site work, the consultant team syn- thesized the data for inclusion in the report findings.

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Phase 4 – Focus Group – While on-site, the consultant team conducted two open focus groups with internal stakeholders including the dispatch staff and frontline paramedic staff.

Phase 5 – Online Survey – Using a commercial survey software application, a targeted survey was created and deployed to internal stakeholders (i.e., all Med- Star employees). Surveys were completed online and included multiple choice and open-ended questions.

Phase 6 - Data Compilation and Client Input – At the conclusion of Phase 5, the consultant team had collected a mass amount of data regarding the EMS system. This data was reviewed and cataloged to identify any gaps, make additional requests for information, and to identify areas requiring client input for interpreta- tion. Additional data was requested and received.

Phase 7 – Benchmarking and Compliance Assurance – To provide the Authority with direction on changes needed in the system and to provide assurance that the system was aligned with local, state, and national standards and congruent with best practices, the consultant team benchmarked the EMS system with high performing organizations as well as with data from industry surveys and benchmark projects. The results of the findings are presented throughout this report.

Phase 8 – Define Future States – The Authority is committed to adhering to a system that provides high quality service, improves response times, offers acceptable value, and can be an example again within the State and across the country. Throughout the report are recommendations for how the system can achieve this goal and specific discussion of potential future scenarios.

Phase 9 – Report Results – This report represents the final phase, which involved reporting the consultant team’s findings in an initial draft report. Following client input, edits were made and this final report was drafted and submitted. The findings are presented in-person in an executive summary format to the Authority Board and invited system stakeholders Wednesday, May 28, 2008.

The nine phase process is intended to provide a comprehensive appreciation of the current and future needs of the system, identify opportunities for system enhancement, and position the Authority to be an informed emergency service leader as system decisions are made in the future.

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Report Structure The report to follow includes sections directly related to the scope of work, project components, and specific observations felt to be important by the consultant team. The flow of the report loosely follows the anatomy of an EMS incident and provides a summary analysis of the consultant’s findings in each area. The report begins with an executive summary and concludes with a list of recommendations. Appendicess are included at the end.

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Ordinances & Interlocal Agreement

State Regulations, Uniform Ordinance and Interlocal Agreements A key task for the consultant team was to review regulations related to EMS systems in the State of Texas and review the Uniform Ordinance related to the local EMS provision and the Interlocal Agreement and its amendments.

State of Texas Regulations The State of Texas is the primary regulatory body for EMS Systems within the State. The Department of State Health Services has authority over EMS rules, regulations, statutes, and laws. The rules specific to EMS systems are found in Texas Administra- tive Code Titles 25 and 37. These rules specifically address individual and provider certification and licensure, quality assurance, education, medical advisory, and trauma systems. The Area Ambulance Authority is in compliance with the requirements of the Texas Administrative Code.

Uniform Ordinance At the local level, EMS systems are guided by local ordinance. The Ambulance Au- thority has developed a Uniform Ambulance Ordinance, developed under state authority cited in Sec. 773.051 of the Texas Health and Safety Code, which provides that municipalities may establish standards for ambulances, and to Sec. 791.001 of the Texas Government Code which provides that combinations of local governmental units may contract for the provision of governmental services.

The Uniform Ordinance was reviewed by the consultant team. In addition, we compared that document to the local enabling legislation of four different systems that are considered high performance systems operating in different states and using a variety of service delivery models.3 The Uniform Ordinance generally follows the form of similar ordinances that provide definitions of key components, frame the requirements for ambulance operations as well as outlining the “active supervision” functions, which are central to maintaining the anti-trust protection. The Uniform Ordinance clearly delineates the responsibilities of the Emergency Physicians Advi- sory Board (EPAB) and the Authority.

3 Kansas City, Missouri; Richmond Virginia, Arlington, Texas and Volusia County, Florida.

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Amended and Restated Interlocal Agreement and the 2006 Amendment to the Interlocal Agreement In simple terms, the Amended and Restated Interlocal Agreement is the agreement to participate in the system and outline commitments between the Cities and the Au- thority. The 2006 Amendment gives the Authority the option to directly operate the system.

Several provisions of the Interlocal Agreement need to be modified. These include the provision related to the Price/Subsidy Option and the provision of Special Events coverage at large events.

Price Subsidy Option The Interlocal Agreement allows the individual participating jurisdictions to set the level of subsidy and the rates that will be charged in that community. At the time of the Interlocal Agreement’s development, this provision provided flexibility for each community to independently choose the subsidy contributed and/or user fees charged. It was thought that the impact of this provision would be revenue neutral to the Authority. In subsequent years, given the significant changes to federal and state healthcare reimbursement programs, this is no longer the case. The impact of this decision and a recommendation to change this provision in the Interlocal Agree- ment is outlined in the section of the report titled System Finance.

Special Events Due to the growing large scale events hosted in member communities, language should be added to the Interlocal Agreement that sets minimum prehospital medical coverage levels based on attendee size in both public venues and large gatherings such as sporting events. This language from Sec 34-377 of the Kansas City Ordi- nance may be useful.

“Contracts for use of City owned or operated buildings negotiated after May 1, 2001 will require utilization of components of the prehospital emergency medical services system to provide first aid/paramedical stand-by services when EMS service is prudently required for the safety of the public attending the event or when the event involves an element of physical danger. Con- tracts for all events involving an element of physical danger or expected to attract 10,000 or more attendees will require ambulance stand-by services. Contracts for all public events not involving an element of physical danger and expected to attract at least 5,000 but less than 10,000 attendees will require a minimum of paramedical stand-by services. Contracts for all public events not involving an element of physical danger and expected to attract at

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least 2,500 but less than 5,000 attendees will require a minimum of EMT stand-by services. Persons working as fire guards, security police or other required positions are not preempted by this section from providing EMS service within the level of their training when it may be necessary to protect the life or safety of another person.”4

All ALS, Full Service vs. Tiered The Interlocal Agreement states that the Authority will provide advanced life support (ALS) service to the member Cities. The MedStar system is best described as an all ALS, full service delivery model. This means that every ambulance in the system is staffed and capable to provide paramedic level service on every call and that ambulances serve both 9-1-1 reported emergent calls and interfacility, non-emergent transports. An alternative is a tiered system, which segregates calls to ambulances scheduled at different levels of care (e.g., ALS and BLS) or different service needs (9-1-1 vs. transports).

There are many reasons an EMS system might consider a tiered system. These include: wanting to reduce the load of transfer volume, concerns over skill exposure and proficiency, perceived paramedic shortages, recognized lower volumes of ALS calls, and an assumption that the system will be significantly cheaper. EPAB has expressed interest in considering tiered service temporarily or on a long-term basis to assist in the performance issues in the system.

While tiered service delivery seems to make sense at a high level, the complex issues associated with adopting it over the current full service, all ALS model are not well understood. First, is the added complexity, including having to triage calls in communications for the level of care, the need for BLS crews to assess for potential ALS upgrade, inefficiencies resulting from managing two tiers of deployment, and the significant increase in quality assurance and control required to ensure processes and human decisions are being made appropriately.

In the current system model, the only decision to be made is, Do I send an ambulance or not? No decision process or quality control checks must be in place to make sure patients are not underserved. In addition, with non-emergent transfers equal- ing just 5% of the total call volume, non-emergency calls are not drawing significantly from the system to warrant a change. Finally, Ornato et al. published a cost comparison of an all ALS model versus tiered and found the cost per call difference to be just a few dollars.5

4 Sec 34-377 of the Kansas City, Missouri EMS Ordinance 5 Ornato, J. P., Racht, E. M., Fitch, J. J., & Berry, J. F. (1990). The need for ALS in urban and suburban EMS systems. Annals of emergency medicine, 19(12), 1469-70. doi: 2240763.

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These are just a few of the many considerations when looking at the current delivery model versus a tiered system. MedStar is not advised to alter the Interlocal Agree- ment from an all ALS, full service system. The current model provides efficiency, uniform ALS care delivery, and reduced risk potential.

Ordinances & Interlocal Agreement Recommendations: 1. Price Subsidy Options must be changed – see finance reimbursement section for specific details. 2. Special Events - Due to the growing large scale events hosted in member communities, language should be added to the Interlocal Agreement that sets minimum prehospital medical coverage levels based on attendee size in both public venues and large gatherings such as sporting events. 3. All ALS, Full Service - MedStar is not advised to alter the Interlocal Agreement from an all ALS, full service system.

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Emergency Communications

Requests for emergency and non-emergency ambulance service are received, triaged, and dispatched by the MedStar communications center. The EMS system communications center is a secondary Public Safety Answering Point (PSAP). When a citizen dials 9-1-1, the call is initially answered at a primary PSAP in the community where the call is initiated. Once the nature of the emergency is determined to be medical, the caller is transferred to the MedStar PSAP for protocol-based interro- gation and ambulance dispatch. The center also may be accessed for scheduled non- emergency calls through a 7-digit direct number.

The MedStar PSAP is located on the grounds of the MedStar operations and administrative headquarters. The center uses the Medical Priority Dispatch System (MPDS) based on the protocols developed by Jeff Clawson, MD and all communications personnel are certified Emergency Medical Dispatchers (EMD). The center is using protocol version 12 (version 11.3 is the current version), which is the most current version in beta testing.

Each shift is staffed with a minimum of one communications supervisor and three controllers. There are twenty-four controllers on staff. Controllers are required to either be currently certified as Emergency Medical Technicians (EMT) or have one year of experience as an EMD. One controller is dedicated to dispatch calls and manage the system status plan while the other controllers are responsible for call taking. Controllers rotate responsibilities throughout the shift and are cross-trained to do call taking and dispatch functions.

Communication Center Operations The center has six workstations equipped with a TriTech CAD and a Baker phone/radio system. All phone lines are recorded with Dictaphone Freedom recording. The center has both Automatic Number Identification (ANI) and Automatic Location Identification (ALI) through Tarrant County 9-1-1. Latitude and longitude information is available to locate cellular callers. The center also can identify ad- dresses from landline numbers.

The MPDS protocol is applied to all 9-1-1 callers. The communication center manager estimates it takes 30-90 seconds to complete the protocol questions and determine the call type and severity. Ambulances are “pre-alerted” of a call via the radio and followed up with the complete information via radio, pager, and VisiNet Mobile. While pre-alerting is intended to enable crews to begin traveling towards the

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call, it was anecdotally reported that crews do not always begin moving towards the call and chute times have been as much as three minutes following dispatch.

The dispatcher is responsible for managing the system status plan and ensuring coverage. The CAD alerts the dispatcher of the unit recommended for dispatch to a call or for movement for system coverage. Controllers have discretion as to whether to follow the recommendation or make an alternative decision.

The communication center is part of the City of Fort Worth’s 800 trunking system which allows direct communication with the city’s fire department. The Fort Worth police department and other area police and fire departments are accessible via Tar- rant 1 and Tarrant 2 radio channels. MedStar communication is conducted over the Baker phone/radio system. One limitation to this system is that it doesn’t allow in- coming traffic when the channel is in use, which can make communication a challenge or result in missed or delayed radio traffic.

Data related to call activates and time is captured by controllers in the VisiNet CAD when reported to them via the radio and in the ambulance, via VisiNet Mobile. The communications manager reports that the VisiNet mobile is not being used consistently and, as a redundancy, crews are required to follow up verbally by radio when responding, arriving on scene, and for all other event notification; increasing radio traffic. The communications manager estimates 30% of event data may be suspect based on the process issues.

The communications manager participates in the After Action Review (AAR) meetings. Common issues reported or discussed include chute times, routing, and radio traffic. She feels the issues continue week after week and are not resolved. There also appears to be no feedback loop when issues are forwarded to Operations for resolution.

The center is accredited by the National Academies of Emergency Dispatch as an Ac- credited Center of Excellence. It was the 75th accredited medical dispatch center and the Authority has been independently accredited since January 2007. The previous private contractor had been accredited since November 2002. Accreditation indicates that the center has been independently validated to be meeting or achieving the 20 points of accreditation outlined by the Academy.6

6 20 points of Accreditation/ReAccreditation (for Medical Dispatch Centers). Retrieved May 8, 2008 from: http://www.emergencydispatch.org/acc_20points.php?a=accHome&b=acc20Points.

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The center is managed by a communication manager. The manager is not certified as a Communication Center Manager (CCM) by the National Academies or an Emer- gency Number Professional (ENP) by the National Emergency Number Association (NENA). Three personnel are trained and certified by the National Academies at the EMD-Q level to conduct case review.

As an ACE accredited center, continuous quality assurance is required. The center has one fulltime EMD-Q Supervisor that regularly reviews cases for protocol compliance. The Communication’s Manager is also a certified EMD-Q and one of the communications supervisors has recently completed EMD-Q training to provide assistance to the EMD-Q Supervisor. The center reports reviewing at least 20 calls per controller each month and an average of 480 total calls. This exceeds the minimum case review required by the academy for a center of this volume, which ranges from 1-3% of the center’s call volume.

Summary of Communications MedStar’s communication center is an ACE accredited center and uses protocol- based dispatch. Overall, it meets the core standards of a quality center. The Baker radio system is not ideal for 2-way emergency communication and could be considered for future upgrades. Also, VisiNet Mobile requires process redundancies and concern exist that the data is not reliably accurate.

Communications Recommendations 1. Assess pre-alert process to confirm crews are reliably initiating response as intended. 2. Evaluate existing radio system and consider future replacement with system that allows unobstructed 2-way communication. 3. Study and improve process for data input in VisiNet Mobile to reduce process redundancies that may not be necessary and improve data inte- grality. 4. Consider having the Communications Manager participating in the Com- munication Center Manager program sponsored by the National Acad- emies of Emergency Dispatch.

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System Status Management

From the patient’s perspective, when calling 9-1-1 for an ambulance, they want it to arrive quickly and render aid that provides relief. A key responsibility of any EMS system is to ensure that requests for service are handled promptly and ambulances reliably respond to any call. To do so, EMS systems must continually focus on meeting two objectives: effectively covering the geographic coverage area and adjusting the location and number of resources to compensate for the ebbs and flow of call demand. In addition, performance reliability, or responding at a predictable level (e.g., 9:00 @ 90%), is important. This is commonly referred to as managing the system status or strategic deployment.

System Status Management can be defined as the art and science of matching the production capacity of an ambulance system to the changing patterns of demand placed on that system. It involves strategies and tactics used to continuously manage the resources available so as to anticipate and prepare for the next call.

Traditional ambulance services have constructed stations at different locations within their service areas, with each fixed station staffed 24 hours a day to handle calls. Staffing levels remain constant with the same amount of ambulances and staff available at the same locations at the same times. The problem with this form of static deployment is that demand for emergency services fluctuates dramatically according to the day of the week, the time of day, and the area of the city. As a result, there are times when the system is underused, and times when it is overwhelmed by an increase in responses.

The MedStar EMS system has long been committed to operating at a high level of performance and efficiency. Instead of having fixed stations and resources like many peer Cities in Texas, MedStar has a flexible deployment strategy where EMS resources are fully deployed and may be relocated as the predictable patterns of system demand and unforeseeable surges occur to ensure response time reliability.

MedStar does not maintain regular ambulance quarters, like a fire station, but rather move frequently throughout their shift. While this approach is optimal for System Status Management (SSM), it also adds additional stress on employees and increases the attention needed for crew considerations and comfort to ensure their wellbeing, effectiveness, and morale.

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There are three principal reasons for system status management:

1. What is invested in Bricks and mortar cannot be invested into the field, as such the cost of simply constructing facilities and “keeping the lights on” (utilities, repairs etc.) creates a requirement for capital expenditures that must be offset with reduced operating costs. 2. The notion of “chute time” (time from when crews receive the calls to the time the wheels are rolling) is introduced in a significant way, a best practice chute time from a station is 90 seconds, conversely the best practice for SSM deployed units is 30 seconds. This minute is a significant cost for the service to offset if it considers using station-based units. 3. Change in demand and following the flows of demand. The notion of chasing demand, while not fully understood or appreciated by crews is certainly a gold standard in EMS. Clearly placing ambulances where calls are is better than placing ambulances where calls are not. This is true punctually and even more true over time as demands for service change with the demographic changes in the population.

Deployment Analysis Assumptions A fundamental issue facing MedStar is its inability to consistently produce response time reliability. This was the primary reason for the termination of the operations contract with the previous private ambulance provider and continues to plague the existing leadership team. Using Computer Aided Dispatch (CAD) data from the system, Senior Consultant Guillermo Fuentes conducted a comprehensive demand and deployment analysis of the MedStar system. The findings are attached as Appendix A to this report and are summarized here.

The demand analysis started with a few basic assumptions:

1. MedStar was committed to providing economically efficient, high performance EMS response. 2. Response time compliance must be achieved reliably. 3. Fixing or improving the process was a primary goal to limit the need for the infusion of significant additional funding. Process improvement is always required; it is the expectation of the payer that the service is being run opti- mally prior to the infusion of extra cost. 4. Less is more. A system plan that achieves the goal with the least amount of complexity is preferred over a complex plan. 5. The system is one system with 15 member city stakeholders. The analysis was done as if the system was one. If the deployment plans are followed and

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schedules are set to meet the demand (and staffed accordingly), the trickle down effect will be that the 15 member Cities will receive the required service. That said, as an attempt is made to eliminate the notion of overload the member communities should reduce the amount of stakeholders (amount of zones by which the service is measured) in order to maximize deployment during peak periods. 6. While customer service and performance are primary drivers, personnel comfort and wellbeing is a significant close second.

Executive Summary of Deployment Analysis The results of the demand and deployment analysis revealed several key findings. The following is an executive summary of these findings. For more detail, please refer to the attached analysis report (see Appendix A).

1. A quarter of the system’s calls have to be responded to within nine minutes from call sent to queue. An additional 45% have to be responded to within eleven minutes of call sent to queue. The system has very little flexibility within its emergency call volume. 2. Transfers and the other category represent only 5% of the total call volume. 3. Emergency (priority 1, 2 and 3) calls represent about 94% of the activities. This is very significant because the ebbs and flow of the emergency call volume will dictate how the system behaves. 4. There exists little variability from year to year on the distribution of calls for service. In the three years of data, emergency calls represented 94% to 95% of total call volume. 5. Call volume growth is approximately 4.0% per year. 6. Somewhere between 2008 and 2009, the system will break the hundred thousand-call volume marker. 7. Winter months have significantly less activity than the summer months. It can be observed that by November of any year until March of the following year, the activity level is lower. This is consistent in 2004, 2005, 2006 and 2007. While in 2005 this notion is less pronounced it is still nominally true. 8. At least three different patterns exist in demand: a. From November to March; with an average activity per day of less than 250 calls per day.

b. From May until July, with an activity pattern of greater than 260 calls per day.

c. All other months lie between 250 and 260 calls a day. Scheduling needs to be considerate of these patterns.

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9. The urban EMS volume is concentrated in a small geographic area with small pockets of urban call density distributed throughout the rest of Fort Worth. The EMS leadership in Fort Worth has recognized this because they have distributed ambulances to geographic locations even though the call volume would not justify the positioning of ambulances to those locations. 10. Twelve posts are required to supply coverage of 90% of the total demand. During the hours of 1000 and 1500 hours, the primary 12 posts must be continually covered in order to meet response time compliance. 11. It is strongly recommended that the deployment plans be reviewed by frontline and management staff for both final location of the post and for acceptance or agreement that this is really the optimal plan. 12. MedStar produces statistics on the service performance regularly. It does so with both diligence and honesty. The service has a contract that uses a double exclusionary rule called overload. Overload is a statistical correction based on the prior 20 week challenges. The harder the challenges from the prior weeks, the lesser the performance requirements for the weeks that follow. 13. The effect overload creates is that the 90th percentile is situated between 10 minutes and 11 minutes with the vast majority of days being below 11 minutes. If this is compared with the linear trend line, one can see that the linear trend line sits constantly at 11 minutes. The net effect of applying the overload formula is approximately a 45 second mathematical saving at the 90th percentile. 14. System overload and delayed responses are not an optimal way to deal with peak call volume; it is preferable for MedStar to negotiate with the 15 communities a reduced number of zones. In this size service area, three or less, zones that are volumetrically balanced would allow for a better management of peak volume by maximizing deployment during the most challenging times. 15. Schedules and performance are set at 90% of system compliance. 16. Two types of schedules were run, both of which are set out as samples, they represent mathematically optimal schedules; one using 12 hour schedules only and the other a blended schedule of 8-hour, 12-hour and a weekend only schedule. 17. Schedules should be constructed with staff as they are one of the corner stones to reducing absenteeism. With staff input, a commitment to work place presence can be established and managed. 18. Schedule start/stop time options should be reviewed with field staff in order to achieve commitment that they are optimal.

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19. The blended schedule can accommodate effectively both the operational demand and the desire to give scheduled lunches to paramedics and save the service approximately $50,000 per year. 20. The entire 12-hour schedule costs approximately $256,000 per year more than is currently being spent; it has the advantage of having additional weekend staffing so that absences on the weekend can be accommodated. 21. Absenteeism is a problem in the service and needs to be addressed. The mathematical schedules tolerate only 5% absence. Absenteeism should not be used as a crutch for non-performance. Proactive strategies that vertically integrate employee concerns into the organization need to be introduced in order to reduce the absence, such as employee desired schedules, employee focus groups on deployment, and employee focus groups on time on task, metrics to deal with outliers, etc.

Daily Operation of SSM A core component of successful SSM is the recognition that it is an ongoing and fluid process. It is not possible to implement a plan and just sit back and watch. To achieve consistent and even higher levels of performance, the EMS system leadership must continually monitor performance data, meet to discuss opportunities for improvement, and act on those opportunities. This often includes using real-time reporting and frequent targeted meetings, known at MedStar as After Action Reviews (AAR).

System Performance Report Each business day, the deployment manager emails a detailed report (i.e., System Performance Report) providing a panoramic snapshot of daily performance and the two weeks immediately preceding it to his management colleagues. Data includes core cycle times like call processing, chute times, response times, and hospital drop times. Also included is information on lost unit hours, scheduling efficiency, and pos- iting moves. Daily reports on performance data are common in High Performance EMS Systems (HPEMSS) and are frequently used to drive performance inquires and system tweaks to reduce inefficiencies. A review of the report immediately raised several process questions for the consultants that seemed worthy of process inquir- ies and improvements.

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Initial reaction to seeing the System Performance Report (SPR) was: a) this is a lot of great data; and b) how is it used or acted on? The SPR is very data intense. So much so, it requires a smaller than traditional font size and is printed on legal size paper. While access to this level of data is wonderful, it may be more effective if managers received a more refined scorecard each day and the deeper layers of data were reserved for AAR meetings or were included on additional tabs in the spread- sheet.

One concern with so much data is that it becomes overwhelming to managers and does not provide them the immediate feedback they need to know about how the system is operating. Curious about how managers used the report, we asked several core operations personnel about the SPR and discovered that many had not read it on the day we visited or were several days behind. The impression was that the data was not something they used on a frequent basis or that guided daily actions.

After Action Review Once a week, the management team meets for an After Action Review (AAR) meeting. This is where response time performance and compliance is reviewed in more detail, questions about performance are discussed, and action plans for improvement are initiated. Immediately following the Authority taking over the operations of the system, AAR meetings happened several times per week to attempt to get a handle on the system’s performance and in hopes of returning to compliance. Each week, issues of staffing, routing, and chute times were discussed, but without resolution. Eventually, in spite of the system continuing to remain out of compliance, AAR meetings reverted back to only weekly.

The consultant team did not participate in an AAR meeting. In discussing the meetings with each of the managers, several common themes emerged. First, none of the managers appeared to feel the meeting resulted in its intended mission of improving performance. Second, reported issues raised appear to be explained away by management assumptions without truly exploring the root cause through process inquiry. Third, while low staffing is a true system issue impacting compliance, it has become a blinding issue and management is failing to address other issues that are also tangibly repairable (e.g., late starts, out-of-chute, hospital drop times, etc.).

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Frontline Input SSM has a less than favorable reputation in the EMS industry; especially amongst frontline field personnel and EMS professionals who are not engaged in system design and are not current in the breadth of EMS related peer-reviewed and expert au- thored literature. In many circles, the alternative term “deployment” is used to not ignite the stigma of SSM.

Unfortunately, the stigma of SSM is valid and is the result of organizations applying the concept in an effort to increase the profit margin and often doing so without consideration of employee well being. SSM, in concept, principal, and ethical application, is a sound practice focused on providing high levels of performance, in a cost effective manner. When applied that way, however, system operators are acutely aware and focused on the comfort and work environment of the frontline field personnel and recognize they are core to the system’s success.

Employee understanding of SSM seems very low. Only one hour of instruction is provided in their initial new employee orientation and little, if any, refresher training. This is down from eight hours initially. Discussions with field personnel and the comments they contributed in the survey give an impression that frontline personnel do not have a foundational knowledge of this fundamental practice that is core to the operations of the EMS system. MedStar should increase the training hours devoted to SSM in the orientation and provide continuing education throughout the year to maintain competency and awareness.

Attached to this report are the deployment plans and schedules recommended to guide the system in achieving compliance. Noted in Appendix A and reiterated here is the caution that not including frontline personnel in the review, modification, implementation, and follow up alteration of the deployment strategy will result in a failure of the process to achieve results. Sound SSM starts with system data, but it can only reach its full potential when all stakeholders participating in the process are able to provide their real experience input to refine it. Frontline personnel are critical to the success of the process.

Lack of Sense of Urgency A major issue facing the leadership of MedStar, in relation to compliance, is the lack of a sense of urgency. For a system reportedly struggling with failed performance compliance and poor media coverage, there is almost no sense of urgency. Re- sponse time compliance and fixing the problem is not the driving agenda of any manager’s day and day-to-day operations maintenance and extra stuff (e.g., the ro- deo) is consuming management attention. The management team needs to be focused on its core business and key performance before settling in. The consultant

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team was struck by a prevailing sense that, since the core problem was identified as staffing, nothing else could be improved until that single issue was fixed. While staffing is a significant issue, it is not the only one and the management team should be aggressively pursing every other opportunity concurrent with its efforts to improve staffing. Discussion of the management team and its challenges are discussed in more detail in a separate section of this report.

Summary of System Status Management A recommended deployment plan created using existing CAD data is included with the report. The plan achieves response time compliance. Field crews need to be included in the review and implementation of any future plan. System Performance Reports are currently not being used as intended by managers and after action review meetings are not achieving their goals. Frontline employees need more instruction in SSM concepts and practices. The organization lacks a sense of urgency that response time compliance is an emergent performance problem.

System Status Management Recommendations 1. Twelve posts are required to supply coverage of 90% of the total demand. During the hours of 1000 and 1500 hours, the primary 12 posts must be continually covered in order to meet response time compliance. 2. It is strongly recommended that the deployment plans be reviewed by frontline and management staff for both final location of the post and for acceptance or agreement that this is really the optimal plan. 3. MedStar should negotiate with the 15 member Cities for a reduced number of zones. System overload and delayed responses are not an optimal way to deal with peak call volume. 4. In this size service area, three or less, zones that are volumetrically balanced would allow for a better management of peak volume by maximizing deployment during the most challenging times. 5. Two plans are presented that balance operational demand with crew considerations. 6. Schedule start/stop times options should be reviewed with field staff in order to achieve commitment that they are optimal. 7. The mathematical schedules tolerate only 5% absence. 8. Absenteeism should not be used as a crutch for non-performance. 9. System status report should include a high level scorecard (approximately six to ten measures) developed by the management team to allow quick appreciation for the system performance. The full system report adds context.

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10. After action reviews (AAR) should return to multiple times per week and focus on noted processes cycle time issues and crew considerations con- currently with efforts to increase staffing. 11. AAR meetings should utilize an improvement methodology for process enhancement. 12. Frontline personnel and supervisors should be regularly engaged in AAR efforts. 13. MedStar should increase the training hours devoted to SSM in the new employee orientation and provide continuing education throughout the year to maintain competency and awareness. 14. The management team must foster a sense of urgency and focus on core business activities first.

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First Response

First response is an important part of the EMS system design in life threatening emergencies because it enables help to respond quickly in localized areas while a transport paramedic unit is responding. It is often a BLS first responder skill that can make the true lifesaving difference in time sensitive situations like uncontrolled bleeding, an occluded airway, a heart needing to be defibrillated, or a patient in ana- phylaxis needing an Epi-pen injection.7

MedStar co-responds with 15 agencies, but the majority of responses are with the Fort Worth Fire Department. The Fort Worth fire chief reported that the fire department responds to all priority 1, 2, and 3 calls. This is not uncommon, but is not necessary in an EMS system using medical priority dispatch; especially a center that is ACE accredited. In addition to applying uniform protocols to every caller and initiating pre-arrival instructions, one of the core goals of MPDS is to reduce the use of lights and sirens and help determine exactly what appropriate resources are required to reduce the dangers of emergency response. MedStar, the member city fire departments, and Emergency Physicians Advisory Board (EPAB) should review the MPDS response determinants and compare them with industry best practices to determine which calls are appropriate for first responder response and at what response level.

Response Times The Fort Worth fire chief reports a physical response or drive time of 5:00 minutes 75% of the time. He admits the department is not in compliance with NFPA 1710, which defines response standards for fire apparatus and says, “it’s too controver- sial”.8 The consultant team did not visit with other first responder agencies in the system, but did not see response time data or expectations for any of the departments. First responder response time performance is not reported as an EMS system measure and there is no knowledge of or penalty for not achieving response time reliability. The Authority should work with the member city fire departments to establish a response time standard and receive regular reporting of the compliance of meeting that standard on EMS calls.

7 Fitch, J.J., Keller, R.A., & Williams, D.M. (2005). EMS in critical condition: Meeting the challenge [Item No. E-43338]. IQ Report, 37(5), Washington, DC: ICMA. 8 National Fire Protection Association (2001). NFPA 1710: Standard for Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by Ca- reer Fire Departments. Quincy, MA, National Fire Protection Association.

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First Responder Credentialing All Fort Worth Fire Department firefighters are certified as Emergency Medical Tech- nicians (EMTs); some are Paramedics. Other Fire Department personnel within the MedStar System are certified as Emergency Care Attendants (ECAs). ECA is the minimal level of EMS provider listed in the EPAB protocol. The Fort Worth Fire De- partment Chief describes all of his staff as being “credentialed”, but not at the Med- Star level of proficiency. EPAB Policies 101, 102, and 103 define the credentialing or permitting process of MedStar and first responder personnel. Policy 104 defines the minimum skill level of each provider level. All 15 first responder agencies in the MedStar system are under the medical direction of Dr. Griswell and the EPAB and participate in quality assurance.

Summary of First Response Fifteen entities provide first response in the MedStar system with the Fort Worth Fire Department serving the majority of calls. Currently, response time expectations are not established or recorded for first responder agencies that may actually make the biggest difference in time sensitive emergencies. All 15 first responder agencies in the MedStar system are under the medical direction of Dr. Griswell and the EPAB. EPAB Policies establish minimum training and certification requirements and a permitting process to practice medicine in the system.

First Response Recommendations: 1. EPAB should work with first responder agencies to match call priority to the need for first responder dispatch and response level. 2. EPAB and the Authority should work with the first responder agencies in member communities to establish a response time goal and measure and report performance with the EMS system response time reporting.

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Clinical Care & Medical Oversight

MedStar is an All-ALS, full-service provider model. This means all ambulances are staffed at the paramedic capable level and respond to emergency and non- emergency calls. Standard staffing of an ambulance is one EMT and one paramedic. This staffing model is common in high performance model systems because it reduces inefficiencies and quality control needs and allows for flexibility since all ambulances are identical and provide the highest level of care possible.

Clinical care operations are currently split in half between the Emergency Physicians Advisory Board (EPAB) and the clinical department of MedStar. This arrangement is a result of the original PUM model, which has a medical oversight entity separate from the operator. Even though the contractor is no longer part of the system, Med- Star and the EPAB maintain a similar structure and relationship, which is more oversight than integrated.

Emergency Physicians Advisory Board (EPAB) EPAB is lead by a fulltime medical director – Dr. John Griswell – who is also a member of the advisory board. Dr. Griswell has been in the role for 12 years. A staff of six employees provides day-to-day support.

The role of the EPAB is to provide medical oversight. This includes developing system treatment protocols, providing continuing education, making sure base hospital physicians are adequately prepared to assist medics, and conducting system level quality assurance. These roles are defined in city ordinances and in article seven, Medical Director and Staff, of the bylaws of the EPAB.

EPAB holds the Texas Department of State Health Services (DSHS) continuing education course number and provides review and approval of all educational programming including continuing education and orientation. EPAB staff also delivers continuing education programming. In addition, the office monitors clinical data metrics, reviews patient care reports, and investigates clinical complaints. EPAB includes a board of physicians that represent local hospitals within the MedStar system.

MedStar Clinical Department The clinical department of MedStar is staffed by a director who oversees two staff members and multiple field training officers and trainers. The clinical department is responsible for initial orientation, certification classes, and continuing education. It

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also tracks clinical performance measures, conducts patient care report audits, and investigates quality assurance complaints.

EPAB/Clinical Working Relationship EPAB staff and MedStar clinical staff indicate that they are cordial with each other and attempt to work together, but that there is tension between the two. Definition of responsibilities appears to be unclear and some processes are not defined. This was evident when a draft review of this report resulted in comments from EPAB that the roles and responsibilities described for the Clinical Department and EPAB were strikingly similar.

The current lack of role clarity results in confusion and mixed expectations. For example, if a clinical complaint is received, who will initiate the review is based on who took the complaint. Field crews are rumored to have been instructed to call the clinical department first, instead of EPAB. A clear charter of roles and responsibilities needs to be established and agreed upon and processes should be developed that are in the best interest of the system and its stakeholders first. ePCR The MedStar system is using the Siren ePCR© Suite from Medusa Technologies for Electronic Patient Care Data Capture and Reporting. This paperless system is great because it allows electronic storage, improved bill processing, and enhanced data extraction for quality assurance reviews and key performance indicator tracking. An update installed by Medusa had resulted in an extended interruption of key reporting features. This has since been repaired, but the system should work with its ePCR vendor to ensure that future upgrade installations include planning for ongoing continuation of reporting for day-to-day operations. Interruptions should be measured in days not weeks or months.

Key Performance Indicator Data Tracking MedStar tracks several Key Performance Indicators (KPI) on a routine basis, but they are not necessarily reviewed continuously. There is not a clinical performance dashboard. KPI definitions were included in the Information Data Request (IDR) for a plethora of common clinical measures like capnography use, intubation success, STEMI cycle time, scene times, etc. The definitions are basic, but uniform, allowing for consistency in measurement.

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KPI data reports provided were predominantly reflected in tables and sometimes in run charts (data graphed over a time period), but none using Statistical Process Con- trol charts (SPC). A clinical coordinator produced a binder of hardcopy SPC charts of data during our onsite meeting. The charts were created using a Microsoft Excel Macro program developed by 3M that floated around the EMS industry several years ago. When asked about special cause variation flags in some of the measures, it was apparent the staff member was not familiar with reading SPC charts and was not aware that a statistically significant variation in the measure had occurred.

MedStar and EPAB should develop a continuous clinical dashboard of relevant data supported in the medical literature or advocated in the EMS performance measure project.9 Data should be reported over time and using SPC charts to analyze if the process is in control and differentiate between common cause and special cause variation. Improvement efforts should focus on reducing the overall variability and elimination of special cause events. Using the problem solving methodology described later in the Management Team section on the cycle improvement methodology would be helpful for quality improvement efforts.

Clinical Care Review of the treatment protocols reveals treatment standards that are within the norm or progressive for similar EMS systems nationally and in the region. Providers are given adequate freedom to practice and have access to online medical consultation when needed. The medical director is also available and accessible. While individual patient care records were not reviewed as part of the system review, KPI data reveal no major caution areas.

EPAB Boundaries It is very clear from the discussions with MedStar management, the Authority Board, and EPAB members that EPAB is an asset of the EMS system and is passionate about the caregivers, patients, and sound clinical care. Currently, there is significant tension between EPAB and the MedStar management team and additionally between Dr. Griswell and Mr. Eades. This tension appears to generate from two main issues: 1) there is not a clear, mutually agreed upon established boundary set between the role of EPAB and MedStar administration; and 2) Dr. Griswell and EPAB are feeling anx-

9 Emergency Medical Services Performance Measures Project: Recommended Attributes and Indicators for Service/System Performance (2006, December). Presented to NHTSA EMS Division, retrieved May 14, 2008 from http://www.nasemso.org/Projects/PerformanceMeasures/documents/EMSPerformanceMeasuresFinalDraftf orNHTSA12-06.pdf or Myers, J. B., Slovis, C. M., Eckstein, M., Goodloe, J. M., Isaacs, S. M., Loflin, J. R., et al. (2008). Evidence-Based Performance Measures for Emergency Medical Services Systems: A Model for Expanded EMS Benchmarking. Prehospital emergency care, 12(2), 141-51.

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ious to fix problems that are identified, but often feel Mr. Eades listens but does not act in a timely manner.

The tension described is rooted in good intentions, but is counter productive and resulting in more strife than solutions. First, EPAB and the Authority need to establish clear boundaries of roles and responsibilities or review existing rules and come to consensus. Secondly, Dr. Griswell and Mr. Eades need to establish a mutually effective method for working through issues, identifying actions, and following through to reach solutions in a way that both are comfortable with. The end result will be less frustration and more collaboration that benefits the system.

Summary of Clinical and Medical Oversight MedStar meets or exceeds the training and clinical care standards routinely seen in the region and the industry. The system benefits from fulltime and passionate medical oversight. The pieces are in place for a robust quality assurance and process improvement system, but some minor enhancements need to be made. MedStar, EPAB, and their respective leadership need to decide on the boundaries of their responsibilities and figure out how to constructively partner to solve problems and serve patients.

Clinical and Medical Oversight Recommendations 1. EPAB and the clinical department must establish a clear charter of roles and responsibilities needs to be established and agreed upon and processes should be developed that are in the best interest of the system and its stakeholders first. Work processes should be integrated collaboratively not duplicated. 2. ePCR – MedStar should work with its ePCR vendor to ensure that future upgrade instillations include planning for ongoing continuation of reporting for day-to-day operations. Interruptions should be measured in days not weeks or months. 3. A clinical Key Performance Indicator (KPI) with uniform definitions should be established system-wide. Data should be reported in run and statistical process control charts (SPC) in addition to data tables. 4. MedStar’s leadership team should learn how to read and interpret SPC charts. 5. The Authority needs to reestablish the boundaries of EPAB and Operations and rebuild the professional relationship and communications of the two leaders.

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Deployment Center - Supply & Fleet

In the MedStar system, the ambulances that the crews work in throughout their shift are their primary workspace and mobile office. Having confidence that the ambulance is in sound working order and that it will provide safe transport throughout the shift is essential. In addition, crews need a well-supplied truck that ensures they are able to handle the various types of calls that may be encountered in a shift and be able to serve their patients. The supply and fleet management operations of an organization are essential to the success of the service and the reduction of lost unit hours for restock and maintenance. The following is a summary of our impressions of these two operations at MedStar.

Centralized Deployment Center MedStar is similar to many fully deployed EMS operations. A central deployment center acts as the primary operations headquarters and is home to the administrative offices, EPAB, fleet maintenance, and supply. This is advantageous because almost anything that may need to be accomplished may be handled at one place.

Crews reporting to duty arrive to work and are assigned an ambulance for their shift. The ambulance is already cleaned and has been checked and stocked by trained supply technicians. This allows ambulances to quickly be placed in service and entered into the system status plan.

Conducting all shift changes at the central facility means that all ambulances will start and end their shift there. If a vehicle is scheduled for preventative maintenance or a scheduled repair, it is easy for a fleet mechanic to pull it out of service and cycle it through fleet services.

A centralized facility also offers crews and administration an advantage. Fully deployed systems do not always make for easy employee management or accomplishing routine work related tasks. In the case of MedStar, crews will be at the headquarters at least twice during any day at the start and end of the shift. This allows at least two opportunities to catch crews and interact with them.

Having a centralized facility for the deployment, supply, and maintenance of resources is ideal for a fully deployed system. It allows maximum flexibility and improves efficiency and provides a central point to interact with crews.

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Supply Management In any EMS system, sound supply management is essential. This is even more so in a fully deployed, high performance EMS system. Effective management of supplies and logistics helps control material costs and reduce waste, lessens the risk of lost unit hours for supply, and contributes to response time compliance.

Approximately two and one half years ago, MedStar hired a supply manager with a degree in materials management. Since that time, the field crews report that supply reliability has improved dramatically and it was indicated in the Fitch Survey as one of the areas consistently working well. Supply has two main functions: 1) purchase and store needed medical supplies and 2) prepare ambulances for service and support crew change. The following are a summary of the consultant team’s observations of the supply operations.

The supply operation is managed from a small space directly off of the station bay. Supplies appear organized and are stored in bins and along floor to ceiling shelves stacked in the space. It is not hard to note that processes are in place to effectively manage supply considerations. For example, some medications are stored in bins that are top loaded to ensure that when a medication is taken from the bottom of the bin to stock a field bag or ambulance, it is taking the oldest medications first to reduce waste from expirations.

Supply technicians are responsible for checking out the ambulances and all of the bags the crews carry into a call. Reference guides are available in the supply area with pictures showing exactly what items go in what areas and the exact quantities. This process check allows for clear direction and significantly reduces potential for error. All cabinets and compartments in the ambulance, as well as the bags, are sealed once confirmed stocked. This provides visual confidence to the crews that the unit is stocked and also allows supply techs ease in returning a truck to service because only broken seals must be rechecked, stocked, and sealed.

To expedite the restock process, MedStar has adopted a best practice from a public utility model peer by using speed loading. Bins within the ambulance are organized and stocked based on function and frequency of use. The bins are then shrink- wrapped. This way, if a crew needs an item, he or she breaks open one shrink- wrapped bin and takes care of the patient. When the ambulance is retuned at the end of the shift, the supply tech simply removes the opened bin with a prepared replacement and the unit is ready for service.

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In addition to removing the traditional unit check off task from the crews, supply technicians also wash the units after each shift. While these tasks may seem insignificant, they reduce workload on the field providers, ensure the unit is ready for service, and extend the physical wear and tear of the vehicle body.

In addition to the Post 4 supply operation; there is a mobile unit that can be requested to assist crews in need of supplies during the shift. This can be helpful if a single unit has an unusual volume of advanced life support calls or a mass causality event has occurred. The mobile supply unit is able to go directly to the crews’ location and restock the unit while they are out of service at the hospital and reduce lost unit hours. This should be a relatively rare occasion and requests should be tracked to ensure that a process improvement is not in order or that crews’ are not abusing it to remain out of service.

Summary of Supply Review of the supply operation revealed process focused activities that are focused on cost and waste control, unit hour loss reduction, and unit readiness. Feedback from employees echoes the consultant findings that the supply operation is working well and serves as an example of the potential for process focus and improvement to enhance organizational performance.

Supply Recommendations 1. Mobile Supply Unit Utilization: Crew utilization should be a relatively rare occasion and requests should be tracked to ensure that a process improvement is not in order or that crews’ are not abusing it to remain out of service.

Fleet Management MedStar has in-house fleet maintenance also operating out of post 4. This is essential as fully deployed units working within a system status plan have higher mileage rates and engine ideal times than ambulances in a static system and may require more frequent preventative maintenance and unscheduled repair.

The fleet manager has been with the system for 20 years and has worked with multiple contractors. He has a staff of two mechanics and two vehicle technicians. At the time of the consultant interview, a third fleet mechanic had been requested and approved and he was trying to fill the position.

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Urban EMS is a 24-hour a day operation and requires continuous fleet maintenance. The fleet maintenance division is open seven days a week from 0600 – 2300 hours. From 2300 – 0600 hours, a mechanic is on call and can come in if a unit is down and limited spares are available or the unit is inoperable on the side of the road.

Fleet mechanics do all routine service and preventative maintenance. Bodywork and front end alignment are outsourced. On occasion, if the volume of work is high and the mechanics are backed up, routine work will be outsourced as well.

The fleet consists of 45 ambulances with two currently on order. The recommended number of in-service ambulances a system needs varies from system to system and is based on multiple factors. In general, 130-150% of peak load is recommended to ensure adequate spares are available for unscheduled vehicle failures and to allow flexibility for preventative maintenance. The more advanced the fleet maintenance services, the less extra capacity needed to safely manage the system and not risk lost unit hours. MedStar has a peak of 30 ambulances, so its fleet of 45 in service units is above the minimum level of 39 ambulances traditionally recommended, but within the recommended range.

MedStar ambulances are currently on a five year depreciation schedule with replacement based on 250,000 miles or five years. This is similar to high performance peers in the CAEMS benchmark study data. MedStar reports a critical vehicle failure rate of 1.50 per 100,000 miles traveled, which is below the mean (2.30/100,000) and median (2.00/100,000) of other participating cities.

MedStar has a relatively low age fleet, but the units have wear and tear. The fleet manager reports that crews do not appear to take care of the units and that even tobacco products are being used in the vehicles. Reports and pictures are forwarded to the operations director, but no follow up was reported and the behavior has not changed. MedStar management should work with field personnel representatives to identify ways to improve crew cab maintenance and wear and tear.

Vehicle Safety Ambulances are equipped with the Road Safety SafeForceTM Driving System. The system tracks data on how the ambulance is being operated and records information about speed, braking, and turning. Significant events trigger an audio recording. EMS systems are discovering that use of an ambulance “black box” recorder system lowers accident rates, reduces fleet costs, and can be defensible in the event the ambulance is not at fault. The fleet manager reports that crew tampering has been discovered with the Road Safety System.

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MedStar reports a fleet collision rate of 1.82 per 100,000 miles. The rate is greater than the mean (1.35/100,000) and median (1.30/100,000) rates reported by the CAEMS benchmark study participants.

Reporting The fleet manager tracks all lost unit hours related to fleet maintenance for operations. This information reportedly must be pulled from three separate databases to produce the key performance indicator data. Optimizing this data process would streamline the fleet manager workflow.

Shop Work Area The fleet maintenance space is not large, but there appears to be adequate space to work on the ambulances and safely move them in and out. The work area appeared tidy and there were no obvious risk hazards readily apparent to the consultant team. The fleet manager’s office is immediately adjoining the work floor.

Summary of Fleet Services MedStar’s fleet maintenance operation is comparable to peer fleet operations. The fleet manager is vested in the system and appears to run an effective operation. Vehicle failure rates are below that reported in peer systems, but vehicle collision rates are slightly higher. The fleet age is relatively low, but shows wear and tear. Employees noted fleet services as one of the areas in the organization that is working well.

Fleet Services Recommendation 1. MedStar management should work with field personnel representatives to identify ways to improve crew cab maintenance and wear and tear. 2. Crew tampering and care of ambulances (e.g., smoking) should be reviewed and management should focus on improvement efforts to reduce events. 3. Optimize the fleet data reporting process to streamline the fleet manager workflow.

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Strategic Human Resources

In a service industry, the people at the frontlines who interact with customers and patients are essential to the success of the organization and the outcomes it at- tempts to achieve. Just being able to fill the necessary spots on the ambulances is critical to every element of EMS operations. This requires MedStar to be an employer prehospital care providers desire to have.

Providing competitive compensation is key to meeting the employee’s basic needs. Organizations must also engage personnel in their work environment and in improving service delivery to enhance services and maintain employee commitment. Fail- ing to do so results in low morale, static performance, and attrition.

As part of the system review, the consultant team reviewed the human capital environment at MedStar. This included reviewing the findings of an employee satisfaction survey conducted by the human resources firm The Whitney Smith Company and also deploying a short survey targeting service delivery and workplace considerations. In addition, the consultant team benchmarked MedStar’s compensation with industry available data.

The Problem of People MedStar currently has 184 authorized full time equivalent (FTE) employees for frontline operations, which includes communications and ambulance personnel. Of the 16 authorized communication FTEs, 13 are currently filled. Of the 84 approved Emer- gency Medical Technician (EMT) FTEs, 72 are currently filled. And, of the 84 approved paramedic FTEs, only 64 are currently filled.

The ability to fill open shifts and staff needed unit hours has been a critical issue for the system and its ability to achieve performance. The ripple effect of the deficit in staffing is discussed in several places in this report. The following data is an example of the impact of the staffing inadequacy (see Figure 2). For example, in the month of April, the average scheduling efficiency was 87.9%. This means that 12.1% of the unit hours scheduled were unable to be staffed in the system. This is an average of 70 unit hours per day or more than five ambulances. This is not significantly improved from January 2008 when scheduling efficiency was 86.6%. Fig- ure 2 shows a comparison of the scheduled unit hours for the month of April with the actual unit hours that were produced in the same month. Note that the system never achieved full staffing. This is a core reason for the failure to achieve consistent response time reliability and is very likely a factor in the high attrition and morale issues noted in the current staff.

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Figure 2: April 2008: Scheduled vs. Actual Unit Hours

While this disparity between needed unit hours and actually staffed unit hours has been an issue for past and current performance, it will also have an impact on future performance if not corrected. For example, in the deployment recommendations included in this report, there is only cushion for a five percent (5%) staffing deficit. This is almost half of the current deficit in the system. Until staffing is increased and stabilized at a reliable level, performance will remain an issue.

The following sections of the report provide context to human resource considerations for MedStar. Recognizing that staffing is directly tied to achieving performance, the results provided here and the recommendations presented should be taken as critically important to improving the overall system performance.

Employee Satisfaction – The Whitney Smith Company Early in the consulting engagement, MedStar received delivery of a report conducted by a local human resources firm - The Whitney Smith Company - measuring employee satisfaction. The report was presented to the Authority Board and a copy was shared with the Fitch consultant team to review.

The survey was administered to all staff electronically and had a high rate of response at 84%. More than three-quarters of EMTs (78%) and paramedics (77%) responded, as did 95% of system status controllers, making for valuable data. The survey included Likert scale (Stongly Agree to Strongly Disagree) and open-ended questions and covered five core categories: leadership, communication, work environment, management support, and job satisfaction.

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The Whitney Smith Company presented a professional report of the survey findings that are objective and informative. The conclusions of the report do not vary from the opinion of the consultants based on our experiences in the system. It is worth noting that the average scores for all of main categories are just slightly above the middle and don’t reflect strong agreement or disagreement. Also, the five items identified as scoring the lowest strongly echo the feedback we received directly from employees. The bottom five items are:

1. Policies and procedures are enforced consistently at MedStar. (2.32) 2. The wages for my job are fair. (2.46) 3. I have confidence in Top Management. (2.64) 4. Top Management provides clear direction for the company. (2.68) 5. Employees are respected and appreciated here. (2.73)

The Whitney Smith Company survey data report provides a lot of information for the leadership to act on. The feedback is very raw and can be at times frustrating or hurtful for the MedStar leadership, but it is the opinion of the staff from their current perspective. Staff will be looking to see how management acts on the data. It will be important for management not to filter or attempt to explain the results, but to engage the staff in the findings and take steps to act on the information learned.

Fitch Survey Results Fitch & Associates recognizes that there is no way to meet and speak with every stakeholder in the system. At the same time, the consultants know that everyone has a valid perspective of the system and has information to offer to enhance an EMS system. Recognizing that the staff may feel “over surveyed” and not wanting to duplicate the efforts of The Whitney Smith Company, the consultant team developed a brief survey inquiring input on a few specific areas. Employee identifiers were not tracked in the results. A survey template is attached to the report in Appendix B. The following is a qualitative summary of the results.

Demographic Data The survey asked respondents to provide data about themselves to see if results varied across genders, education levels, job function, tenure, generations, and race/ethnicity. Consultant review of the various cross segments did not reveal any noteworthy variations.

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What’s Working Well at MedStar? Question: In every organization, something works and works really well. From your perspective, describe three examples of things that are working really well at Med- Star?

Employees identified almost two dozen different things they feel are working well at MedStar. The following is a description of the themes that received repeated recognition:

! Supply Management – The supply process was the most identified process viewed as working well. Respondents acknowledged it has greatly improved in recent months and are pleased with having consistently stocked and washed ambulances that are ready at the start of the shift. ! EPAB – Employees responded with strong endorsement of the efforts of EPAB. Feedback included that EBAB provided involved and progressive medical direction, clinically appropriate protocols, and worthwhile educational content. ! Billing – Respondents in the field and administration acknowledge and recognize that the billing office is effective at its work and strongly supports the organization’s success. ! Fleet Maintenance – The ambulance is a mobile office and the field crew’s primary workspace. Respondents report that fleet maintains the ambulances well and is responsive to issues. ! Frontline Supervisors – Many respondents mentioned the accessibility and support they feel from their field supervisor. ! Communications – Controllers and the work of the EMS communications center was described positively in many cases.

Improving Response Time Compliance Question: Response time compliance was a major challenge for the previous contractor and remains a continued issue for MedStar today. From your experience, describe three things your organization can do to improve response time reliability? [Please try to consider actions in addition to/other than adding resources and personnel].

Employees identified almost a dozen different things they feel could be done to improve response time compliance. Respondents, in many cases, were unable to identify solutions other than more resources or more personnel even though the question specifically stated to do so. The following is a description of the only two themes that received repeated recognition for potentially improving compliance.

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! Deployment Plan – The deployment plan was described as needing change. Included was mention of peak staffing, geographic coverage, and post-to-post movement. ! Cycle Times – Mention of improving cycle times like out-of-chute and hospital drop times was mentioned often.

Reading the responses leaves a sense that System Status Management (SSM) and compliance are an emotional issue for many of the respondents. Comments also leave an impression that field personnel do not understand basic SSM concepts and activities and see it purely as a ‘penny pinching’ process.

Frustration: 80/20 Rule Question: While most people can identify several opportunities for improvement in your workplace or the operations, often there are a few specific issues that are creating the majority of your frustration. What are those issues for you?

The Pareto Principle says that the majority of an organization’s frustration is the result of only a small number of core issues. Employees responded with the following themes related to the issues that frustrate them the most. More than a dozen issues were identified and many employees identified multiples. The following is a description of the two most common themes.

! Leadership Issues – The most common issue identified was tied to leadership issues. Specific frustrations included feeling like there was little accountability, inconsistent practices, a perception of favoritism, a lack of follow through, and a disconnect between the frontline personnel and the leadership team. Answers were very emotionally charged. ! Pay – Employees identified pay frequently as a frustration.

Retention Question: The quality of frontline personnel is essential to providing excellent service delivery. MedStar is not satisfied with the retention rate of your valuable personnel. From your perspective, what are three things your organization can do to improve employee retention. [Please try to consider actions in addition to/other than increasing pay and/or benefits].

Employees were also asked how long they intended to remain employed with Med- Star.

! Pay – In spite of the request to identify things other than pay, it was identified over and over as a core to retention.

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! Reduce Strict Attendance Policies – Several references were made to the points system and policies related to the use of paid time off. There was a sense that fear of management action exists if time is used. ! Scheduling – Several references to scheduling were discussed including types of shifts and flexibility. ! Management – Management was described as being inconsistent in their actions and detached from the field personnel. Recognition for work well done was also indicated.

Employees were asked how long they intended to remain employed by MedStar. Nearly 70% of respondents report they are in it for the long haul. When asked what is one thing that would cause them to leave, they identified continued management issues, better pay, or a change in their schedule would be the primary drivers.

The Whitney Smith Company Survey Question A: Recently, MedStar contracted with The Whitney Smith Company, Inc to conduct an anonymous employee survey. In your opinion, what is your level of agreement with the following statement? The employee survey asked me the right questions to accurately capture a snapshot of my feelings about our workplace.

Question B: What did The Whitney Smith Company, Inc survey not ask you that you wish it had? What would your response to the question(s) have been?

The majority of respondents indicate that they agreed (58.8%) or strongly agreed (9.8%) that The Whitney Smith survey asked the right questions. When asked what the survey did not ask, the following themes were described:

! Questions were broad and did not get down to specifics. ! The questions were not broken down to allow for responses targeted at specific departments. ! The questions were fine, but the management follow through is an issue. ! Many thought the questions were appropriate and adequate.

Results of Fitch Report Questions: Employees at MedStar have high hopes and expectations for what will result from the Fitch & Associates study. For you, what do you hope most will result from the findings of the consultant report?

Respondents offered more than a dozen outcomes they hope result from this report. The most common there were:

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! Change in Management – The removal of a specific manager or a complete replacement of the management team and/or how it operates. ! Pay Increase – A competitive change in the salaries offered employees. ! Work Environment - An environment that respected each other and was desirable to be part of. ! Recognition of Mistakes - Identification of mistakes that have been made or problems that exist in the organization. ! Really listen and act - That the Authority actually act on the recommendations and not allow the report to be an exercise and not generate change for the better.

Gallup 12 Based on in-depth interviews with over 80,000 managers in 400 companies, the Gallup Organization has identified 12 questions it believes measure the core elements that attract, maintain, and retain talent people. No study has been done to validate these questions in EMS or public safety, but MedStar employees were asked them anyway. The results are:

Table 1: The Gallup 12 Questions

1) Do I know what is expected of me at work? 91.50% (140) 6.54% (10) 2) Do I have the materials and equipment I need to do my 70.59% (108) 27.45% (42) work right? 3) At work, do I have the opportunity to do what I do best 66.67% (102) 31.37% (48) every day? 4) In the last seven days, have I received recognition or 25.49% (39) 72.55% (111) praise for doing good work? 5) Does my supervisor, or someone at work, seem to care 65.36% (100) 32.68% (50) about me as a person? 6) Is there someone at work who encourages my develop- 49.02% (75) 49.02% (75) ment? 7) At work, do my opinions seem to count? 24.18% (37) 73.20% (112) 8) Does the mission/purpose of my company make me feel 53.59% (82) 44.44% (68) my job is important? 9) Are my co-workers committed to doing quality work? 58.82% (90) 39.22% (60) 10) Do I have a best friend at work? 51.63% (79) 46.41% (71) 11) In the last six months, has someone at work talked to 39.87% (61) 58.17% (89) me about my progress? 12) This last year, have I had opportunities at work to learn 66.01% (101) 32.03% (49) and grow?

Note: Buckingham, M. & Coffman, C (1999). First. Break all the rules: What the world’s greatest managers do differently. New York: Simon & Shuster.; Red - highlighted scores represent questions where the respondents indicated in the negative or very close.

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Drawing conclusions from the results of asking the Gallup 12 to MedStar employees is not possible. However, if Gallup’s assertion of the validity of these questions is accurate, than several questions (especially those highlighted in red) indicate areas in need of improvement.

Summary of the Survey This section of the report discussed The Whitney Smith Company, Inc employee satisfaction survey results and provided a summation of data captured in the Fitch survey distributed to all MedStar employees. Respondents acknowledge that they are vested in the success of, what they believe, is an organization with potential, but their tone and the content of their responses indicate a staff that is frustrated and unhappy. Personnel indicate they are “surveyed out” and disappointed that these efforts never appear to them to ever result in tangible actions. Only a summary of key themes are presented here; anonymous raw data with the individual comments are available separate to this report.

Compensation In one on one conversations with frontline employees and in the Fitch survey, staff indicated that their pay is an issue and they believe they deserve to be paid more and more competitively in the local and regional market. Low compensation can affect retention and make an organization less attractive. In addition, lower pay can make it difficult for employees to focus beyond their own interest to support an organization’s success.

Fitch & Associates did not conduct an independent salary market analysis of System Status Controller, EMT, and paramedic pay. The following comparison is based on data presented to the Board from a recent report by The Whitney Smith Company, Inc. The recommendations are based on benchmark data collected by EMS Consult- ant Steve Athey. The data was not independently validated. The additional benchmark data was published in the annual JEMS 2007 Salary & Workplace Survey, of which Senior Associate David M. Williams is the principal researcher and author.

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Table 2: Salary Benchmarks

Source JEMS10 Athey Survey MedStar

Position Call Volume Region VI Regional PUMs Current Proposed Differ- (70,001- (NM, OK, (TX, LA) 2007 2008 - ence 90,000) TX, AR, LA) Whitney Smith Company

EMD $44,803.20 $42,000.00 $32,735.00 $35,230.00 $29,868.00 $33,986.00 +13.8% EMT $31,699.20 $29,853.73 $31,979.00 $28,268.00 $26,290.00 $30,129.00 +14.6% EMT-I $34,859.50 $32,700.00 $38,466.00 $30,743.00 $29,100.00 $33,440.00 +14.9% Para- $43,281.00 $40,700.00 $44,646.00 $40,931.00 $38,336.00 $42,231.00 +10.2% medic

Note: JEMS data is reported and published as base annual salary and is not adjusted to the annual 2782 MedStar shift.

MedStar’s current pay rates are noted to be below the JEMS data for systems of similar response volume and for Federal Region VI and the Regional and PUM benchmarks provided in the Athey study for all positions. The proposed 2008 pay rates are a significant increase from current salaries, but may fall short of being competitive to the benchmarked comparators.

Table 3 shows the average of the four benchmarks with MedStar’s proposed 2008 salaries. Comparing the averages of the benchmarks against the proposed MedStar pay rates is a simple way to reflect that the proposed rates, in many cases, are still lower than the market benchmarks.

Table 3: Comparison of the Average of the Salary Benchmarks with Pro- posed MedStar 2008 Salaries.

Source Position Average of Bench- MedStar Proposed Difference marked Salaries 2008 Salaries EMD $38,692.05 $33,986.00 (13.9%) ($4,706.05) EMT $30,449.99 $30,129.00 (1.7%) ($320.98) EMT-I $34,192.13 $33,440.00 (2.3%) ($752.13) Paramedic $42,389.50 $42,231.00 (0.4%) ($158.50)

10 Williams, D. M. (2007, October). JEMS 2007 Salary & Workplace Survey. Journal of Emergency Medical Services, 32(10), 42-56.

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In a staffing environment where employees are working harder than they would if MedStar was fully staffed and where high levels of job satisfaction are not present, salaries become very important to personnel. Salary parity can significantly influence recruiting and retention. The proposed changes are a significant increase (10- 15%) from the current salaries, but still fall short of the average of the benchmarks for all positions. MedStar should evaluate each position’s pay rate individually for further adjustments.

Recruitment and retention of paramedics is of critical importance to the system today and into the immediate future. Existing paramedics will appreciate the increase, but they, as well as perspective candidates, will compare the salary for parity with other organizations in the region to gauge its quality. The 2008 base wage proposed for paramedics by The Whitney Smith Company, Inc is 0.4% below the mean of the benchmarks reviewed in this report and 5.7% below the regional benchmark data collected by Mr. Athey. The Board should consider a proposed paramedic salary that is in parity with the benchmarks provided.

Summary of Compensation In an organization where employees are having to work extra hard to make up for vacant shifts, are fully deployed in a high performance system model, and are not feeling satisfaction in their workplace environment, pay becomes central to employee satisfaction and retention. If employees are not satisfied, perceived inequities in pay may result in increased turnover. MedStar should reconcile the existing pay rates for all positions with market benchmarks so they are competitive to enable employees to focus their attention on the improvement of other workplace factors.

Retention MedStar reported a turnover rate of 29.6% for 2007, which included 59 voluntary terminations and 23 involuntary terminations. The national average turnover rate reported by the Bureau of Labor and Statistics is 23.4%.11 Respondents to a recent national EMS salary and workplace survey report an average turnover rate nationwide of 15.2%.12 That is almost half of the rate of MedStar.

11 Nosbot Corp.: “Latest BLS employee turnover rates for year ending August, 2006.” www.nobscot.com/survey/index.cfm 12 Williams, D. M. (2007, October). JEMS 2007 Salary & Workplace Survey. Journal of Emergency Medical Services, 32(10), 42-56.

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Management Fear of Staffing Very early on in the system review process, it became apparent that the leadership team viewed employee staffing, and the deficit that existed in the system, as the primary driver of the response time compliance issue. Response time compliance and the issues associated were discussed earlier and staffing is core factor. While a significant contributing factor, it is not the only reason. The fixation on staffing created a chain reaction that is negatively influencing the operations. The following are a few of the results.

1. Several managers and staff have indicated that the field crews are in control. Managers have been described as not wanting to upset staff or inconvenience them for fear of losing them. The result is a lack of needed personnel management and assumption that accountability equals turnover. 2. To fill shifts, MedStar implemented a financial incentive program. While this may have been okay for a short-term emergency period, its sustained use has now embedded it as an expectation and part of the employee’s earning potential. It also has set up an expectation that premium pricing is required for extra work. The incentive programs have long been known to have negative affects on employee performance.13 3. When employees are dissatisfied, pay and freedoms like wearing t-shirts or baseball caps become vocal requests from the field staff. This phenomenon was witnessed in the survey results and in one-on-one interactions. Med- Star’s pay rates are below the market as discussed elsewhere in this report. MedStar is attempting to address the inequity. However, while distracted by the pay issue, the management team is not recognizing the engagement and appreciation needs that the frontline personnel are yearning for and that appears absent in the workplace. MedStar needs to refocus its attention on creating an organizational culture that people want to be a part of.

Employee satisfaction is essential to the effective and efficient operation of the Med- Star EMS system. Management has to transition from looking at spreadsheets of scheduling efficiency and increasing staffing numbers to developing a work environment that is attractive to be part of, where employees feel they are held accountable and appreciated, and where there is a clear sense of a vision to move the organization in the right direction. Doing so will reduce turnover, increase staffing, and improve performance.

13 Deming, W.E. (1994). The new economics: For industry, government, education (2nd Ed). Cambridge, MA: Massachusetts Institute of Technology Center for Advanced Engineering Study. Or, Kohn, A. (1993). Punished by rewards: The trouble with gold stars, incentive plans, A’s, praise, and other bribes. Boston: Houghton Mifflin Company.

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Summary of Strategic Human Resources Turnover at MedStar is above industry and national standard rates. Employees express themselves emotionally and are frustrated with the state of the organization. Pay, management, and scheduling are the three most common issues. Recent surveys offer insight into the needs of employees and they are awaiting management follow through. MedStar's proposed pay increase remains below reported benchmarks. Management seams apprehensive to manage employees for fear of turnover.

Strategic Human Resources Recommendations 1. Staffing levels must be increased to greater than 5% of full staffing. 2. Results of The Whitney Smith Company, Inc and Fitch & Associates surveys show pay, scheduling flexibility, and management issues and consistency as consistent issues. MedStar should continue its efforts to review and act on the results and make changes to address core issues. 3. Proposed pay rates are below reported benchmarks in spite of improvement. MedStar should review each individual rate against the average of the benchmarks and the region for additional adjustment. Proposed paramedic salary should be in parity with the benchmarks provided. 4. Management needs to transition to managing people effectively and creating a desirable work environment.

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Management Team

MedStar and its leadership team are the result of a unique circumstance not frequently encountered in the EMS industry. In 2005, when the Authority took over operational responsibility and dismissed the services of the contractor, it inherited a system out of compliance and no team to manage the change needed to realign the system. As would be expected, MedStar pieced together a patchwork of management team members; some who had previously worked for the Authority and others the contractor. On day one, they were starting with a performance deficit.

The forging of a management team consisting of existing system talent and having to immediately jump into the trenches required very specialized leadership to successfully manage the transition and lead the change. Team members needed to be engaged in developing a shared vision and be redirected to a new mission as a single entity versus a contractor and an Authority. In addition, the team needed to be con- currently focused on fixing performance issues in its core business. This did not happen.

Executive Director Jack Eades has been the Executive Director for 16 years. The Authority Board is very open in describing Mr. Eades as a steady and committed Authority Director who has worked diligently to always act in the best interest of the system and the patients and communities it serves. He also receives high praise for his work to bring the management of the operations into the Authority and coordinate the transition following their termination of the previous contractor.

Mr. Eades is a knowledgeable director and is regularly engaged in the industry. He regularly attends forums like the Pinnacle EMS Leadership Forum and participates in the American Ambulance Association (AAA) and the Coalition of Advanced Emer- gency Medical Systems (CAEMS). He is well regarded among peers.

Currently, the Executive Director position is the only position that holds all other managerial positions together. This means that the executive director must be responsible for overseeing the entire operation, interact with the Authority Board, work with EPAB, communicate with member cities, partner with fellow public safety and healthcare organizations, and lead day-to-day operations of the system. This scope of responsibilities is uncommon for an EMS system of this size.

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While Mr. Eades did not participate in a personality profile, it is reasonable to con- clude that he would be considered an introverted, hands-off manager. He appears to trustingly delegate the appropriate authority to his management team members, expect them to achieve results, and assume they will come to him if there are issues.

While Mr. Eades’ delegation to managers and directors is appropriate, it appears that there is no loop to ensure that people are performing their roles and responsibilities unless it is brought to his attention. It was clear from interactions with the management team and staff that they do not communicate problems or underperfor- mance adequately to him. This does not appear to be due to a lack of accessibility or receptiveness. Unfortunately, the result has been inefficiency and ineffective management integration and the enabling of issues to linger instead of being fixed.

As part of the ongoing consulting engagement, the Authority was advised to create a new Associate Director position with the core responsibilities to include being the internal thread to lead day-to-day operations of all EMS departments and guide change to the future state of MedStar. The Authority has acted on the recommendation and has engaged the Firm to assist in recruiting and selecting an appropriate candidate to fill this role. Allowing Mr. Eades’ to return to an oversight role and inserting a qualified tactical leader will hopefully curtail issues with performance and integration in the management team.

Mr. Eades has served the EMS system respectfully and has always acted in the best interest of the EMS system and its constituents. Authority Board Members freely acknowledge his service and their respect for him and his work.

Associate Director Position Fitch & Associates has recommended that the Authority Board create an Associate Director position and recruit and select a qualified candidate. The position would be an executive level leadership position between the Executive Director and the management team of directors. The primary responsibilities of the position are to provide cohesive management of the system on a day-to-day basis, assuring alignment of all departments and activities, and keeping focus on organizational priorities and initiative management. This would allow the Executive Director to return to providing executive oversight and stakeholder connectivity. Fitch & Associates has been engaged to provide support in the recruitment and selection of an appropriate candidate.

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Existing Management Development Public safety is notorious for promoting high performing frontline employees into management and expecting them to become proficient in the necessary skills in knowledge to successfully lead and manage an EMS operation through trial and error and informal mentoring. Recognizing the critical importance of targeted management training and the benefit of academic preparation, the consultant team reviewed the self-reported professional development of the management team.

Management Specific Training No member of the MedStar management team has participated in a management certificate program similar to the Communication Center Manager program sponsored by the National Academies of Emergency Dispatch or the Ambulance Service Manager program sponsored by the American Ambulance Association. Dr. Griswell has completed the Medical Directors course sponsored by the National Association of EMS Physicians. These types of management programs offer targeted content related to industry specific best practices, enable managers to network with peers, and provides an opportunity to learn from industry leaders.

Academic Preparation Formal academic degrees are becoming more common in the EMS industry. Associ- ates degrees are most common with bachelor’s degrees increasing in popularity; especially with the ease of participating in an online degree completion programs in EMS management. Graduate degrees are becoming more common and are often a requirement for executive level roles. Only three members of the leadership team have earned a college degree and only the Executive Director has earned a graduate degree. While undergraduate degrees are not adequately valued in the industry because people can still ascend into leadership position without them, there is great value in the critical thinking, project management, and research skills developed in the university level education process.

Conference Attendance Conferences offer a valuable opportunity to network and stay abreast of industry trends and practices. Each department has a professional development budget based upon the budget request submitted by the department’s manager. Budgets have remained the same since the Authority assumed operations and no one has been denied their requested budget. Members of the staff and management team regularly attend national conferences such as the National Academies of Emergency Dispatch’s Navigator Conference and EMS Expo, as well as, regional offerings like the annual Texas EMS conference. The Executive Director and the operations and de-

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ployment managers have attended the Pinnacle EMS Leadership Forum and the American Ambulance Association Annual Meeting.

Current Management Practice Each director or manager the consultants met with or corresponded with was responsive, cooperative, and expressed commitment to the greater good of MedStar. There is no indication that anyone is not working in the best interest of the EMS system to the best of their ability or skill set. The consultants did however strongly per- ceive that each position and function within the organization is being managed as a silo and little integration exists.

In talking with management team members about the system, there is a sense that people feel they are doing their best to manage their individual processes, but that there is tension with peer managers related to their competency or work product. While team members sit in offices in close proximity to each other, there is a sense that there is little face-to-face constructive communication unless in a meeting. There were reports, as well, that what is presented in meetings or in front of the Ex- ecutive Director as professional interactions is not what is occurring behind the scenes between each other. The consultants did not participate in regular operational meetings over time to witness the behavior, but signs of the behavior were present in several individual interviews. It does not appear that this behavior is reported to the Executive Director.

Operations Manager Confidence One position receiving consistent criticism from management team colleagues is that of the operations manager. In several interviews, personnel reported forwarding issues, data, or requests to him, but they felt he either did not take the appropriate action or took one counter to what had been asked of him. Several team members expressed that many in the management team do not support him.

The consultant team members visited with the operations manager on several occasions in person and via telephone. After discussing the issues at MedStar and his role in directing the operations, we felt that he was a good person, but his skill set and knowledge base were not congruent with the high level required of the position in a high performance EMS system. The Authority should evaluate the current person in the role and develop a short and targeted developmental plan or remove the individual from the position and replace with a person capable of the running a high performance EMS operation.

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Cycle of Improvement During individual discussions with the management team members about the response time compliance issues and their individual process roles, it became apparent that there was not a clear awareness or methodology in use to investigate process or system issues and conduct experiments to make improvements.

For example, the management team currently is struggling with improving response time compliance. As mentioned earlier, short staffing has been a formidable obstacle in need of correction, but it has also been a significant distracter from other improvement opportunities. The MedStar team needs to learn a manageable approach for investigating and solving problems.

One simple methodology advocated by the Institute for Healthcare Improvement involves four components (see Figure 3)

Figure 3: Institute For Healthcare Improvement – Deming’s System of Pro- found Knowledge Model.

1. Appreciation for a system: understanding that all the parts of a process are related in such a way that if you focus on optimizing one part, other parts may suffer and that improvements to the whole system yield the greatest results; 2. Knowledge about variation: using statistical process control and understanding the difference between common causes of variation and special causes and when it is appropriate to act; (see Figure 4)

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Figure 4: Sample Statistical Process Control Chart

3. Theory of knowledge: being aware of what we think we know, how we know it, and how we can test what we know; 4. Psychology: Recognizing how human motivation (e.g., incentive) and change influence outcomes and successful performance.

The Institute for Healthcare Improvement terms this the science of improvement. This approach is useful because it places attention on understanding the process and its components, measurement to make sure focus is on reducing variation and acting on statistically significant factors, testing assumptions, and appreciating the influence of change and incentives on the workforce. Once management has assessed the processes they wish to improve (e.g., response time compliance, employee morale, etc), it is possible to experiment with improvements and gauge their impact using objective and constructive information. One simple tool for mini-experimentation is IHI’s Model for Improvement (see Figure 5).

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Figure 5: IHI Model for Improvement

The tools advocated by IHI, and recommended here, are not new or groundbreaking; they are all rooted in the early works of W. Edwards Deming. Other managerial tools, like Six Sigma, would also suffice to assist the management team. The goal is to have an approach that ties process thinking and data together in a methodology that purses objective results. Currently, that is absent in the MedStar management team’s work processes. The MedStar and EPAB management team should receive training in process improvement and be facilitated through applying it to several improvement initiatives to develop foundational proficiency.

Process Coaching Many of the recommendations included in this report require the management team to act and perform differently then they currently do and outside of their zone of experience and comfort. In our consulting experience, management teams have strug- gled with doing so independently and often require an expert industry facilitator to provide a framework and initial process coaching to build a foundation to start from and gain proficiency at the new ways practices.

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Summary of Management Findings The management team is an unplanned patchwork of members from the authority and former contractor. Team effectiveness is siloed and lacks an improvement methodology. Academic preparation and management training is lacking. The Board needs to consider if the leadership team includes the most appropriate leaders to guide the transition into a future state. The leadership team requires skilled, facilitated process consultation to get unstuck.

Management Team Recommendations 1. Management team members need to be engaged in developing a shared vision and be redirected to a new mission as a single entity versus a contractor and an Authority. 2. The management team needs to be focused on fixing performance issues in its core business. 3. The Executive Director should evaluate the current management team and its interactions and make adjustments to improve reporting, performance, and collaboration. Delegation to the management team is good if they are managed to ensure outcomes are achieved. 4. The Authority should continue efforts to design an Associate Director position and recruit and select a worthy candidate. 5. The leadership team should be encouraged to pursue and earn a minimum of undergraduate education. 6. The Authority should consider rotating leadership team members through the American Ambulance Association’s Ambulance Service Manager program and the National Academies of Emergency Dispatch Communications Center Manager program. 7. The skill sets and performance of existing managers (e.g., Operations Manager) should be evaluated and improvement plans or replacement should be initiated as appropriate. 8. The MedStar and EPAB management team should receive training in process improvement and be facilitated through applying it to a several improvement initiatives to develop foundational proficiency.

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System Finance

The Area Metropolitan Ambulance Authority (d/b/a MedStar) maintains it financial records in accordance with generally accepted accounting principals and has adopted the Government Accounting Standards Board format for its annual financial statements. MedStar’s statements are annually audited independently by Weaver and Tidwell, LLP. In its January 2008 report for the year ending September 30, 2007, the independent auditing firm expressed no adverse opinion. Management indicates there have been no substantive changes in accounting policies or other significant changes in the intervening period.

This section of the report discusses the financial background and environment in which MedStar provides it services, provides an overview of revenue generation policies and processes, expense management and controls and provides observations and recommendations for enhancement.

Background Funding for MedStar is secured from two primary sources—patient fees and subsidies. A number of other alternative revenue sources are captured by some ambulance services in the form of donations and subscriptions, but these sources generate a relatively small amount of the total revenue recovered for the delivery of ambulance services.

Payer Mix As with other healthcare agencies and ambulance providers, MedStar depends on cost-shifting to achieve supportable margins. There are four major categories of payers for ambulance services. These include: 1) Medicare, 2) Medicaid, 3) private insurance, and 4) patients. Medicare and Medicaid are fixed fee payers and both, on average, pay less that the fully allocated costs of ambulance services. Medicaid pays significantly less than Medicare in Texas. The patients are responsible for co- insurance, deductibles, and the full cost when they have no insurance coverage to reimburse for ambulance services. Only a small percentage of billed charges are recovered from patients (10 to 15%). This leaves the insurance companies to make up for the under-funded governmental programs, indigents, and low percentage of patient payments.

The ambulance industry mimics the rest of the healthcare community by cost shifting to insurers. While there is a limit to the amount that can be charged and reasonably reimbursed by insurance companies, ambulance services, including MedStar, will continue to push the cost shifting envelope since they really have few other options.

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Figure 6: MedStar Payer Mix

10% 1% 13%

Self pay Insurance 28% Medicare Medicaid Other indigent 48%

Note: Source MedStar Management Response to Data Request

Medicare Nationwide, cost shifting results in gross ambulance bills that typically range from 150% to 300% of the total allowed by Medicare and the average cost of providing the service.

Medicare beneficiary utilization of ambulance services increased 16% in three years from 2001 to 2004 across the nation. At MedStar, the utilization increase is less pronounced.

This national trend is expected to continue as the baby boomers acquire Medicare eligibility. Medicare is the largest single payer for ambulance services, accounting for 40% of all ambulance transports and 31% of the ambulance services’ total revenue throughout the nation. As such, all ambulance organizations must pay close attention to the trends and policies for the Centers for Medicare and Medicaid Services (CMS). At MedStar, Medicare patients are 28% of the organization’s total revenue.

The Medicare Fee Schedule, initiated in 2002, has impacted reimbursement available to MedStar. Prior to the implementation of the Medicare fee schedule in 2002, Med- Star and other services were reimbursed by Medicare based on reasonable charges. Essentially, MedStar could add charges for supplies, services, and mileage or bundle these into the base rate and mileage charges. With the implementation of the fee schedule, MedStar can now only charge a base rate and loaded mile fee to Medicare for reimbursement. The largest impact of this change was the preclusion of MedStar from billing separately for medications, some of which are very expensive. Previ- ously, these medications were reimbursed separately by Medicare.

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A recent Government Accounting Office (GAO) report indicates that there is a gap between Medicare payments and service costs that will exist after several temporary funding provisions expire in 2008-2009. This gap is estimated at 6% on average.14

Medicaid Medicaid is a federal health care program administered by the states. Each state implements its coverage levels, rules, regulations, and reimbursement rates. Con- sistently, Medicaid reimbursement falls far below the costs of providing the services.

Medicaid represents 11.5% of MedStar’s revenue.

Commercial Insurance Commercial insurance companies pay based on their contracts with the insured and in most instances pay a fixed percent of the total charges (e.g. 80%) or the total charges particularly for emergencies.

Insurance companies pay a high percentage of the billed ambulance charges. As other payers decrease or limit payments, the insurance companies have received higher charges to compensate. This cost-shifting is a fundamental part of healthcare funding in America and will not change significantly in the future, although insurers will continue to try to contain costs and limit benefits to ensure their margins.

In FY 2007, commercial insurance represents 40% of MedStar’s revenue.

In other parts of the nation, insurance carriers have attempted to cap commercial reimbursement at the same rate at Medicare. Others have written into policies a maximum benefit for ambulance service. The effects of these types of efforts on MedStar will be to seek payment for non-covered charges from the patient, negatively impacting the service’s collection rate. In some cases carriers are reimbursing the patient directly. In these instances, the patient’s are reclassified as “self-pay” and the cost of MedStar’s collection efforts to attempt to obtain payment from the patient increases significantly.

Self Paying Patients Patients that cannot be categorized in one of the above payer classes by MedStar, are considered self pay patients. Many patients ultimately have their account written down or written off by MedStar as bad debts when it has exhausted all reasonable means to collect on the account.

14 http://www.gao.gov/new.items/d07383.pdf

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MedStar uses objective screening tools to determine a patient’s ability to pay and uses both internal collection efforts and external collection agencies, as appropriate, within the Board approved collection policies.

At MedStar, Self Pay accounts for approximately 15% of the system’s net revenue.

Summary of Payers The funding sources for ambulance services are varied. Governmental subsidies often cover the gap between patient revenue and service costs, especially in markets with poor payer mixes, low density population, and in communities with stringent performance requirements.

Medicare has not fully covered the costs of ambulance services in the past and is not expected to cover the average costs in the future. Medicaid reimbursement is woefully inadequate and that deficiency is not expected to change. Only pressure on state legislators will have any long-term impact on Medicaid reimbursement.

Commercial insurers have, and will continue, to pay the way for the under- and uninsured with a significant portion of ambulance service expenses being cost-shifted to insured patients.

Revenue MedStar has an unusually complex subsidy and rate payment mechanism among its member communities. Historically, MedStar has allowed individual communities to choose the level of subsidy provided. This is not by choice and is in the terms of the Interlocal Agreement. This has resulted in significant variances to the average subsidy per capita and average rate charged in each community.

To assist in understanding the changes overtime in the system, it is helpful to recognize the overall growth in the population served by the member Cities. Figure 7 Shows the total population served by MedStar overtime.

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Figure 7: Total Population Served by MedStar (1989 to Present )

For those communities that provide subsidies, the per capita subsidy varies from a low of $1.37 to a high of $4.15. Conversely, respective average charges vary from a high of $1,200 to a low of $994. Seven of the 15 communities served by MedStar provide no subsidy and their average charge approximates to $1331. This is problematic given the fixed levels of reimbursement from Medicare and Medicaid and the industry wide cost shifting noted above. Figures 8 and 9 show the Subsidy per Cap- ita and Average Charge respectively over time. Note that while the population has grown, the Subsidy per Capita and Average Charge have not matched the growth trend.

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Figure 8: MedStar Mean Subsidy per Capita (1989 to Present)

Figure 9: MedStar Mean Bill (1995 to 2008)

Fort Worth is the largest member community and provides a per capita subsidy contribution of $1.90. The subsidy provided by Fort Worth has not been adjusted for more than a decade. The net dollar value of the per capita subsidy contribution, when factored for inflation and considered against the flat reimbursement available from Medicare and Medicaid, has declined significantly.

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Comparing Fort Worth’s per capita subsidy to other high performance EMS System cities that are members of the Coalition of Advanced Emergency Medical Systems (CAEMS), of those with a subsidy, MedStar has the second to the lowest with $1.74 reported in 2006. The lowest was Tulsa at $1.00. (See CAEMS comparison in Figure 10 below).

Figure 10: Subsidy per Capita of CAEMS Member Cities (2006)

When the collection percentages for each member communities were analyzed, only two of the seven non-subsidized communities’ collections rates would be considered at the higher end of the collection range. This underscores the point that in non- subsidized communities, the higher rates charged do not reflect a commensurate higher collection rate due to the fixed amounts payers, such as Medicare and Medi- caid, actually reimburse.

This revenue generation policy does not consider the differentiation in costs to cover some of the individual jurisdictions.

Compared to similar high performance EMS systems, the Base ALS rate reported by MedStar is the highest among the 13 benchmark services. Conversely, of the seven benchmark services that receive direct subsidy, only Tulsa reports a lower subsidy per capita than MedStar.15

15 Coalition of Advanced Emergency Medical Systems “High Performance and Market Study – 2006”

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Figure 11: MedStar Gross Charges, Contractual Allowances, and Payments

MedStar’s “gross to net” collections reported at year end were 27.06%. Other communities in the Dallas-Fort Worth metropolitan area, with similar demographics and using similar gross to net reporting methodologies, are reporting similar collection results.

The 16 staff members assigned to billing and collections are within expected ranges and result in a per staff metric of managing approximately 4,000 transactions per person per year. This is slightly higher than benchmark at approximately 3,500 transactions per person.

Based on FY 2007 year end data, MedStar’s gross days in accounts receivable (A/R) are approximately 175 compared to industry norms of less than 90. Using MedStar’s adjusted days in A/R methodology, it benchmarks at 76 days compared to an industry optimal range of 40-60 days. MedStar indicates this is the result of the number of accounts that are on monthly payment plans.

MedStar reports $5.6 million in more than 180 days. There are certain categories of accounts that are concerning. Accounts that are awaiting Medicare signatures is one such category. Approximately, $200,000 to 250,000 per month are put in this schedule where the crews were unable to get signatures and the billing office has to secure them before filing. These amounts do not seem to decline from month to

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month indicating that not getting signatures continue to be an issue. Additional follow-up and changing the accounts to private pay and moving to collections is recommended.

Other categories that need to be addressed include: The collection review category for Medicare. Over $1.3 million is in this payment category and over 180 days. These should be reviewed on an account by account basis and either written off or sent to collections. There is also $350k in bills sent to facilities in the over 180 days category. Typically, these would be due within 30 days and should not be over 180 days. Management needs to intervene to get the facilities to meet their obligations. There is nearly $1.3 million in the over 180 day schedule for Collection Review In- surance. These accounts also need to be reviewed individually and either written off or sent to collections.

MedStar’s internal processes and time intervals for processing claims are within normal ranges and have been tailored to each class of payer. MedStar utilizes Rescue- Net billing software, which is commonly used by EMS agencies throughout the nation. No independent claims reviews were conducted as part of this scope of work. MedStar reports that it has not been audited by Medicare or Medicaid in the past five years.

Expense MedStar’s expenses are managed in the context of a detailed line item program budget similar to those used by other high performance EMS systems and units of local government.

The system’s cost per transport and cost per capita when compared to benchmark communities are the lowest reported (see Figures 12 and 13).16 This lower cost should be considered against the lower levels of performance currently being achieved by the MedStar system. When additional costs are applied to improve specific response time performance to levels achieved by other benchmark Cities, it appears that the MedStar system will still represent excellent value and will be at or below the median of reporting communities.

16 Ibid

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Figure 12: CAEMS Benchmark of Cost per Transport (2006)

Figure 13: CAEMS Benchmark of Cost per Capita (2006)

Summary of System Finance Funding needs to be increased to achieve and maintain performance. The system has functioned year after year by being frugal. To avoid cost increases, the system has not added or managed resources in a manner required to maintain performance. Failure to increase funding to levels of required performance will ultimately result in patients being harmed. While some local official might say “we can’t afford this system” MedStar represents excellent value. Any other option that member Cities could reasonably pursue to achieve equivalent clinical performance will likely be more expensive.

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A minimum subsidy per capita should be established. The option of allowing member Cities to choose the subsidy rate mix is no longer effective. A floor per capita funding level should be established that all member communities contribute. The rational for this recommendation is that MedStar was created during a very different economic period. The policy offered communities the option of choosing their subsidy and rate mix. The premise was that if a community chose lower subsidy, the additional revenue from rates would make up the difference. At the time it was a reasonable policy decision. However, post implementation of the Medicare Fee Schedule, MedStar is no longer allowed to balance bill. As a result, MedStar shifted the cost of uncompensated care to commercial payers. (e.g. despite a Medicare re- cipient in a member community being billed at a higher rate the net receivable from the account is low due to the mandatory adjustments.) In some cases, these communities are more difficult to serve and contribute only the net fees collected by MedStar. The floor level subsidy should not be less than the contribution of the largest member and should be annually adjusted at the average percentage increase in participating communities’ annual budgets. MedStar should continue to monitor and adjust its rates to maximize reimbursement from all payer sources.

Monitor and act on information developed using routine internal billing benchmarks. Key performance metrics such as the requirement to obtain a signature, days in A/R, collection review category for Medicare over 180 days, and facilities with accounts over 30 days should be monitored monthly. These efforts will enhance cash flow but will not negate the primary need to increase the baseline subsidy.

Business Management Recommendations 1. Funding needs to be increased to achieve and maintain performance. 2. A minimum subsidy per capita should be established. 3. Monitor and act on information developed using routine internal billing benchmarks 4. Crew failure to capture patient signatures needs to be evaluated and process improvements implemented to reduce events. 5. The collection review category for Medicare, there is over $1.3 million and over 180 days. These should be reviewed on an account-by-account basis and either written off or sent to collections.

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Lateral Industry Benchmarking

MedStar is in a unique position because it regularly engages in a benchmark project with High Performance EMS Systems (HPEMSS) across North America that are similar in operations and philosophy. Known as the Coalition of Advanced Emergency Medical Systems (CAEMS), the group includes Public Utility Models (PUM), former PUMs, and other EMS systems based on the high performance model. The following is a brief summary of how MedStar compares with its industry peer systems.17

Response Time Reliability The CAEMS benchmark study does not benchmark actual response time compliance and only discusses attributes of their compliance processes. Comparing the characteristics reveal the following:

! Life-threatening response time goal - MedStar’s 9:00 (min/sec) at 90% compliance is comparable to six other domestic HPEMSS (all use 8:59 at 90%). Four HPEMSS use a stricter standard between 7:59-8:30 at 90%. Two systems use a less strict standard of between 10:00-10:59. ! Non-life-threatening response time goal – MedStar’s 11:00 at 90% is stricter than eight of the peer systems whose goals range from 10:59-20:00. Only two systems are stricter at 7:59 and 10:00 respectively. ! Clock Start/Stop Emergency Response – – CAEMS members are almost evenly split on their definition of the initiation point of their response time measurement. Five HPEMSS use call receipt and five, like MedStar, begin with the confirmation of condition and call location. Only one starts at the first keystroke. All of the systems stop the clock when the ambulance arrives at the curb of the call location. Fitch & Associates traditionally advocates starting the clock as early as possible (e.g., first keystroke or phone pick up).

Clinical Capability The CAEMS benchmark study uses limited outcome measurements and again focuses on many attributes like skills course training and certification (e.g., Pediatric Ad- vanced Life Support).

17 Overton, J. & Anderson, D. (2007, August). High Performance and EMS Market Study 2006. Richmond, VA: Coalition of Advanced Emergency Medical Systems.

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! Cardiac Arrest Survival – Defined as patients with cardiac etiology delivered to the hospital with Return of Spontaneous Circulation (ROSC). MedStar reports 23.00%, which is below the mean of 31.00% and the median of 30.00%. Only one system reported lower success in the sample at 18.91%. ! Skills Performed – Availability of procedures and medications such as Cap- nography, 12-lead ECG, ventilators, Amiodarone, Vasopressin, and Critical Care Transport are benchmarked and MedStar is within the norm for each category. ! Accreditation – Members benchmark whether they are accredited by the Commission on the Accreditation of Ambulance Services (CAAS) or the Na- tional Academies of Emergency Dispatch (NAED – ACE). MedStar is one of only two that is not currently accredited by CAAS, but it’s recognized they are in the process and CAAS did accredit the system under the previous contractor. MedStar joins the majority who has medical communication centers that are recognized as ACE.

Economic Efficiency The CAEMS study benchmarks several economic efficiency factors. The following is a discussion of the key comparators relevant to MedStar.

! Scheduled Unit Hours – MedStar reported 182,208 total unit hours. This is more than the mean (123,479) and median (103,512) reported by HPEMSS with a contractor and above the mean (191,753) and median (201,166) of HPEMSS without contractors. It is above the mean (151,926) and median (131,846) of all of the systems participating in the study combined. ! Cost per Unit Hour – MedStar reported $104.37 per unit hour, which is below the mean ($111) and Median ($104) of HPEMSS without contractors and below the overall mean ($120) and median ($124) of systems in the sample. ! Unit Hour Utilization (UH/U) – MedStar reported a UH/U of 0.36, which is greater than the means (0.33/0.30) and medians (0.34/0.32) of HPEMSS with contactors versus without and greater than the overall mean and median of 0.32. ! Total System Cost – MedStar reflects the median of HPEMSS without a contractor at $19,017,475 and is below the mean ($20,274,184). It is greater than the total median ($16,234,743) and less than the total mean ($21,052,201) when comparing all systems in the sample. ! Cost per Capita – MedStar reports a cost per capita of $24, which is below the mean ($33) and median ($29) of other HPEMSS without a contractor and below the total mean of $38 and median of $32 when including all systems in the sample.

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CAEMS Sources of Revenue The CAEMS report discusses several benchmarks related to revenue including the price/subsidy trade off, payor mix, subscription programs, and revenue recovery. These benchmarks are discussed in detail in the System Finance section of this report and are not repeated here.

Lateral Benchmark Summary MedStar is unique and fortunate in that it is of a system model with peers that regularly participates in a transparent benchmark process. Based on review of the benchmarks included in the CAEMS report, MedStar is comparable across the vast majority of indicators. If the Authority wished, it could consider adjusting response time standards to match those of peer systems, but it is not necessary and will not change outcomes. MedStar should study why its cardiac arrest survival (ROSC at the ED) is lower than the majority of systems in the study.

Lateral Benchmark Recommendation 1. MedStar should study why its cardiac arrest survival (ROSC at the ED) is lower than the majority of systems in the study.

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Future Scenarios

The Authority Board and member communities have experienced significant change in the system in the last few years and have had performance levels that do not meet expectations. It is important that the future be different and set a path for improved performance, enhanced quality, and long-term sustainability. The consultant team considered several future scenarios for the MedStar system. These are not predictive models based on quantitative analysis, but rather qualitative summaries resulting from the consultant review of the system and market and current trends in the region and industry.

The consultants considered four potential future scenarios: 1) Status Quo, 2) Com- petitive Bid for an Ambulance Contractor; 3) Governmental Third-Service or Fire De- partment; 4) Authority Manages Operations.

Status Quo MedStar has managed the operation of the EMS system since the termination of the ambulance management contractor in 2005. Since then, the leadership team has kept the EMS system operating at an economically efficient level, but has been unable to consistently meet response time performance expectations. In addition, employee morale has waivered and retention and achieving full staffing has been an ongoing challenge, which inversely impacts response time compliance. MedStar at- tempts to maintain the level of performance originally defined in the contract, but there is no penalty for non-compliance. In the fall of 2007, local media drew attention to issues in performance and employee morale and local officials requested expert input to improve the system.

This report documents much of MedStar’s current situation and the present issues. Continuing on the current path without significant alteration will result in continued failure to consistently meet performance goals, decreased employee morale and turnover, and increased costs as the leadership team struggles to maintain the day- to-day operations. In addition, the strain between MedStar operations and EPAB will worsen. Eventually, the Authority Board will be forced to act to redirect the system, which will require financial infusion. The status quo is not sustainable if the system is to remain clinical sound, economically efficient, and providing high performance.

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Competitive Bid for an Ambulance Contractor Between 1986 and 2005, the MedStar EMS system contracted with for-profit, private providers for the management of the ambulance service. Contractors include both of the large national ambulance service providers. The Authority Board and the leadership at MedStar have been candid that there is a sense of relief not being engaged in a traditional public utility model system that relies on for-profit ambulance contractors. The Authority and member communities have left the Interlocal Agreement open to reconsidering the use of a contractor, but have expressed little desire to return to that management of the EMS system.

Performance-based competitive ambulance contracting can be a successful model. Success is based on having a thorough understanding of the system needs and limitations, developing an effective request for proposal and procurement process, and providing continuous constructive oversight with appropriate incentives and disincen- tives. Seven of the CAEMS member Cities currently contract for ambulance service management.

The main challenge facing systems wishing to partner with private providers in performance-based contracting is a lack of vendors. Fewer private providers have the resources, experience, and skill set to successfully bid and fulfill a high performance EMS system contract. If MedStar were to put the system out to bid, it could expect to receive bids from American Medical Response (AMR) and Rural/Metro Corporation. In addition, East Texas Medical Center’s Paramedics Plus – the contractor for the EMSA System in Oklahoma City and Tulsa and Sunstar in Pinellas County, FL – is likely to bid. Other private providers in Texas, including Acadian Ambulance Service and CareFlite, have also shown interest in submitting bids for performance-based contracts and may be prospective bidders to MedStar.

Putting the EMS system contract out to bid remains an option for MedStar and can be successful with modification of the contract. The consultant team understands however that recent experience with private contractors has not been positive and the Authority is not likely to consider returning to this system model unless no other options are feasible.

Third-Service Governmental or Fire Department An unlikely future state, but worth noting, is a transformation from an Authority to a government department, either as a stand-alone third service or division within the fire department. These models are common in Texas. Austin is the only major city with a stand-alone third service, but Dallas, Houston, and San Antonio all have fire- based EMS systems.

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Third service EMS departments are often considered the Holy Grail by field providers and many within the industry because it retains an EMS focus and is believed to provide job and system security. Third service EMS is not a very common model and represents only 11.7% of the 200 most populous Cities in America.18 Third services are not traditionally operated economically efficiently and usually only represent a city or county, but not a region of member communities.

Fire Service-based EMS systems are another model of government-based EMS delivery. It is very common for fire departments to pursue acquiring EMS. The Fort Worth Fire Chief specifically told the consultants that that was not in his strategic vision although he is willing to support the EMS system as needed. Fire-based EMS is very common in major Cities in Texas and across the United States. In general, Cit- ies that have had EMS absorbed into their fire departments in recent years have not had positive experiences. Insufficient upper leadership EMS knowledge and experience, EMS service being placed behind fire suppression as a priority in spite of it being the majority call volume, and clashes of culture have all been contributing factors. In most cases, a fire-based EMS system, like a third service, is not traditionally operated economically efficiently and usually only represent a city or county, but not a region of member communities.

While it is very unlikely that the Authority or member communities would make a recommendation to move to a government-based system, based on the current system, its funding mechanisms, and performance expectations, the consultant team would not support transforming the system to one of these two models.

Authority Manages Operations MedStar is one of five CAEMS systems that do not have a contractor, but are managed using the high performance concepts and strategies. It is the consultants’ opinion that the system should continue in a high performance model. A key distinc- tion between the status quo option and this option is in the way in which the Author- ity approaches the management and operation of the EMS system. The core differences include: building a foundation for success, realigning to the core business, developing the organization, and holding itself accountable.

18 Williams, D.M. (2008, February). 2007 JEMS 200-City Survey. Journal of Emergency Medical Services.

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First, the Authority needs to revaluate the fundamental components of the system to ensure that they provide the best outcomes for the patients and member communities, while allowing the greatest potential for MedStar to operate. This includes equitable membership expectations and performance requirements and patient-centric performance standards. By starting with a clear an equitable framework, the system is better suited for achieving quality service in reliable manner.

Second, the Authority Board and MedStar leadership must redirect all attention to the core business of responding to ambulance requests. Daily effort to improve processes, enhance performance, and meet goals should be a primary focus. Activi- ties that are not directly associated to that effort will become second tier until performance compliance is consistent.

Third, MedStar has evolved, unplanned, into the organization it is today. Efforts must be made to aspire to a shared vision of the system for the future, identify the competencies needed to achieve it, and then lay organizational development initiatives to move in the direction of that future workplace.

Finally, the authority may consider applying similar accountability to itself that it once did to its contractors. This may sound counterintuitive to apply rewards and penalties to yourself, but with the loss of rewards and penalties also came a loss of continuous attention to performance and the entrepreneurial thinking that is a hall- mark of the system design.

Of the CAEMS members without a contractor, only one system – Mecklenburg EMS Agency (MEDIC) in Charlotte, NC – has penalties for not making response time compliance. MEDIC is assessed a penalty of $10 per minute up to a maximum of $200 per call for both emergency and non-emergency calls.

Summary of Future Scenarios The MedStar EMS system has several options for the future including, staying the course, putting the system out to bid, transforming to a governmental model, or en- hancing the current model of Authority run EMS delivery. The decision is a local one and must be made based on what is in the best interest of the community and the patients it serves.

Future Scenarios Recommendations 1. Not Applicable

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Summary of Report

The MedStar EMS system has been in rough waters for several years. It has terminated its ambulance contractor, taken over management of the operations, and continued to fail to meet performance expectations resulting in attention from the media and member Cities. In spite of its performance, the underlying system model has maintained service levels that are equal to or better than those of peer Cities in Texas and nation-wide. The community and the Authority want the system to return to its preferred level of quality and service.

Response time compliance has been a major issue. Low staffing and deployment struggles have made it difficult to achieve performance goals. MedStar has gathered data to better understand the needs of its employees and it is proposing raising the pay of staff to better match the market. These two activities will hopefully level of turnover. Management needs to redirect attention to building an organization that is attractive to work for and has long term sustainability.

An initial deployment plan created by the consultant team is included in the report. With input from stakeholders, the plans will bring the system into compliance without putting unnecessary workload on EMS crews, but it will require improved staffing.

Leadership and day-to-day management is essential to the success of the system, improving performance, and improving employee satisfaction. The Authority Board needs to evaluate the effectiveness and developmental level of the existing staff and make adjustments as necessary. An Associate Director position should be added to manage the day-to-day operations. Clear boundaries and process must be established between MedStar and EPAB.

The management team must transition from positional silos to a cohesive and integrated team. Some form of problem solving methodology must become part of their daily practice. A skilled process facilitator is likely needed to begin their development.

Ultimately, the system is repairable. With focused attention on the core business and clear direction, the system can perform at the levels expected and move out of its current state.

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Recommendations

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6. Schedule start/stop times options should be reviewed with field staff in order to achieve commitment that they are optimal. 7. The mathematical schedules tolerate only 5% absence. 8. Absenteeism should not be used as a crutch for non-performance. 9. System status report should include a high level scorecard (approximately six to ten measures) developed by the management team to allow quick appreciation for the system performance. The full system report adds context. 10. After action reviews (AAR) should return to multiple times per week and focus on noted processes cycle time issues and crew considerations con- currently with efforts to increase staffing. 11. AAR meetings should utilize an improvement methodology for process enhancement. 12. Frontline personnel and supervisors should be regularly engaged in AAR efforts. 13. MedStar should increase the training hours devoted to SSM in the new employee orientation and provide continuing education throughout the year to maintain competency and awareness. 14. The management team must foster a sense of urgency and focus on core business activities first.

MedStar EMS System Review 75 © Fitch & Associates, LLC Fort Worth, Texas May 23, 2008 AMR 04736

4. MedStar’s leadership team should learn how to read and interpret SPC charts. 5. The Authority needs to reestablish the boundaries of EPAB and Operations and rebuild the professional relationship and communications of the two leaders.

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3. The Executive Director should evaluate the current management team and its interactions and make adjustments to improve reporting, performance, and collaboration. Delegation to the management team is good if they are managed to ensure outcomes are achieved. 4. The Authority should continue efforts to design an Associate Director position and recruit and select a worthy candidate. 5. The leadership team should be encouraged to pursue and earn a minimum of undergraduate education. 6. The Authority should consider rotating leadership team members through the American Ambulance Association’s Ambulance Service Manager program and the National Academies of Emergency Dispatch Communications Center Manager program. 7. The skill sets and performance of existing managers (e.g., Operations Manager) should be evaluated and improvement plans or replacement should be initiated as appropriate. 8. The MedStar and EPAB management team should receive training in process improvement and be facilitated through applying it to a several improvement initiatives to develop foundational proficiency.

Lateral Benchmark Recommendation 1. MedStar should study why its cardiac arrest survival (ROSC at the ED) is lower than the majority of systems in the study.

Future Scenarios Recommendations 1. Not Applicable

MedStar EMS System Review 77 © Fitch & Associates, LLC Fort Worth, Texas May 23, 2008 AMR 04738

Appendix A

Demand Analysis Metropolitan Fort Worth, Texas AMR 04739

Appendix A

Consultant Report – Appendix A Demand Analysis Metropolitan Fort Worth, Texas

Table of Contents

REPORT ON VOLUME AND DISTRIBUTION FOR METROPOLITAN FORT WORTH, TEXAS ______1 VOLUME ______2 DISTRIBUTION OF THE DATA SET______2 COMPARING THE DISTRIBUTION ALONG DEMAND TYPE ______4 INTERVENTIONS PER YEAR ______6 INTERVENTIONS FOR MONTH______7 RESPONSE TIME CONSIDERATIONS ______10 URBAN VS. RURAL ANALYSIS ______11 ACTUAL PERFORMANCE ______15 SCHEDULES AND PERFORMANCE ______17 PERFORMANCE AS A VALUE OF DEMAND ______19 SCHEDULE______21 DEPLOYMENT/DEMAND ANALYSIS SUMMARY ______28

TABLE 1: CALL PRIORITY DEFINITIONS ______2 TABLE 2: INTERVENTIONS PER YEAR BY PRIORITIES ______2 TABLE 3: GROWTH IN CALL VOLUME ______7 TABLE 4: WEEKDAY PLAN: 1000-1500 ______13 TABLE 5: COMPARISON OF SYSTEM PERFORMANCE WITH AND WITHOUT OVERLOAD ______15 TABLE 6: NEEDS CALCULATION BASED ON 2007 HOURLY DATA______19 TABLE 7: SCHEDULE PATTERN ______22 TABLE 8: COMPARING SCHEDULES AGAINST ACTUAL ______24

FIGURE 1: DISTRIBUTION OF CALLS: 2005-2007 ______4 FIGURE 2: NUMBER OF INTERVENTIONS PER YEAR (2004-2010) ______6 FIGURE 3: NUMBER OF INTERVENTIONS PER MONTH (2004 – 2007)______8 FIGURE 4: AVERAGE NUMBER OF INTERVENTIONS PER DAY PER MONTH (2004-2007) ______9 FIGURE 5: AVERAGE NUMBER OF INTERVENTIONS BY DAY PER MONTH (2004-2006) ______9 FIGURE 6: URBAN VERSUS RURAL DEMAND: PRIORITY 1 - 5 ______11 FIGURE 7: MEDSTAR WEEKDAY 1000-1500 HRS, LEVEL 30 - 7 MINUTES ______14 FIGURE 8: RESPONSE TIME FROM UNIT ASSIGNED TO UNIT ARRIVED ON SCENE A ______16 FIGURE 9: RESPONSE TIME FROM UNIT ASSIGNED TO UNIT ARRIVED SCENE B______17 FIGURE 10: AMBULANCE REQUIRED FOR CALL VOLUME (BASED ON 2007 DATA) ______18 FIGURE 11: NUMBER OF AMBULANCES REQUIRED (BASED ON 2007 DATA) ______20 FIGURE 12: SCHEDULES AND DEMAND (SCENARIO FW2-V01: BASED ON 2007 DATA) ______23 FIGURE 13: 12-HOUR SCHEDULE AND PERFORMANCE ______25

MedStar i © Fitch & Associates, LLC Demand Analysis May 21, 2008 AMR 04740

Appendix A Report on Volume and Distribution for Metropolitan Fort Worth, Texas

Demand analyses are done in order to determine the different tendencies that are found within a system’s data set (datum). Demand has two distinct components:

1. The volume of activity; and 2. The requirement for performance.

In order to meet a specific performance standard, ambulances need to be fully available and placed strategically throughout a geographic area. Thus, demand is a combination of the ambulances required to meet the volume, plus the amount of ambulances required to meet the performance standard.

The first moment of demand, for the purposes of EMS, is the cumulative notion of volume. Volume in EMS encompasses multiple facets of activities, including: calls, unique incidences, transports, etc. The individual sum of these activities represents the volume of activities for the service. The temporal notion of demand is introduced when a volume of activity is divided by a denominator of time. The tendencies of the system are established through the observation of the temporal demand.

The second moment of EMS demand is the notion of performance. While it seems somewhat contradictory to speak about performance as a notion of demand, in reality, because it takes units (ambulances) to meet a performance standard, it needs to be considered within the system requirements (demand).

Therefore, demand is equal to volume plus performance. In the following sections, a quantitative analysis will be performed on the notions of both volume of activity and performance of the system.

MedStar 1 © Fitch & Associates, LLC Demand Analysis May 21, 2008 AMR 04741

Volume

Volume is most commonly attributed to total call volume. This normally encompasses calls for service, unique incidences, and transports. In this particular analysis, volume will be distributed over time in order to assess the tendencies and traits of the system. This will allow the data to become useful for the creation of schedules.

Distribution of the Data Set

The system has a series of different call priorities, which are defined in Table 1.

Table 1: Call Priority Definitions Priority Definitions 1 Highest priority call (commonly referred to as Echo and Delta) Less than or equal to 9:00 minutes response 2 2nd Highest priority call (commonly referred to as Charlie and Bravo) less than or equal to 11:00 response minutes 3 3rd Highest priority call (commonly referred to as Alpha) less than or equal to 15:00 minutes response 4 Transfer BLS and special duty 5 Transfer BLS and ALS

Each of the call priorities represents different call acuities and call volume is distributed across the five priorities. The sum of the call acuities volumes represents the total activity of the system. The distribution of the different priorities is also important to understand as it represents the level of life-threatening emergencies the system responds to and the amount of flexibility the system has. Table 2 shows interventions by priority and includes the call volume and the distribution.

Table 2: Interventions per Year by Priorities1 2004 2005 2006 2007 Priority Num % Num % Num % Num %

01 20,859 26% 21,142 25% 21,829 25% 23,696 25%

02 38,964 48% 40,930 48% 40,758 46% 43,530 46%

03 17,051 21% 18,574 22% 21,028 24% 22,563 24%

04 393 0% 353 0% 351 0% 503 1%

05 4,344 5% 4,089 5% 3,998 5% 3,603 4%

Total 81,611 100% 85,088 100% 87,964 100% 93,895 100%

1 Calls counted only once. Irrespective of amount of units assigned. MedStar 2 © Fitch & Associates, LLC Demand Analysis May 21, 2008 AMR 04742

Based on this data, a quarter of the systems require response within nine minutes from phone pickup and an additional 45% must be responded to within eleven minutes of phone pickup. That means that the system really has very little flexibility within its emergency call volume.

MedStar 3 © Fitch & Associates, LLC Demand Analysis May 21, 2008 AMR 04743

Comparing the Distribution along Demand Type

It is important to understand the distribution of call volume based on a loose notion of emergency calls because, as seen above, there is very little flexibility within the emergency calls. Non-emergency transfers and other category represent only five percent of total call volume. It is useful from two perspectives to first understand what the actual activity drivers are for the service, but also to see if the distribution is similar from year-to-year. Based on the previously discussed data, it would be expected to be.

Figure 1: Distribution of Calls: 2005-2007 2005 Distribution of Calls

5% 2%

Emergency Transfer Other Agency

93%

2006 Distribution of Calls

5% 1%

Emergency Transfer Other Agency

94%

MedStar 4 © Fitch & Associates, LLC Demand Analysis May 21, 2008 AMR 04744

2007 Distribution of Calls

5% 1%

Emergency Transfer Other Agency

94%

The three figures show there exists a large percentage of emergency calls within the system. Emergency calls represent about 94% of the activities. This is significant because the ebbs and flow of the emergency call volume dictate how the system behaves.

The other observable element is the existence of little variability from year-to-year in the distribution of the calls for service. This is important because the increases in the volume of activity represent proportional requirements for the need to increase staffing. This is due to the fact that limited control can be exerted to stay the tide of emergency call volume.

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Interventions per Year

As previously indicated, interventions per year are a good reflection of the system's overall growth. Due to the high prevalence of emergency calls (priorities one to three or Alphas to Echo in MPDS), interventions and emergency calls can be used interchangeably.

The system’s volume of activity has been growing annually, based upon existing growth, Figure 2 projects potential volume growth through 2010.

Figure 2: Number of Interventions per Year (2004-2010)

Interventions per Year

110,000

105,000

100,000

95,000

90,000 Projected Growth Numberof interventions

85,000

80,000

75,000 2004 2005 2006 2007 2008 2009 2010 Years

Interventions refer to unique calls (a unique call indicates that calls are counted only once irrespective of units assigned) with an arrival at scene. Calls with one unit assigned account for only one incident. Projections were based on a linear model represented in the formula that follows: y = 18.383x + 4626.2; R2 = 0.4226

The growth for the system is significant and consistent. This could be an issue as staffing will need to keep pace with growth in order to maintain performance. While the consultant observed some operational inefficiency (i.e. time on task) in different statistical data presented to him, the overall management of the system will only allow for limited optimization. Net new resourcing will need to be invested into the

MedStar 6 © Fitch & Associates, LLC Demand Analysis May 21, 2008 AMR 04746 system to keep pace with the growth. Table 3 shows projected growth in call volume through 2010.

Significant growth has been seen to date and significant growth is projected to continue at a pace of around four percent per year for the next couple of years. More significantly, somewhere between 2008 and 2009 the system will break the hundred thousand-call volume marker.

Table 3: Growth in Call Volume

Year Volume Percent growth from prior years

2004 81,611 0.00% 2005 85,088 4.26% 2006 87,964 3.38% 2007 93,895 6.74% 2008 97,901 4.27% 2009 102,040 4.23% 2010 106,179 4.06% Average 3.85% Note. The values in red are projected

Interventions for Month

Interventions per month represent the total monthly call volume. The key is to ob- serve the change of volume of activity from month to month. The more the variability, the harder it is to create schedules that will match the demand throughout the year.

There are two ways to look at variability:

1. Gross volume of activity per month; and 2. Smoothed out value (averaging activity per day per month).

MedStar 7 © Fitch & Associates, LLC Demand Analysis May 21, 2008 AMR 04747

Figure 3: Number of Interventions per Month (2004 – 2007)

Interventions per Month 8,500

8,000

7,500

7,000 Number of interventions

6,500

6,000 1 2 3 4 5 6 7 8 9 10 11 12 2007 7607 7288 7974 7924 8091 7972 8002 7988 7774 7972 7485 7818 2006 7208 6701 7156 7294 7638 7221 7519 7825 7383 7479 7019 7521 2005 7016 6896 7128 6913 7147 7185 7206 7378 7376 6965 6640 7238 2004 6621 6304 6998 6744 7085 6919 6981 6964 6801 7054 6316 6824 Month

In Figure 3, winter months have significantly less activity than the summer months. It can also be observed that by November of any year until March of the following year, the activity level is lower. This is consistent in 2004, 2005, 2006 and 2007. While in 2005, this notion is less pronounced, it is still nominally true. This is more accentuated when the smoothing principle is applied as can be seen in Figure 4.

A smoothing technique allows for a cleaner distribution of activity per month since it removes the variability in the month associated with additional days, weekends, holidays, etc. Using the 2007 year line, a moving average technique can be applied. A moving average technique simply means a line is drawn using the point before and the point after.

When applying a moving average, it is seen beginning in April that the average call volume is approximately 260 calls per day. This holds true until September (using a round up at 257.5). It is also notable that between the months of May and July there is a significant probability that the call volume per day will exceed 260 calls. Thus, it is concluded that at least three different patterns exist in demand:

1. November – March; with an average activity per day of less than 250. 2. May – July; with an activity pattern of greater than 260 calls per day. 3. All other months that lie between 250 and 260 calls a day.

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These patterns are critically important for scheduling considerations. This is difficult to manage as most people take vacations during the summer months. It will require management to be proactive in the search for solutions, including casual staffing, part time members, and contracting.

Figure 4: Average Number of Interventions per Day per Month (2004-2007)

Average Number of Interventions by Day per Month

280

270 Trend line

260

250

240

230

220

Number of interventions 210

200 1 2 3 4 5 6 7 8 9 10 11 12 2007 245 260 257 264 261 266 258 258 259 257 250 252 2006 233 239 231 243 246 241 243 252 246 241 234 243 2005 226 246 230 230 231 240 232 238 246 225 221 233 2004 214 217 226 225 229 231 225 225 227 228 211 220 Month

It is easiest to see the repetitive patterns and system growth when they are combined on a singular figure and it allows the reader to see the significant challenges that the system faces both annually and over time.

Figure 5: Average Number of Interventions by Day per Month (2004-2006)

Average Number of Interventions by Day per Month

280

260

240

Number of interventions 220

200

1 2 3 4 5 6 7 8 9 1 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 0 10 1 12 10 11 12 10 11 12 1 11 12 2004 2005 2006 2007 Month MedStar 9 © Fitch & Associates, LLC Demand Analysis May 21, 2008 AMR 04749

Response Time Considerations

Response times are a factor of the amount of vehicles (ambulances) required at a specific geographic location for a specific period of time in order to meet a set performance standard. This can be observed through data or simulated using computerized modeling. A computerized modeling process was used in the analysis of metropolitan Fort Worth. This was done, because the necessary statistical elements were not present in the data set in order to properly evaluate response time versus observed available units. (This requires that available units be tracked as an independent status; this is something the service should consider in the future).

Computerized modeling has some significant advantages; primarily it requires significantly less data in order to properly determine the amount of required vehicles on standby in order to achieve desired response time metrics. It allows the evaluation to be done using a deployment analysis and, as such, generates the required response plans. The disadvantage to using computerized modeling is that many of the parameters are set according to the analyst's evaluation. In other words, road network speed, driving conditions, rate of travel, etc. are left to the discretion of the analyst.

MedStar 10 © Fitch & Associates, LLC Demand Analysis May 21, 2008 AMR 04750

Urban vs. Rural Analysis

Urban versus rural analysis was designed to allow an apples-to-apples comparator when measuring different systems throughout the world. The traditional urban distribution is done through urban planning. The problem with that method is that urban planning is a function of convention and is usually bound from country to country and sometimes from state to state.

Fitch & Associates designed a modeling system in order to establish a more univer- sally applicable metric of urban to rural distribution in EMS. The FITCH model uses call volume as the standard of measurement. An urban call volume is established at two calls per kilometer with at least half the adjacent kilometers having an equivalent value. When this rule is applied to the Fort Worth data set, it generates the map in Figure 6.

Figure 6: Urban versus Rural Demand: Priority 1 - 5

The urban EMS volume is concentrated in a small geographic area with small pockets of urban call density distributed throughout the rest of Fort Worth. The EMS leadership in Fort Worth has recognized this because they have distributed ambulances to geographic locations even though the call volume would not justify the positioning of ambulances to those locations.

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Using the urban and rural distribution created by the computer simulator, we are able to create deployment plans and strategies that ebb and flow with the different hourly demand patterns. In order to maximize the benefits of deployment plans, deployment strategies need to be shared and understood by the many, not the few. It is in the sharing of the deployment strategies that the maximum effect and benefit is achieved amongst the generalized paramedic population. The biggest challenge to the service is that the deployment plan does not appear like ‘voodoo magic.’ If the paramedics are not engaged in the development of the solution until after the deployment plan has been implemented, then paramedics will ensure its failure.

A sample plan or strategy is set out in Table 4. Aall deployment plans that are required to maximize the efficiency of the system are presented in Annex 1. It is strongly recommended that the deployment plans be reviewed by staff for both the final location of the post and for acceptance or agreement that this is really is the optimal plan (optimal refers to a plan that meets both the system performance requirements and the human factors).

As Figure 7 reflects, a total of 12 Posts are required to supply coverage of 90% of the total demand. This means that between 1000 and 1500 hours, the primary 12 posts must be continually covered in order to meet response time compliance.

A few rational steps need to be followed prior to implementation of the scenario. The first and most important discussion includes the paramedics and seeks to reach agreement on how maximum coverage is achieved. Until this has occurred, no commitment will exist and strong resistance from the paramedics will be encountered while attempting to cover these 12 Posts. One obvious trade-off is that this plan suggests significantly less posting plans than originally suggested by an earlier consultant’s deployment plan. The hope is that by reducing the posting plan, the posting plan becomes intuitive. This is still going to represent a significant challenge because, today, a singular plan exists. It will require a proper implementation strategy to achieve success.

One of the things that will become quickly apparent when reviewing all the posting plans is that the service pivots around the 12 posts; so achieving a consensus for every hour of the day on these 12 Posts is crucial. The service has many occasions that more than twelve ambulances are available for post coverage; these posts should be negotiated in order to have maximum field commitment to the post plan. The nominal number of 12 is carried forward in the creation of schedules.

MedStar 12 © Fitch & Associates, LLC Demand Analysis May 21, 2008 AMR 04752

Table 4: Weekday Plan: 1000-1500

RANK NAME LATITUDE LONGITUDE RAWCNT RAWPCT COUNT PERCENT SUBTOTAL RUNNINGPCT TYPE

1 77W 32.712137 -97.320514 21045 23.50% 21045 23.50% 21045 23.50% LOAD

2 74A 32.749677 -97.434287 12042 13.50% 11891 13.30% 32936 36.90% LOAD

3 89Q 32.674803 -97.381162 10219 11.40% 9647 10.80% 42583 47.60% LOAD

4 80A 32.746075 -97.216279 9480 10.60% 9480 10.60% 52063 58.30% LOAD

5 62G 32.795248 -97.349094 8948 10.00% 6410 7.20% 58473 65.40% LOAD

6 78T 32.713278 -97.279919 17382 19.40% 5497 6.20% 63970 71.60% LOAD

7 50E 32.839624 -97.290477 6354 7.10% 4664 5.20% 68634 76.80% LOAD

8 119T 32.563126 -97.317798 3288 3.70% 3238 3.60% 71872 80.40% LOAD

9 75M 32.7326 -97.369958 19785 22.10% 2492 2.80% 74364 83.20% LOAD

10 46V 32.813448 -97.411911 6146 6.90% 2422 2.70% 76786 85.90% LOAD

11 92T 32.661849 -97.281282 6867 7.70% 2299 2.60% 79085 88.50% LOAD

12 65E 32.788574 -97.256458 5810 6.50% 1524 1.70% 80609 90.20% LOAD

13 103H 32.634945 -97.369746 4076 4.60% 1144 1.30% 81753 91.50% LOAD

14 59S 32.76599 -97.477355 6249 7.00% 1093 1.20% 82846 92.70% LOAD

15 21X 32.914552 -97.317059 1678 1.90% 1073 1.20% 83919 93.90% GEOGRAPHIC

16 55T 32.816691 -97.099684 960 1.10% 960 1.10% 84879 95.00% GEOGRAPHIC

17 33L 32.880821 -97.381687 1625 1.80% 902 1.00% 85781 96.00% LOAD

18 66N 32.778333 -97.212215 6386 7.10% 558 0.60% 86339 96.60% LOAD

19 7U 32.972304 -97.308868 950 1.10% 498 0.60% 86837 97.20% LOAD

20 118AQ 32.520788 -97.348214 2275 2.50% 282 0.30% 87119 97.50% LOAD

21 76W 32.706145 -97.360406 8576 9.60% 245 0.30% 87364 97.80% LOAD

22 56U 32.819314 -97.050256 956 1.10% 201 0.20% 87565 98.00% LOAD

23 45N 32.826365 -97.480089 1644 1.80% 180 0.20% 87745 98.20% LOAD

24 32T 32.870203 -97.426012 1754 2.00% 174 0.20% 87919 98.40% LOAD

25 93T 32.665856 -97.242149 5709 6.40% 144 0.20% 88063 98.50% LOAD

26 88H 32.688933 -97.412384 8625 9.70% 143 0.20% 88206 98.70% LOAD

27 62T 32.768739 -97.356751 16738 18.70% 142 0.20% 88348 98.90% LOAD

28 36E 32.893882 -97.289631 2023 2.30% 114 0.10% 88462 99.00% LOAD

29 119AB 32.543902 -97.314361 3076 3.40% 110 0.10% 88572 99.10% LOAD

30 64Z 32.758705 -97.261722 17314 19.40% 103 0.10% 88675 99.20% LOAD

MedStar 13 © Fitch & Associates, LLC Demand Analysis May 21, 2008 AMR 04753

Figure 7: MedStar Weekday 1000-1500 hrs, Level 30 - 7 Minutes2

2 The geographic posts were established manually from Fort worth existing list of 116 potential posts because a strictly load-based analysis left the peripheral areas uncovered and concentrated posts into the core area (mostly inside the Loop expressways). Two of the geographic posts (21X and 55T) fall within rural polygons, but were selected because of their access into the peripheral urban loaded areas. MedStar 14 © Fitch & Associates, LLC Demand Analysis May 21, 2008 AMR 04754

Actual Performance

MedStar produces statistics on the service performance regularly; it does so with both diligence and honesty. Included in the existing performance evaluation standards (goals) is a double exclusionary rule called overload. Overload is a statistical correction based on the prior week's challenges. The harder the challenges from the prior weeks, the lesser the performance requirements for the weeks that follow. This is somewhat misleading and is a result of MedStar continuing with a provision that had been part of the original contract with a private provider. While the measure does not accurately reflect actual performance, MedStar is just following the letter of the rules.

As can be seen in Table 5, there is a significant difference in the system performance when the overload rule is applied and when it is not. This percentage difference is significant and cannot be absorbed by the system as it presently stands (the services primary challenge is the inability to fill all the current schedules and thus not matching supply and demand). Overload allows the system to compensate for its chronic absenteeism.

Table 5: Comparison of System Performance with and without Overload

Compliance Jul-2007 Aug-2007 Sep-2007 Oct-2007 Nov-2007 Dec-2007 Jan-2008 Feb-2008

With Overload 83.60% 79.30% 81.60% 88.40% 89.60% 88.60% 87.20% 87.00%

Without Overload 78.30% 74.50% 72.10% 83.50% 85.30% 83.70% 80.20% 79.60%

Difference -5.30% -4.80% -9.50% -4.90% -4.30% -4.90% -7.00% -7.40%

Note: Data provided by the client and not independently validated.

The best way to understand what the overload formula does is to understand that the overload formula is based on standard deviation.

The actual methodology for calculating system overload is that at the start of each quarter (Jan, Apr, Jul, Oct), the service take the previous 20 weeks worth of data then calculate 1.5 STDEV rounded up to the next integer. Our active calls, and those waiting to be dispatched, must exceed that overload calculation in order to be ex- empted.

That means that every call that exceeded the standard deviation of the prior cycle or period helps in establishing the next cycle’s response time performance. (This is lik- ened to the application of a bell curve to normalize school grades).

MedStar 15 © Fitch & Associates, LLC Demand Analysis May 21, 2008 AMR 04755

Figure 8: Response Time from Unit Assigned to Unit Arrived on Scene A

Response Time from Unit Assigned to Unit Arrived on Scene

16.0

14.0

12.0

10.0

8.0 90th percentile 6.0 Response TimeResponse (minutes)

4.0

2.0

0.0

000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000 3030303030303030303030330303030303303030303030303030303030303030303303030303033030303030303030303030303030303030303030330303030303303030303030303030303303030303033030303030303030303030303030303030303030330303030303303030303030303030303303030303033030303030303030303030303030303030303030330303030303303030303030303030303030 01234567891011121314151617181920212223012345678910111213141516171819202122230123456789101112131415161718192021222301234567891011121314151617181920212223012345678910111213141516171819202122230123456789101112131415161718192021222301234567891011121314151617181920212223

1 2 3 4 5 6 7 Weekday

90th percentile Average Linear (90th percentile) Linear (Average)

When looking at Figure 8, two lines are drawn; the first (pink) represents the average response time in half-hour intervals for a week and the second represents the 90th percentile response time for the same week. Drawing a straight line (linear) across both the average and at the 90th percentile, it can be observed that there are approximately four minutes between the two and this remains constant throughout. If the artifact that is above the line at the 90th percentile was used to accommodate the following day’s calls response time, the result would be an artificially push down of response times. The more artifact above the line, the more it forces the line down. This effect is called the polynomial effect. Figure 9 demonstrates this phenomenon.

MedStar 16 © Fitch & Associates, LLC Demand Analysis May 21, 2008 AMR 04756

Figure 9: Response Time from Unit Assigned to Unit Arrived Scene B

Response Time from Unit Assigned to Unit Arrived on Scene

16.0

14.0

12.0

10.0

8.0 90th percentile 6.0 Response TimeResponse (minutes)

4.0

2.0

0.0

000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000 3030303030303030303030303033030303030303030303030303030303030303030330303030303303030303030303030303030303030303303030303033030303030303030303030303030330303030303303030303030303030303030303030303030303030303030303030303030303030303030303303030303033030303030303030303030303030303030303030330303030303303030303030303030303030 01234567891011121314151617181920212223012345678910111213141516171819202122230123456789101112131415161718192021222301234567891011121314151617181920212223012345678910111213141516171819202122230123456789101112131415161718192021222301234567891011121314151617181920212223

1 2 3 4 5 6 7 Weekday

90th percentile Average Poly. (90th percentile) Linear (Average)

The effect that this creates is that the 90th percentile is situated between 10 minutes and 11 minutes, with the vast majority of days being below 11 minutes. If this is compared with the linear trend line in Figure 8, one can see that the linear trend line sits constantly at 11 minutes. The net effect of applying the overload formula (bell curve effect) is approximately 45 seconds at the 90th percentile (the services true 90th percentile response is approximately 45 seconds slower than reported).

The consultants were asked to design a system without considering the overload. It should be noted that with FITCH designs system, it also does not consider overload. A significant issue (staffing of ambulances due to absenteeism) still remains. Thus, the scheduled ambulances on the road are rarely achieved and as such the service is constantly working understaffed.

Schedules and Performance

Using all the information discussed above, we can begin to look at schedules. The consultants created schedules based on the optimal mathematical outcome, as such, all schedules in this report should be considered as samples and not as readily applicable. This is not the recommended methodology since schedules that are created in a vacuum do not have the required commitment of the staff that will work them. Schedule ergonomics are predominately about employee acceptance; while some best practices can be applied at the end of the path, each individual service lives

MedStar 17 © Fitch & Associates, LLC Demand Analysis May 21, 2008 AMR 04757 their own natural realities and must create schedules that deal with these situations elegantly.

The first phase is to revisit the nominal notion of demand. As stated earlier, demand is the sum of call volume for specific periods of time and the required amount of ambulances to manage the required performance. For MedStar, the amount of ambulances required to meet the demand are demonstrated in Figure 10.

Figure 10: Ambulance Required for Call Volume (Based on 2007 Data)

Ambulances Required for Call Volume based on 2007 data

10 Numberambulance ofintervention on

1 2 3 4 5 6 7 Weekday

Average 90th percentile call volume Maximum

It is important to note that call volume, as it pertains to schedules, is a management of risk. In Figure 10, there are three distinct patterns:

1. The lowest line value is the average amount of calls for given days in a week. Assuming that the average and the midpoint are similar (they're not exactly the same but relatively close), then if one covered that demand (average demand), 50% of the days would be covered and 50% of the days would not. 2. The green line represents 90% of the demand. If one chose to cover that call volume demand, then 90% of the days would be covered and 10% would not. 3. Finally, the scatter blue dots represent the maximum call volume for given hours over the week. If the service chose to cover that margin, then it would be attempting to cover 100% of the call volume. This would be both expensive and not useful. It should be understood that, while this line can be graphically represented, it is not a true representation of any one given day and a margin of error would still exist.

MedStar 18 © Fitch & Associates, LLC Demand Analysis May 21, 2008 AMR 04758

Performance as a Value of Demand

As discussed earlier, there are many ways to interpret or evaluate the performance of the system. The consultants chose to simulate the system performance using computer modeling. In the performance section, it was determined that 12 ambulances were required to meet the urban and rural response time criteria’s and accommodate some geographic posts. When these 12 ambulances are introduced into the equation, a total required amount of ambulances for the system could be calculated. Table 6 reflects a sample calculation. (The performance is based on achieving a 90th percentile response time for Priority one calls, the drive time is set at seven minutes assuming a two minute internal time).

Table 6: Needs Calculation based on 2007 Hourly Data Expected 12 Variables number of vehicle for coverage Modulation 5% buffer

Weekday Hour Half Number of vehicles on interventions statis- Needs in vehicles hour tics Average Standard Minimum Maximum Initial Moving Estimation deviation average 1 0 0 8.48 3.09 2 16 21.50 14.26 14 30 8.25 2.39 4 14 21.26 21.31 21 1 0 8.15 2.10 4 13 21.16 20.99 21 30 7.58 2.67 3 14 20.56 20.62 21 2 0 7.17 3.12 1 16 20.13 20.37 20 30 7.44 2.87 1 14 20.41 20.15 20 3 0 6.94 3.04 - 16 19.89 19.87 20 30 6.38 2.23 2 11 19.30 19.48 19 4 0 6.33 2.26 2 12 19.24 19.08 19 30 5.81 2.42 1 12 18.70 18.58 19 5 0 4.96 2.31 1 11 17.81 17.93 18 30 4.46 1.86 1 9 17.28 17.37 17 6 0 4.19 1.84 1 10 17.00 17.06 17 30 4.08 1.88 - 8 16.88 17.02 17 7 0 4.37 1.70 1 8 17.18 17.42 17 30 5.33 2.23 1 12 18.19 18.01 18 8 0 5.77 2.79 - 12 18.66 18.66 19 30 6.23 2.89 - 14 19.14 19.20 19 9 0 6.85 2.66 1 15 19.79 19.71 20 30 7.25 2.36 3 12 20.21 20.25 20 10 0 7.77 2.62 3 13 20.76 20.85 21 30 8.56 3.10 3 16 21.59 21.59 22 11 0 9.35 3.78 2 17 22.41 22.40 22 30 10.10 3.52 2 17 23.20 22.92 23

MedStar 19 © Fitch & Associates, LLC Demand Analysis May 21, 2008 AMR 04759

The consultant uses a methodology that takes into consideration the floating point averages of a half hour prior to the actual activity, the half-hour of the activity, and the following half-hour of activity. This allows for the reduction of the artifact or spike in a particular half-hour of activity and enables you to establish the required number of ambulance needed to cover the system by adding the 12 vehicles on standby to the call volume (or activity). An additional five percent was built in as a buffer for absenteeism. The result is demonstrated graphically in Figure 11.

Figure 11: Number of Ambulances Required (Based on 2007 Data)

Ambulances Required for the System based on 2007 data 30

5 Number of ambulance required Numberof

1 2 3 4 5 6 7 Weekday

Average Needs in vehicles Maximum

By combining both the call volume and vehicles required for performance, the system could cover even the most demanding days. (Clearly schedules that are set to this level of demand will need to be covered. The margin of error built into the demand is 5%, and in this case that represents less than five people per 24 hour).

MedStar 20 © Fitch & Associates, LLC Demand Analysis May 21, 2008 AMR 04760

Schedule

Schedules represent the ability of the service to meet the demand in the most effective and efficient manner possible. The more the recommendations of this report are achieved or the smoother the demand can be made, the easier and more effective schedules can be made to fit the demand.

FITCH uses a computer algorithm to test which schedules would best meet the demand. Two different patterns of schedules were used:

1. An all 12-hour pattern with lunch scheduled at the midpoint, or approximate midpoint, with a value of 45 minutes of uninterrupted time. 2. A combination of 12 hour, 8 hour, and weekend only schedule.

The schedules are presented in Annex 2. Because the second type of combination schedule is difficult to achieve without employee negotiation, it is annexed to the report.

Table 7 reflects the schedule patterns.

MedStar 21 © Fitch & Associates, LLC Demand Analysis May 21, 2008 AMR 04761

Table 7: Schedule Pattern Pattern 1 -1 1 -2 1 -3 1 -4 1 -5 1 -6 1 -7 2 -1 2 -2 2 -3 2 -4 2 -5 2 -6 2 -7 type 0414 W W W W 0714 W W W W W W W W W W W W W W 1014 W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W Note: 4/14 represents weekend schedules; 7/14 represents 12-hour schedule; 10/14 represents 8-hour schedules.

Using the 12-hour schedules and the optimizer, schedules can be matched with the demand and evaluated for efficiencies.

MedStar 22 © Fitch & Associates, LLC Demand Analysis May 21, 2008 AMR 04762

Figure 12: Schedules and Demand (Scenario FW2-V01: Based on 2007 Data)

Schedules and Demand 30 Scenario FW2_V01 based on 2007 data

25 Numberambulancesof 20

1 2 3 4 5 6 7 Weekday Scheduled Vehicles Vehicles in Service (Vehicles scheduled - breaks) Demand

There are three lines on the graph above. The blue line represents the demand (the call volume plus vehicles required to meet performance); the red line represents the amount of resources that are scheduled; and the purple line represents the scheduled ambulance minus the scheduled break. Note that the schedules perform quite well during the week when the supply and demand are very close. On the weekends, the schedules have too many resources available. This is not necessarily a bad situation, as weekends are when absenteeism is at its highest in most systems.

The Table 8 assumes the efficiency of the different schedules in terms of vehicle hours worked. The combination schedule is the most efficient schedule as it allows for a $50,000 per year savings and allows for planned lunches to be accommodated. The all 12-hour schedule costs an additional $265,000 per year and it also accom- modates the midpoint lunch break and meets the demand. As discussed earlier, the schedule has an additional advantage of having excess capacity on the weekend so additional time off can be given to staff on the weekend.

MedStar 23 © Fitch & Associates, LLC Demand Analysis May 21, 2008 AMR 04763

Table 8: Comparing Schedules against Actual Schedules scenarios Combination All 12 hour Schedules model Actual FW1 FW2 Schedules version Actual V01 V01

Demand

ALL Standby vehicles ALL Modulation buffer ? 5% 5% ALL Demand (vehicles hours/week) 3,682 3,682 3,682 ALL Demand (thousand of vehicles hours/year) 192 192 192

Scheduled Hours/Costs

ALL Paid hours (vehicles hours/week) 4,032 4,016 4,125 ALL Paid hours (thousand of vehicles hours/year) 210 209 215

ALL Labor cost ($/week) $219,186 $218,289 $224,260

Cost reduction($ per week<) 0 897 -5,074 Cost reduction($ per year) 0 46,751 -264,577 Cost reduction (%) 0% 0% -2%

Reduction ALL hours (vehicles hours/week) - 16 93 - Reduction ALL hours (%) 0% 0% -2%

Payroll

0414 9 0 0714 96 82 104 1014 17 0

Full time employee on payroll 96 99 104 Part time employee for weekend 0 9 0

Total number of employees 192 216 208

Vehicles

Minimum number of vehicles 33 34 33

MedStar 24 © Fitch & Associates, LLC Demand Analysis May 21, 2008 AMR 04764

Evaluation

Differential (vehicles hours/week) 0 -16 93 Differential (thousand of vehicles hours/year) 0 -1 5

Schedule inefficiency N/A 9% 12% Total compensation Paramedic (ALS) $54

Figure 13: 12-Hour Schedule and Performance

MedStar 25 © Fitch & Associates, LLC Demand Analysis May 21, 2008 AMR 04765

MedStar 26 © Fitch & Associates, LLC Demand Analysis May 21, 2008 AMR 04766

MedStar 27 © Fitch & Associates, LLC Demand Analysis May 21, 2008 AMR 04767

Deployment/Demand Analysis Summary

The following is a summary of the key consultant findings resulting from the analysis of the volume and demand that exists in the metropolitan Fort Worth EMS system.

1. A quarter of the system’s calls have to be responded to within 9 minutes from phone pickup. An additional 45% have to be responded to within 13 minutes of phone pickup. The system has very little flexibility within its emergency call volume. 2. Transfers and the other category represent only 5% of the total call volume. 3. Emergency calls represent about 94% of the activities. This is very significant because the ebbs and flow of the emergency call volume will dictate how the system behaves. 4. There exists little variability from year-to-year on the distribution of calls for service. In the three years of data, emergency calls represented 94% to 95% of total call volume. 5. Call volume growth is approximately 4.0% per year. 6. Somewhere between 2008 and 2009, the system will break the hundred thousand-call volume marker. 7. Winter months have significantly less activity than the summer months. It can be observed that by November of any year until March of the following year, the activity level is lower. This is consistent in 2004, 2005, 2006 and 2007. While in 2005 this notion is less pronounced, it is still nominally true. 8. At least three different patterns exist in demand: a. From November to March, with an average activity per day of less than 250. b. From May until July, with an activity pattern of greater than 260 calls per day. c. All other months lie between 250 and 260 calls a day. Schedul- ing needs to be considerate of these patterns. 9. The urban EMS volume is concentrated in a small geographic area with small pockets of urban call density distributed throughout the rest of Fort Worth. The EMS leadership in Fort Worth has recognized this because they have distributed ambulances to geographic locations even though the call volume would not justify the positioning of ambulances to those locations. 10. Twelve posts are required to supply coverage of 90% of the total demand. During the hours of 1000 and 1500 hours, the primary 12 posts must be continually covered in order to meet response time compliance. 11. It is strongly recommended that the deployment plans be reviewed by frontline and management staff for both final location of the post and for acceptance or agreement that this is really the optimal plan.

MedStar 28 © Fitch & Associates, LLC Demand Analysis May 21, 2008 AMR 04768

12. MedStar produces statistics on the service performance regularly. It does so with both diligence and honesty. The service has a contract that uses a double exclusionary rule called overload. Overload is a statistical correction based on the prior week's challenges. The harder the challenges from the prior weeks, the lesser the performance requirements for the weeks that follow. 13. The effect overload creates is that the 90th percentile is situated between 10 minutes and 11 minutes with the vast majority of days being below 11 minutes. If this is compared with the linear trend line, one can see that the linear trend line sits constantly at 11 minutes. The net effect of applying the overload formula is approximately 45 seconds mathematical saving at the 90th percentile. 14. Schedules and performance are set at 90% of system compliance. 15. Two types of schedules were run; one using 12-hour schedules only and the other a blended schedule of 8-hour, 12-hour and a weekend only schedule 16. The blended schedule can accommodate effectively both the operational demand and the desire to give scheduled lunches to paramedics and save the service approximately $50,000 per year. 17. The entirely 12-hour schedule cost approximately $256,000 per year more than is currently being spent; it has the advantage of having additional weekend staffing so that absences on the weekend can be accommodated. 18. Schedule start/stop times should be negotiated with field staff in order to achieve commitments that are optimal. 19. The system was evaluated as a singular system, while the posting plans will yield the appropriate response for each community. It is recommended that a discussion occur between the parties to reduce the amount of points of evaluation. This will allow the service to manage peak call volumes more effectively and thus realistically allowing them to migrate from the overload formula to a more representative model of reporting performance.

MedStar 29 © Fitch & Associates, LLC Demand Analysis May 21, 2008 AMR 04769

Appendix B

MedStar Employee Survey Results Print Survey Page 1 of 5 AMR 04770

1. Generational View: Please select the range that includes the year you were born. (Select one option)

Before 1940

1940 to 1960

1960 to 1980

1980 to 2000

2. Gender View: Are you male or female? (Select one option)

Female

Male

3. Diversity View: The best description of your race/ethnicity is: (Select one option)

American Indian or Alaskan Native or First Nations People

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White or Caucasian

4. Education Level View: The highest level of non-EMS certification education earned is: (Select one option)

High School Graduate/GED

College Course Work

Associate's Degree

http://research.zarca.com/zprint/print_survey.aspx?cno=5472&sid=7&recno=0 5/13/2008 Print Survey Page 2 of 5 AMR 04771

Bachelor's Degree

Master's Degree

Other (please specify) ______

5. Certification: The highest level of EMS certification earned is: (Select one option)

Not Applicable

Emergency Medical Dispatch

First Responder

Emergency Medical Technician

EMT-Intermediate

EMT-Paramedic

Registered Nurse

Physician Assistant

Physician

Other (please specify) ______

6. Tenure View: I have worked at this organization for: (Select one option)

Less than a year

1 to 2 years

3 to 5 years

5 to 10 years

10 to 15 years

15 to 20 years

Greater than 20 years

7. Organizational View: I would classify my position as being... (Select one option)

Field Staff

Communications Staff

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Supply/Logistics Staff

Billing/Business Staff

Support Staff

Fleet Staff

Frontline/Middle Management

Upper/Executive Administration

EPAB

Other (please specify) ______

8. In every organization, something works and works really well. From your perspective, describe three examples of things that are working really well at Medstar?

______

[Please try to consider actions in addition to/other than adding resources and personnel]

______

[Please try to consider actions in addition to/other than increasing pay and/or benefits]

______

12. How long do you plan to remain employed at Medstar? (Select one option)

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Less than 3 months

3-6 months

6- 12 months

12-18 months

I’m in it for the long haul

13. What’s one thing that would result in you deciding to terminate your employment at Medstar?

______

Strongly Agree

Agree

Disagree

Strongly Disagree

15. What did the Whitney Smith Company, Inc survey not ask you that you wish it had? What would your response to the question(s) have been?

______

http://research.zarca.com/zprint/print_survey.aspx?cno=5472&sid=7&recno=0 5/13/2008 Print Survey Page 5 of 5 AMR 04774

After 80,000 in-depth interviews with employees in over 400 companies, the Gallup Organization says that measuring the strength of a workplace can be simplified to these questions. Please respond for you in your organization.

18. Select Yes or No Yes No (a) Do I know what is expected of me at work? (Select one option) (b) Do I have the materials and equipment I need to do my work right? (Select one option) (c) At work, do I have the opportunity to do what I do best every day? (Select one option) (d) In the last seven days, have I received recognition or praise for doing good work? (Select one option) (e) Does my supervisor, or someone at work, seem to care about me as a person? (Select one option) (f) Is there someone at work who encourages my development? (Select one option) (g) At work, do my opinions seem to count? (Select one option) (h) Does the mission/purpose of my company make me feel my job is important? (Select one option) (i) Are my co-workers committed to doing quality work? (Select one option) (j) Do I have a best friend at work? (Select one option) (k) In the last six months, has someone at work talked to me about my progress? (Select one option) (l) This last year, have I had opportunities at work to learn and grow? (Select one option)

19. What question(s) have we not asked you in this survey that you wish we had? What would you have shared in response?

______

http://research.zarca.com/zprint/print_survey.aspx?cno=5472&sid=7&recno=0 5/13/2008 AMR 04775

Appendix B – MedStar Employee Survey Results Question 8

8. In every organization, something works and works really well. From your perspective, describe three examples of things that are working really well at MedStar? 1 getting the new hires trained, transitioning them into their own shift and shift bids 2 Limited to just three things, I would say the business office, human resources department, and supply department work well. 3 The Lead Secondary Paramedic program works well when the candidates actually get the opportunity to advance to Primary status. The supply department works really well with the exception of having to wait to turn in your stuff at the end of your shift, but you have to wait for crews that are coming on duty to get their stuff....so you could wait 20-30 minutes at the end of your shift, to go home. I can't think of a 3rd "thing" that works really well at MedStar. 4 1. MedStar is excellent at billing / collections. 2. Education is top notch. 3. Sorry, I can only think of two things that work really well. 5 Billing ... they keep what little money we get coming in. Medical Records ... ensures that documentation is complete and accurate. Diployment ... founded on strong statistical information the system works when enough staff is available to operate. 6 I believe the supply department is working really well. I think the manager has come in and reshapped the way Medstar has done things in that department for years. I think he is a proven leader and has made things easier on the field and better for the company. I think EPAB doing our CE's and being more involved in our education now has taking our clinical knowledge to a new level and had acually started to do something clinicly something we have not had for years. I have thought long and hard and really cant come up with 3 good things at this comapany things are in a mess to bad. 7 Good Patient care Good Supply of trucks Good Training opportunitys 8 9 1. The supply department. This department has reduced the workload of the field medics to the bare minimum. This helps expedite trucks to go available at the start of the shift. 2. The maintenance department. They do a tremendous job keeping a worn out fleet response ready. 3. EPAB - Emergency Phyisican Advisory Board - They're great supporters of the field. 10 The Supply Department has done a complete 180 since I have started. For the most part they do a great job daily. EPAB has done a great job at expanding the protocols and have done a great job with clinical training. If I had it my way the clinical department would be encapsulated by EPAB and be one department. I believe this would make the current clinical department function more efficiently. I also believe the billing department does a great job. I do realize they all work very hard to assure we keep the doors open. I have heard they feel they are micromanaged but they must do a pretty good job because they don't have the turnover that the field has. Overall they do a great job and are very structured. I'm somewhat jealous that our department isn't more like them. 11 1. Our supply department does very well and has come a long way. 2. Our fleet department is very dependable and does very well with what they have to deal with as far as units that are being ran 24/7. 3. Our billing/Hr department is very dependable and does a great job taking care of our employees from their side. 12 I can only think of one thing that works really well, and that is my partner. 13 1 ce's provided by epab 2 supply dept inventoring our trucks 3 if something needs to be looked at on the trucks, someone is there during the day to take care of it. 14 1. Management has been trying to improve the pay scale for field employees, even though there is limited funds because of poor support from the city politicians. 2. We have a good health plan. It could be better, but it's better than some companies. 3. 401K is very good.

15 Continuing education, the new revamp of supply, and maintenance..

MedStar EMS System Review Page 1 © Fitch & Associates, LLC Fort Worth, TX May 14, 2008 AMR 04776

Appendix B – MedStar Employee Survey Results Question 8

8. In every organization, something works and works really well. From your perspective, describe three examples of things that are working really well at MedStar? 16 1. Utilization of MedStar 95 for mobile field supply to keep trucks from having to clear to post 4 for stock 2. Ease of access to management (especially operations director) who I know personally is only a phone call away 17 Overtime Accesability, 24 Hr Shift creation, more interaction of some of the Supervisory staff. 18 EPAB has done and continues to do an excellent job at maintaing medical direction for MedStar. The field crews that continously work insane amounts of hours to take care of the citzens of our service area function at the highest level of professionalism. Fleet has always maintained our vehicles well. 19 First, I think the relationships between field personel is what keeps us from going crazy. not field personel and management but others on the same pay grade. Second medstar is very good at empty promises. the empty promises that things will get better. fitch already did one survey last year and what has changed since that went to the city. absoluty nothing. this whole survey thing in my opinion is a joke as nothing ever gets done. what did management do after the last report done by fitch. they went to leadership training. What the hell good is that going to do. jack is still here running things. all the managers are still in office as they were before. a buisness cant make huge noticable changes without changing the people that run the ship starting with the captain. medstar does not take this seriously other than thinking of ways to pad numbers(compliance) so why should I. 20 protocols epab field supervisors 21 everybody working as a team. Although it's hard to in EMS because of scheduling conflicts. 22 The bonuses are great for open shifts. It really is an incentive to work extra time. The new trucks are also nice, as the older ones are not always working properly. The addition of new equipment for patient care is also nice. 23 The field crews work together, we are always looking out for each other, and taking care of ech other. Thats about all ive got. 24 25 The pay is going up, the ambulances are newer and more ergonomic, the protocols are more trusting in paramedic knowledge of when to use a drug without calling for orders. 26 The Paging system when supervisors want to get in contact with us or when shifts are needing to be coverd Plenty of card classes offerd for all the employees. EPAB seems to also be working really well. IM sorry Im not trying to be difficut and Im really not trying to be mean but I cant for the life of me think of things I think are "really well" maybe if you gave me some examples I could do a little better. 27 The supply department does an exexceptional job of rapidly stocking and inventorying the MICUs. Placing new paramedics either new to the system or new to the profession in a Lead Secondary role allows them the additional time and "safety net" to gain the necessary experience to become successful Primary paramedics in system and future trainers of those who follow. The role of the Clinical Educator as a remediator for individuals who need assistance and to continue to evaluate the individuals who function as Lead Secondaries by giving constructive criticism to improve thier skills and knowledge. 28 1) Finnally not being view completely as a "contractor" 2) Stability and retirement for employees 29 I think that the most basic of field supervisors (80s) are working great. The field and communications groups also do well. The supply and fleet people are great too. so basic field and support staff are working well. 30 The Paramedic academy.. I have great friends from work... opprotunitys to teach once I get back in the field.

MedStar EMS System Review Page 2 © Fitch & Associates, LLC Fort Worth, TX May 14, 2008 AMR 04777

Appendix B – MedStar Employee Survey Results Question 8

8. In every organization, something works and works really well. From your perspective, describe three examples of things that are working really well at MedStar? 31 (1) Communication with MY direct supervisor (2) Response to questions to EPAB (3) Uncle D and Papa

32 the field crews, the individual dispatchers, some supervisors. 33 EPAB CE's 34 - the overtime bonuses -fto's -Dto's 35 not sure havent been here that long 36 1. The overtime bonus program helps to encourage employees to work overtime to fill the empty shifts on the schedule. It provides employs the incentive to work overtime. 2. The CEs are very well structured and the content is presented well and organized. I honestly feel that at Medstar we have some of the best instructors. 3. The employee benefits package is nice. 37 EPAB (don't know if it classifies though) Clinical department. Jack listening at round table meetings and other meetings Unfortunately that is a hard question to answer 38 Pay is better than before. Trucks are being replaced. The clinical department (not EPAB) performs well, especially being understaffed. 39 I am not sure what is working very well. I think the meetings might be something that is working well. 40 1. Communcation 2.vacation time 3.my shift 41 1. the field supervisors are awesome, i am a prn supervisor and have been a supervisor at two other ems agencies and i have never worked with a more cohesive, proactive, concerned group of individuals. of course they are pretty much marginalized under the current management. 2. epab has continued to be, in my opinion, world class medical direction. 3. the billing office is very well organized, but that may be due to a very controlling management presence. despite indepth consideration i can only reference two items. 42 1.Supply works really well by keeping the trucks fully stocked and keeping us supplied in the field. 2. Hiring process, DTOs and FTOs work well they have some querks but you will never be able to get them all out. 3. The relationships between the separate Fire dept. and Medstar is good and getting better. Fire listens to the primaries on the truck and if they have problems they do not address them in front of patients. 43 1) Payroll.....our payroll dept is managed by one individual who does the work of several.....paychecks are rarely incorrect, and when they are, she fixes the problem immediately. 2) EPAB.....EPAB is always available when needed, they treat everyone with respect at all times. I have never been made to feel "of no consequence" by them, they consistantly make me feel like I am a valued, and needed, member of the Medstar team. The EPAB required CEs which are provided 4 times a year, and a program has been established with the state of Texas where, as long as I attend all the CEs, the "state" recognizes the CEs and re-certifies me without question. 3) Benefits-excellent insurance benefits, 401, 457 44 1. EPAB works well. We are provided continuing education from EPAB along with protocols and policies. It is easy to approach the people of EPAB regarding clinical issues and those issues are resolved. THE MEDSTAR CLINICAL DEPARTMENT IS A WASTE OF MONEY. 2. I have been here 10 years and I cannot find 3 things we do well. This organization has had a downhill descent since R/M left and that descent has excellerated in the past 2 years. Unless radical changes are made this will become a complete failure. 45 EPAB does a GREAT job supply does a good job payroll does a good job 46 1. The Supply system for restocking and washing the trucks. 2. The billing department. 3. The pretripping of trucks to prepare them for the upcoming tour. 47 Sometimes, communication. They come together as a family when one of own has some kind of family or disaster issues.

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Appendix B – MedStar Employee Survey Results Question 8

8. In every organization, something works and works really well. From your perspective, describe three examples of things that are working really well at MedStar? 48 All the OT that was mandatory and kept us from our families for over a year, brought a lot of money for Medstar. I cant think of 2 more. 49 50 Communication, works well sometimes. 51 the work hours work well. the units that are organized works well. 52 53 Establishing policies and procedures, this is the only thing I can think of. 54 management, customer service, and teamwork 55 56 57 58 59 1. Technology -- we have the latest & greatest technology at our fingertips 2. Talent - there are very talented people employed at MedStar today 3. Compassion -- our FIELD PROVIDERS are full of compassion and are truly called to this line of work. Understand this statement is for FIELD PROVIDERS only and should not be even considered for management 60 Cross training-- You get a chance to do different things and that gives more knowledge to do your job better Supervisors-- are attentive to your work load A positive environment to work in. 61 62 1) The supply process, and standardization of units. Long ago, we needed to stock our own units, figure out where equipment was located on that unit for that day, and carry all the bags to them at start of shift. Now,we can board our unit and rapidly identify needs to get in service on time. 2) HR department. Benefits and needs are addressed almost immediately. 3) Scheduling. The opportunity to actually see all open shifts on any given day, sign up (or delete) OT immediately, and request time off via NetScheduler are invaluable. 63 1) the acknowledgement/appreciation of work that is being completed. 64 1) MWR committee. This group of people does a great job of picking up the slack for employee recognition. They organize lunches, vacations, bar-b-ques, several things that help make working here a little more fun. 2) Communication with Supervisors. Our field supervisors are very accessible and willing to help. They don't always have all of the answers but they frequently go above and beyond to find out for us. I would rate Kathy as the best and most helpful. 3) Repair of trucks. For a while the trucks seemed to all be in pretty bad shape. It seems fleet has gotten a handle on it and now, most of the trucks run pretty well. 65 1. The Business Office operation That is all I can see at this time! 66 1. Business Office 2. Vehicle Maintainence 3. Robert and Richard Carter 67 Over the last few years the supply department has made great improvements with inventory/loss tracking. Additionally, they now stock all of the MICU's and all of the units are now cleaned by additional personnel instead of the field crews. The billing department as well as medical records are constantly keeping everyone updated on new insurance regulations and what we need to obtain as field employees for proper payment and compliance. THe impletmentation of the Lead Secondary role has increased our number of people able to staff an MICU, allowing those people to perfect their skills as a Paramedic. 68 Training through EPAP is just right, not too much overkill. Dispatch center does a great job. Bonus plan for picking up extra shifts. 69 70

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Appendix B – MedStar Employee Survey Results Question 8

8. In every organization, something works and works really well. From your perspective, describe three examples of things that are working really well at MedStar? 71 ??? 72 DTO/FTO process. Daily Scheduling Implementation of new equipment 73 The bonous incentives seem to be working well. Also the MWR. And recruitment efforts. 74 1. It seems that our field employees really know and understand how to provide exceptional patient care. I believe that we are above average in this area, and this can be accredited to our ongoing training and continuing education expectations that have been in place for some time now. 2. Since our media exposure for lack of compliance back in September, we have received some much needed attention in the area of resources. It seems that we may finally have the ear of the cities and of others who have authority with regard to our financial needs. Then again, I am not sure that it will result in any changes due to the lack of funds with the City of Fort Worth, but at least there is a better idea of the stresses to the system due to lack of appropriate funding. 3. Apparently, our collection rates are good, and we are collecting a good percentage of what is available to us. 75 1. Epab and Dr. Griswell's office maintaining a high quality of pt care standards. 2. Being able to count on a Medstar Supervisor - MS-80's only as a field person. 3. Don't know a third. 76 1. MWR - its for the employees, by the employees. Created by an employee to address things that employees wanted. 2. I dont have to inventory my own truck. 3. I dont have to wash my own truck. 77 Business Operations New Hire Academy Recognition Efforts 78 I must admit, I am at a loss after thinking hard and long over this. There is not any one identifiable thing working well other than perhaps (1) they have decided to have a consultant group (y'all) come in and assist us. (2) Perhaps the MWR program, the rewards program, and now (3) the recruiting process upon changing of the guards in that department as well as Avesta (smart move). 79 bonus,bonus,bonus 80 81 great opertunity for continuing education having staff to clean units for field staff supply 82 1) I believe that the interaction between the departments works well. Things have improved greatly in the past few years. The biggest example is the relationship between the field and comm center employees. It used to be "us" vs "them", but now we're all friends, hanging out outside of work and looking out for each other. 2) I believe that EPAB and the Clinical department work hard to bring us these CE's and card classes at no cost to us. It is nice to be able to attend a class that would normally cost upwards of $100 or $200 for free. 3) I believe that the billing department works very hard at what they do, and achieve their goals quite often. 83 Nothing works well at Med Star. To many managers have their own agenda in place and they are not concerned with the citizens that we serve. It is not about patient care, it is about the all mighty dollar. The major issue is that we have managers.....we need leaders. I encourage you to sit down and talk with some of the field crews. 84 ... 85 Schedules appear to be filled better than in the past. New cardiac monitors. Our paychecks continue to arrive on time. 86 supply is working well, we love having our trucks washed for us. 87 The Business office Supervisors. I think they are really great and are a wonderful contribution at MedStar. The way MedStar recognizes their employees with awards and varies gifts is also great. It makes people want to come to work. 88

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Appendix B – MedStar Employee Survey Results Question 8

8. In every organization, something works and works really well. From your perspective, describe three examples of things that are working really well at MedStar? 89 1. Fleet has improved reliability of the units which have had transmission problems in the past. 2. Trucks are remaining clean and stocked more efficiently then ever before. 3. We're able to wear polo's year round! 90 lack of communication, lack of management, lack of pay. 91 92 I think we are on our way to success. Three things that I think are working toward that would be 1. Improving education 2. Improving pay 3. Improving our inventory of tools at hand. I don't think we are quite where we should be, but we are on our way. 93 All field employees are very professional and very dedicated to the service. I have a great schedule and enjoy the expierence of running great calls. 94 The bounus are nice, the equipment is good 95 96 you can work all the over time you want . 97 Over the last year the supply dept has become very provicient. Patient care has been monitored well, and controlled through epab protocols and review. technology has been updated through the cad system which seems to provide adequate patient information and satelite tracked navigation. 98 Unfortunately I am unable to give three examples. The only thing I could say is that Medstar has the ablity to consistantly be inconsistant. 99 cant think of three things 100 posting,protocols,epab 101 1. Shift start and end. The units being stocked and ready to go when the emplyees arrive almost guarentees shift starts on time. Also, not having to wash and restock allows those same employees off on time. 2. EPCR. This allows for quick and complete charting. 3. The round table meetings 102 scheduling - the way the computer and schedule program is set up - works well. it's easy to pick up extra shifts using the scheduler. nothing else really comes to mind right now. 103 MWR Paging system E-mail system works good also 104 1) Benefits 2) Hiring process 3) ?? 105 Teamwork, knowledge, and safety 106 I don't think I know 3 or even 1 thing that is working really well at Medstar. One of the things that works at Medstar is telling on other employees to your supervisor. The snitching to managers & supervisors is horrible. If another employee thinks someone else is getting even the slightest more than they are they go and tell. The tattling is worst that first grade. 107 1. Given the ability to use clinical judgement. 2. Communications Center. 3. Restock and supply. 108 The way each employee is treated, emphasis on teamwork. 109 1. Benifits, great 2. the CAD, wonderful 3. Not having to wash our trucks, fantastic 110 Chris Cunningham the field supervisor and EPAB our medical control and Diana Anderson- payroll 111 Punching in and running calls and then punching out. All areas of this company are in a state of chaos due to the fact that there is no leadership or defined chain of command. We are run like a small city with every manager being autonomous and answering only to Jack Eades. Nothing can ever be done this way because all of the giant egos involved in management. This company could take a note or two from the fire service on chain of command. 112 Timeclock and scheduling procedures Quarterly CEs Hiring process 113 1. The way that the feild crews work together. 2. Pt care. 3. Getting payed bi-weekly

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Appendix B – MedStar Employee Survey Results Question 8

8. In every organization, something works and works really well. From your perspective, describe three examples of things that are working really well at MedStar? 114 IT support. Day or night they are always available. 115 116 the 24 hour stations have good relationships with fire dept the cost is prohibative to go to stations for all shifts but maybe find a way to foster that improved relationship with fire elsewhere in the company supply bins - the sealed bins are a bit of a pain but the system works better than any system we have had in the past 20 years. Training has improved greatly in recent years especially since rural metro left I just wish they would work on variety in the training some. A short discussion on a new subject each time would be nice. 117 118 The education system is great, EPAB and the clinical dept offer a wide variety of classes. The system in supply is going good. That's all I have.....sorry! 119 net schedular to pick up shifts, code six option to refuse a call, my supervisor who works with me to correct problems in a timely manner 120 1. supply dept. 2. building maint 3.epab 121 1. Supply processes: Check in/out is an excellent process. Supply tracking is well performed and managed as well. 2. EPAB: The EPAB staff seem concerned about the well-being of field staff and continuing education of all. 3. Communications: Despite poor popularity, I believe most of our communication processes are effective and useful. 122 1. EPAB medical oversight 2. Card classes as an improvment tool. 3. The computer/ internet driven ability to comm. and schedule shifts and trades. 123 Continuing education classes are scheduled frequently, much better job lately of getting crews off on time, quality equipment on the trucks 124 the only thing I can tel you thats working really well right now is the people work together IE: medics and dispatch, medics with other medics I truthfully cant say anything else is working well because I havent seen much of a change except that we are all pulling together because we get hammered with call after call so hard every night. 125 1.) The changes in the policies has been a huge contorversy in the field. The business office has been going by these policies and although it took some getting use to, it works. 2.) 126 127 MWR helping morale with the field employees. The process in which keeps the service running such as supply, restock (95) and maintance. (even though sometimes it feels maintance is not doing their job well) the process works very well. The 80's helping with the field crews and doing their best to have our backs. They are always there when you need them. Even if it is personal or work related. 128 relationships between crews seems to be doing well the training system is good the dispatch plan is working well 129 the new locked door employee access only is good offering CE's intranet access for all employees 130 1-the end of shift time polocy works great 2- supply taking care of truck works great 3- dropping point every 6 months of ur tardy attendence 131 good ideas are coming from our field people protocols are good comraderie between field people is good 132 Training // QA // 133 1. Communications Center with the Medical Priorities Dispatching 2. Billing Office collections and Subscription sales 3. Supplies of the Ambulances 134 1. The EMD process and EMD QA process works very well. 2. Communications Supervisory Team works very well. 3. All educatin provided by medstar and epab. 135 I have racked my brain and I am having a really hard time coming up with anything

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Appendix B – MedStar Employee Survey Results Question 8

8. In every organization, something works and works really well. From your perspective, describe three examples of things that are working really well at MedStar? 136 new employee orientations actually gets the new employee excited about the company night shift comm works together as a team 137 138 MWR, which really is an employee organization, not medstar.... what you dont seem to realize, is that in every "OTHER" organization something works well... here at medstar nothing works well, including, our pay/benifits vs our job description, our management vs field crews (you know, the ones doing all the dirty work and keeping the system afloat) our equipment that falls apart regularly, ie- brakes going out, ac failing, emergency lights not working, etc etc, honestly, not enought space here to say it all... and im too tired from working 5 days straight to take the time to fill it up. 139 HR staff are very helpful to employees Supervisors in billing area Billing staff work well together 140 pay for overtime 141 Medical Direction - Most services are set up with a figurehead medical direcor. That absolutely is not the case here. Medical Direction is the #1 Right thing at MedStar. Supply is on trackto be the number two right thing here. Comparing it to any other organization supply is doing a great job. There are things that need to be improved but overall the supply department is another one of the things done well at MedStar. Communications - They do a great job managing our limited rescourcees. There are changes that need to be made. Some communicators use their position in a punitive way and some are impossible to understand, but all in all they are doing a great job. 142 1. I believe that process we use to inventory and ready our trucks for shifts works well. With the occassional exception my truck is well stocked and ready for my shift. 2. The net scheduler program is helpful and seems to work well. 3. The EPAB system of oversite seems to work well when unhindered by management and clinical. 143 144 One thing that is working very well for me is the new paramedic pay after the analysis of the pay scale as compared from other similar organizations. Another is the opportunity to transfer from dept to dept..Internal hiring options have improved. 145 I think the way the Billing/Business part is ran very good. The way Fleet services is ran. The Jack E. runs the whole operation. 146 My manager is very supportive of me and it is much appreciated. It is a secure feeling knowing she is willing to fight for the welfare of her employee's and allow an open door policy without retailiation. My Supervisor team is united in working towards making Medstar a better place to live. I remain proud of the uniform I wear, We are the best, most talented, hard working group of people whoo wear our "Star" with honor. 147 MWR seems to really care about how the money is spent, they do their best to provide employees appreciations. Clinical dept offers further education opportunities. Having our trucks washed for us is great at the end of a shift. 148 There are very few things that are working well at Medstar. This has been the hardest question in this survey. One thing that is working well is the supply department. David Lamb has taken a department that was out of controll, and had a horabel acuracey at stocking trucks, and in under two years turned the department around. You can not get on a truck at he start of your shift and fell confadent that all the equipment is going to be on the truck. The other thing that is working well is not even realy a part of Medstar, but should be. EPAB has taken over all of the CE for Medstar, and all first responders. The only thing hampering EPAB is the clinical staff at medstar.

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Appendix B – MedStar Employee Survey Results Question 8

8. In every organization, something works and works really well. From your perspective, describe three examples of things that are working really well at MedStar? 149 supply taking care of everything so that we just check out our stuff and go out and do what we are trained for. we have great protocols i think visinet is great so that we can look over the call information. i like the gps maping system because you can zoom in so even in the areas where there are alot of steets cramped together it is easier to read. i like being able to see who is on what truck and how far my second unit is if i need one and since we can see what the level is it makes it easier to know if you are going to be able to get a second unit in a resonable amount of time since we are usually short staffed at night 150 Chris Cunningham,Diane Anderson,Anita Rivers, 151 I dont know if i can come up with 3 honestly - and thats not a burnt out perspective. Id say the only solid entity we have is billing, and thats due to its manager - Joyce Brown. Everything else has so many flaws, i dont believe this is fixable without scrapping the whole system. 152

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Appendix B – MedStar Employee Survey Results Question 9

9. Response time compliance was a major challenge for the previous contractor and remains a continued issue for Medstar today. From your experience, describe three things your organization can do to improve response time reliability? [Please try to consider actions in addition to/other than adding resources and personnel] 1 crews could use some help at the hospital in between calls (getting the truck back together) crews need to get out on the street in a timely manner (going out late at the beginning of their shift 2 Filling authorized crew positions, scheduling efficiency above 93%, lowering total task times. 3 RETAIN YOUR EXPERIENCED EMPLOYEES! Add more 24 hour stations to cover areas "outside of the loop", and add more resources to the system as a whole. (more employees, more trucks, more equipment). Replace ineffective Leadership Team members. MedStar has no real "leadership" right now. It appears to "line employees" that all of our Management Team is bickering and fighting amongst each other, and our Operations Manager cannot "get along" with anyone. As well, EPAB has their own agenda with the System and cannot get along with other departments. With the lack of Leadeship, comes poor morale and inefficient employees. 4 1. Increase the number of units on the street each day. The computer models are obviously incorrect and staffing should be increased. Besides an immediate reduction in response times form simply having more units on the street and ready for calls, I believe this would allow crews to not be worked as hard, and they would be more likely to pick up overtime shifts to fill in when people are out sick, on vacation, etc. 2. I believe number one is really all that is needed, but if you just want other ideas to consider, you could include the possiblity of BLS first responding units, and an individual non-emergency transfer devision. 5 Work on the easy items: Start times, task times. Identify the best practice within the company and identify why they are able to perform at good levels of compliance. Require a daily justification response from the crews that go out late. Make all the Paramedics part of the line authority, they would supervise the EMT on their truck and do their evaluation. Then hold the Paramedic accountable for all performance issues for that shift. This would give more time to the Field Supervisors to work on other compliance issues. Provide the Field Supervisors with equipment that would allow them to work in the field instead of the office. The office phone could be forwarded to a cell phone and they could receive all calls while working in the field. A portable printer and computer that allows them to have full office function in the field. Place the supervisors office in a more public location so that the supervisors are more accessible and visible to the crews at post 4 during shift change ... 0400 to 0800 and 1600 to 2000 ... all other times the supervisors should be out in the field. This would also be true for the Operations Manager ... at least bring him down from the second floor and place him in an accessable location ... the management personnel on the second floor are considered unaccessable and unreachable. 6 I think SSM needs to be thrown out the door. It has not worked here and needs to change. We are never going to have all the staff in the world to cover this place since SSM wants things done the cheapest way. The posting plans must change to help compliance. We have to stop thinking of each city seperate and not have a level one post in Burleson. Who are we trying to take care of patients or the politics of the people from that city. We need to have dispatcher that are trained better and know our system. A big down fall in dispatch errors stated when we started not requiring any experiance in this department. I know when they were aload to think on there own and not have to follow a computer things worked better. Most this people know how to get to work only and do not know anything about the system. The must have a manager that can get things done as well. We must have more fleet to help with complaince. We also must have 24 hour fleet services since we have to many units going down at night and they spend a hour changing units for a headlight ect. this is lost unit hours and can be fixed. we are a 911 service 24 hour fleet and IT should have been done 20 years ago. 7 Stick to the task times Stop the extended drop times Consistancy from field supervisors 8 Better management/leadership

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Appendix B – MedStar Employee Survey Results Question 9

9. Response time compliance was a major challenge for the previous contractor and remains a continued issue for Medstar today. From your experience, describe three things your organization can do to improve response time reliability? [Please try to consider actions in addition to/other than adding resources and personnel] 9 1. Increase staffing 2. Create a different status plan. The current plan was designed by a field supervisor with no proven experience in field of system status planning or systems design. There are too many challenges facing this organization - Meeting compliance would require a cohesive effort from all departments. There is no sense of urgency or accountability. Everyone must step up to the plate and do their part to help compliance. 1. Assure every conceivable effort has been made to fill the schedule. 2. The communication center MUST send the closest appropriate unit to calls and the favortism must seize to exist. I don't care if this is what happens in other systems or "that's just EMS" This must stop. Operations needs to be out in the field and assist the crews out of the hospitals and scenes. IT department must make sure that IT issues decrease significantly. 10 Obviously we need more people, however we need to keep the ones we currently have. Retention of employees has been a on going problem. We need to look at our competition or the ones we are losing employees to and see what we can change to help keep people at MedStar. I believe we need to look at wages,benefits, working conditions and job security. Looking at these areas and changing what we can will help ensure we keep employees here at MedStar instead of losing them to Fire Departments. I believe having more actual trucks will help reduce Lost Unit Hours due to not enough equipment. We lose several hours throughout the day because fleet has to temporarily fix units to get them up and going. Our trucks work 24/7 and don't have the needed down time to allow fleet to do what actually needs to be done. I'm not blaming fleet because I think they do the best job that they can. Also we need 24/7 fleet operations. Also we need 24/7 IT support due to the fact we have 24/7 IT issues. People have become disgusted with IT and fail to call when they have a problem. The new IT tech has helped but we need more. We are still losing hours due to IT. I know this is all part of a system but I believe we don't account for these lost hours and pay dearly in the field. I also believe we need more field supervision. We currently only have 2 supervisors during the day and one at night. For the amount of field staff we have this needs to be more so that the field staff can actually see a supervisor each day they work. It is difficult to manage this many employees along with keeping up with all of the other operational tasks. This will ensure that people are not wasting time at the hospitals as well as ensure that scene evaluations are complete and that everyone is doing what they should. Also helping the current supervisor staff obtain needed leadership education to ensure they are all on the same page and doing a great job. 11 1. Getting employees in here to fill all the open shifts and retaining our employees. Make Medstar interesting enough to keep the employees from wanting to go somewhere else. Pay, cheaper medical insurance for the family, meal time, no post ponging all day even when were level 29. All these are the negatives I hear out in the field. 2. Being able to decifer between true P1 and P2 calls would be great. If this was the case, our compliance more than likely would not look as bad as it does. There have been a lot of times when a dispatcher has given out a call as a P1 and then turn around and state this really should have gone out as a P3. A lot of dispatchers had mentioned that if they could veer off of the EMD questions a hair or two, they could do this. I know there are possible failures with that part of it. 3. Look at changing our System Status Posting Plan. 12 SSM does not work for this system Get rid of it. We need to function somewhat like a Fire Dept, and have somewhere to go,..i.e. permanent posts. 13 1 have 40 trucks in the day and 30 at night 2 obviously increase staffing 3 raise the compliance times 14 1. We need dispatchers who know what they are doing. 2. Control needs a manager with MedStar field experience and is willing to be employee focused. Tammy is not. 3. We need more 24 hr stations and less moving from post-to-post. 15 I would have to say to let crews put together a truck like it used to be. Give the same bonus all the way across the board instead of choosing which one gets more money.

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Appendix B – MedStar Employee Survey Results Question 9

9. Response time compliance was a major challenge for the previous contractor and remains a continued issue for Medstar today. From your experience, describe three things your organization can do to improve response time reliability? [Please try to consider actions in addition to/other than adding resources and personnel] 16 responmse time relaibility is a very crucial point that MUST be addressed however killing your current staff is not the most logical explanation in maintaining morale and safety. I work a 16 hour shift and it is not uncommon for us to have as many as 20 patient contacts with 14-18 transports within that time frame. I would not want a medic that is stretched that this taking care of me because mistakes in judgement do happen due to crews being exhausted and not as mentally sharp as they could be. 17 Retention of ALL personel in ALL departments, More CE (continuing education) availabilty directed at completing All NREMT re-registration objectives, Different types of posting plans/Districting plans (all of life does not revolve around SSM) 18 We to change the posting plan. We need more 24 hour units as well as a variety of 8,10,12, and 16 hour units. We also need to get rid of EMD disptach and the dispatchers that continously cross units and play favorites. 19 Medstar needs to decide what they want. they either want to make a profit or run good pt care for the community. it all starts with money. the upper management of medstar has no back bone to go to the city and demand more money. they are satisfied with the excuses the cities give for not being able to pay. this causes medstar to have to cut in alot of places. in order to make complaince, they need to have more trucks on the street. period. there is no other alternative. its a waste of time to try and think of ways to improve times without putting more trucks on the street. more trucks means more money. since the cities wont pay more medstars hands are tied. i know for a fact that epab has offered to go hand in hand with medstar to the city and ask for more money. jack said no thanks. as a primary medic working on the streets, the busier it gets the slower i go. if i know its level zero, im in no hurry to get back on the streets. thats how it is with every one who works on the streets. upper management thinks we care about compliance. what we care about is our job. i dont care one bit about compliance. that doesnt mean i goof off, nor that i am slow getting in route to calls, but its not my fault jack refuses to put more trucks on the street. he is so concerned about the bottom dollar. this is ems and no computer program can calculate how many calls are going to drop at a given time. more trucks means better coverage and fewer calls per truck. none of this will happen while jack is in charge. 20 increase staffing increase number of vehicles create a more deversified schedule with 8- 10-12-16 and several more 24's 21 Have trucks that actually runn correctly. We have trucks that bog down when you try to drive them. Therefore it takes a few minutes to get up speed. Have a maintenence person here 24/7. We are having to change trucks just because of a headlight being out 22 Closer monitoring of dispatch in order to make sure the proper trucks are being assigned to calls would help. Glaring errors have been made on many occasions. Better map training for new employees would also be helpful, particularly those that are unfamiliar with the area. 23 We need to have a larger budget to have better salaries. Sure, they say that we are equal in pay to other services our size, but that is only by population served, they dont have the same call volume that we do. Our pay isnt comparable to our work load. 24 dispatch system that works, and the people to run it the correct way more crews with better pay and better attitudes 25 GET RID OF SYSTEM STATUS MANAGEMENT. SET A GOAL OF 100% COMPLIANCE NOT 90% COMPLIANCE. I believe we need a certain set of 15 main posts strategically positioned throughout our response area. It doesnt take a genious to figure out where to set these posts in order to achieve a 100% response time compliance and these posts need to be filled constantly with at least one truck, when we reach higher levels of posting trucks these posts can be double even triple filled and the first unit in to the post is the first unit out of the post. This gives ample time for the second in unit to grab a bite to eat and even use the bathroom. 26 Put more trucks on the street. More employees start shifts on time Less call offs

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Appendix B – MedStar Employee Survey Results Question 9

9. Response time compliance was a major challenge for the previous contractor and remains a continued issue for Medstar today. From your experience, describe three things your organization can do to improve response time reliability? [Please try to consider actions in addition to/other than adding resources and personnel] 27 Ensure the field supervisors are functioning to their potential by assisting the field employees by first responding to non critical calls as well as critical calls, assisting at the hospitals to decrease at destination times. Change the posting plan/schedule to provide the most coverage with the minimal resources. Ensure the First Responders are doing all they can to assist in cancelling unnecessary responses by performing Release at Scenes and AMAs. 28 1) Reduce late starts 2) Reduce routing errors 3) Reduce hospital drop times 4) Reduce chute time delays 5) Reduce post move delays (sorry, I couldn't stop) 29 Better incentives for response times would be good, not just cake in the crew lounge with no management showing up to show their appreciation for our hard work. other than that posting in more appropriate places would be good too. And adding more trucks, especially at night, would greatly improve responses and lighten the work load of all crews in general. 30 Give dispatch the ability to do their job, instead of having a computer tell them what to do... Continue the bonus, because while we are understaffed, atleast people have an insentive to work. 31 (1) Static posting plan (2) More staggered start times (3) Changing the Code 6 policy 32 if you don't have enough butter to cover the toast to begin with, you can only spread it so thin before you start to miss some spots. No survey, market analysis, or system assessment will make 25 trucks(at best) cover 300 square miles all the time. Keep in mind guys the numbers they are giving you have had "overload" times taken out, and we still can't make compliance? The last survey said we need 45 trucks, we need that at minimum. FWFD has about 60-70 apparatus and there are 14 other cities we cover. Also, Fort Worth is expanding, significantly come october but who has plans for that? If I were to make one blame besides short staffing and short funding, it would be the management. I have 12 people who can, and will, write me up at a moments notice, there are even more who have to come up with a good reason but can still make it happen. Do you know how many I can write up? It starts with z and sounds like hero, something the public thinks were not. If they start thinning out upstairs (what does clinical do that EPAB doesn't? what does dan brunner really do? why do we have 7 comm supervisors when we only have 4 field supervisors?) maybe we could afford some more trucks. Did you realize that the company somehow manages to run on sunday when management isn't here, do you think they know what would happen come monday if field wasn't. 33 more trucks on the street dedicated transfer trucks 34 -hire more employees -put more trucks on the street - 35 without more personnel you cannot improve the city is to big to only have a limited amount of staff and trucks 36 1. restructure the schedule to be more balanced and consider all trucks that start during the day and leave at night, leaving night shifts with hardly any at 2 am on a friday or saturday night when the bars close. 2. have a more geographically balanced posting plan rather than basing it all on statistics. 3. consider more 24 hour stations in locations that are more distant from the inner city. 37 LOL The first thing that I think we can do to assist in response time for the short term is give incentives to run more calls. I wrote all of the supervisors and operations staff about a plan that I thought would work in which employees would get paid to run a late call or extra calls throughout the shift. The pay wouldn't be much but at least the employees would get something out of being slammed. I think we are a system of burnouts. I think another thing that would help is to really look at our system and see who is burned and who is going to be burned and fix that. In order to fix that we must help them realize what is going on and help them help themselves. With all of that being said I really don't think there is any better way to get better response times other than paying our people what they deserve. If we just started our paramedics out at about

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Appendix B – MedStar Employee Survey Results Question 9

9. Response time compliance was a major challenge for the previous contractor and remains a continued issue for Medstar today. From your experience, describe three things your organization can do to improve response time reliability? [Please try to consider actions in addition to/other than adding resources and personnel] 10000 more a year then we would see a influx of paramedics wanting to come here. My personal opinion is that our pay is the biggest problem that our system has. 38 First: Judging an EMS system soley by response time TO a call is obtuse and outdated. The flawed perception that "it is better to have a new EMT arrive early than a trained Paramedic late" reflects a lack of understanding of the true nature of our industry and does a disservice to our customers. That being said: The best way to improve response time reliability is to change the "acceptable" response time. While there is a perception that every 911 call "deserves" an ambulance within 9 minutes, the reality is that this can not be acheived consistently without adequate funding, resources, and trained personnel. In Seattle, the Medic 1 system has an average response time of 12-14 minutes for an MICU. They, unlike our system belive in patient care FIRST. Adding to this problem is EPAB's disruption of the established SSM. Interfacility calls are given priority over 911. Priority 3 calls are upgraded to priority 2 if they have to "wait too long". Next: Accept the fact that these are EMERGENCY vehicles. The ONLY significant effect the field crews can have regarding response time reliability is their ability to drive faster. The Road Safety system in our trucks blocks this effect. No electronic gagetry will ever compensate for good training and decision making skills. To date, Road Safety has made NO change (if it has then PROVE it, financially and statistically) in the number or severity of accidents, improving safety, nor has it been used for any purpose than to discipline employees. Train the employees to drive, and let them do their job. Finally: Motorcycle response units. London and other major metropolitain systems use these to get trained personnel on scene long before MICU arrival. In many cases, they can free up the responding MICU by treating patients and handling paperwork on non-transport calls. 39 As a person in the field, the only solution to this problem is to stop using SSM and to add trucks to the street. It is to treat the persons on the street with respect and understand that we are the money makers for this company. Better benefits, better wages, a better attendance point system. Some of us have families that we need to take care of and some of us are single and when our child is sick we have to be there for them. Medstar does seem to understand that. 40 1. Crews not being selfish 2. going available on time 3.employees that truly care, not just around management 41 1. remotivate employees so that they will respond immediately to prealerts, clear hospitals in as timely a manner as possible and otherwise maximize unit hour availability. notice the motivation piece rather than discipline. 2. place a greater emphasis on training to route appropriately. a remedial mapping class would be an awesome idea, oh wait.. thats been suggested several times... 3. changing our posting plan may help, biasing our posting to the problem areas rather than demand may be an idea.. its a little difficult to describe in this format. 42 1. Quicker chute times 2. Van for night shelter. For Pt. who don't need an MICU to go to the hospital. Not a Medstar van. (MITS) Same with nursing homes. For example: Pt. with General med. issuses. No life threating problems 43 1) Remove "system status" from our system 2) Restructure the dispatch system, and put stricter guidelines/supervision to monitor/eliminate favortism, and to develope a system which dispatches the "closest unit" , and takes "dispatcher discretion" out of the "mix". "Favortism" and "dispatcher discretion" are key factors in our failure to maintain compliance, along with the need for more units and staff. 3) Design a tiered system, with additional, available "transfer/transport" units, which can be used to transport non emergency calls as well as the emergency calls which are deemed by the medic onscene as truely non-emergent. 44 I have made every attempt to bring suggestions up to management but that falls on deaf ears. If it's not a management idea then it won't be put in place. 1. Make things easier on crews- put an ice chest in the truck filled with a 6 pack of water, bag of

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Appendix B – MedStar Employee Survey Results Question 9

9. Response time compliance was a major challenge for the previous contractor and remains a continued issue for Medstar today. From your experience, describe three things your organization can do to improve response time reliability? [Please try to consider actions in addition to/other than adding resources and personnel] granola bars, newspaper on the dash and sattelite radio. Tell your employees I know your going to get busy but I hope this helps. This was suggested and ignored. 2. We have the most state of the art computer program to forecast demand but it's not used. Our posting plan does not change for anything. When we have annual events in a certain area every year the demand will shift but there is NEVER a change in the plan. We do not change on the fly like we should. 3. GET RID OF MANAGEMENT. Every member of management has contributed to our failures so get rid of them. We would be fully staffed in 2 months if three things would happen: 1. GET RID OF MANAGEMENT. 2. PAY PEOPLE A DESCENT WAGE. 3. GET TRUCKS AND EQUIPMENT TO COVER THE ENTIRE AREA WITH NO OVERLOAD FACTOR. People will show up in busloads if this happens. 45 post move/ posting plan schedule 46 1. Change shifts to 24 to 48 hour shifts and assign you to fire stations. This creates a working relationship between you and other emergency responders in your area. You develop a ownership for the coverage area that you are responsible for. Shifts are basically all the same. 2. Go to a all paramedic system by sending all emt's and new hire applicants that are not paramedics to paramedic school this will decrease the paramedic work load in half. 3. Develop a more structured command system with oversignt of the field. 47 Hiring more EMTs. 48 49 not applicable to me. I dont work in the field 50 Hire more EMTS/Paramedics. 51 maybe post a ambulance to every fire dept/maybe offer a bonus after every 5 response times made. Instead of monthly recognition give it to them in the here and now. they'll be jumping calls then. 52 employees have to know that they are cared about and the small things Medstar does for us lets us know that. 53 1. Recruiting volunteer nursing/health prfessional staff to work at homeless shelters and to frequent places where the homeless are to "triage" them. We spend so much time transporting the homeless because they are cold and hungry or hot and tired and then we have to write off those trips as well as use our medics for non-emergency situations. 2. Better educate the public on 911 emergencies, a stubbed toe or hang nail not cause to call 911, especially if they are not going to allow us to transport them anyway. 3. Allow police to do more in transporting patients to the hospital that exhibit sucicidal or psychotic behavior without having to involve ems. All of these will help to cut down on the non-emergent or frivolous calls so that we can be free to attend to those critical patients that have true and urgent needs. 54 Im not a field employee 55 56 57 The medics need to go available as soon as they are finished. They usually wait around for a while, then they are available. 58 59 60 Not Applicable 61 62 Although I tried to consider actions in addition to/other than adding resources and personnel, that is first and foremost. Sorry. Allow more time at start of shift to confirm unit readiness, and pay the medics for that time. Not 30 extra minutes, but at least 5- 10. It takes, on average, 15min to completely check out a unit prior to beginning a shift. And it takes 5-10min to complete transactions at the supply window.

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Appendix B – MedStar Employee Survey Results Question 9

9. Response time compliance was a major challenge for the previous contractor and remains a continued issue for Medstar today. From your experience, describe three things your organization can do to improve response time reliability? [Please try to consider actions in addition to/other than adding resources and personnel] 63 1)add more micu's 2)more employees to take calls for dispatching 3)MORE EMT'S/PARAMEDICS 64 1) Improve EMD. So many of our calls are categorized as P1 that have no reason to be. P1 sick person shouldn't exist and when someone calls in with a benign complaint, it shouldn't be changed to a P1 breathing problem because of a caller's subjective judgement of the pt.'s breathing status. 2) More trucks. Plain and simple, we're covering a vast area serving nearly a million residents. We can't always do it with what we have. We need 24 hour trucks outside of the loop and 12 hour trucks within the loop to support them. You're going to have to pay people to sit around and do nothing. I know it's the opposite of every other business model but EMS is a different animal. 3) Get Opticom transmitters. The infrastructure for Opticom is already throughout Ft. Worth because FWFD uses it. From my understanding, the city wants MedStar to pay a per intersection fee to use this system. If the city wants to help us meet our times, they need to be more flexible regarding this system. This will also improve safety which would decrease employee down time from accidents. 65 66 Stop allowing response delays due to sig 3. Back in the day, crews had 1 minute to respond or the supervisor was talking to you. It appears this is behavor is condoned by the supervisors. Also if crews will start moving toward the call on the pre-alert, that would cut the response time. Fueling...if a crew is fueling and is pre-alerted to a call, stop fueling and start moving. It seems there are crews that will complete fueling before ever moving on the call. Again, It appears this is behavor is condoned by the supervisors. Shorten hospital drop times. Knowing it's not always possible, but there was a time when the crew had 10 minutes to be code 5, response ready pending paperwork and another 10 minutes to be available for the post. Maybe something along this line with a small increase in time would be helpful. If crews would clear the hospital faster, the system would be able to post them appropriately and have more coverage. Crews routing appropriately to post and calls. Not delaying post moves hoping another unit will come available so they won't have to move. Again, back in the day, if you weren't moving within 1 minute, the supervisor was talking to you. Controllers be able to control the system, knowing how to move units for maximum coverage in response to how the system is running, not just responding to the CAD and covering the empty posts. 67 Back in 2001 when i first started here, we had limited staff and MICU's, there was no road safety, no GPS tracking and all of the crews and supervisors worked together as a team to get the job done. It was Ok then to tell dispatch if you were closer to a call without being accused of trying to do their job. Crews would back each other up and take care of our own. Today there is a limited amount of team work, everyone appears to be afraid to say or do anything other than what is assigned to them. We need moral, teamwork, confidence in our supervisors and management and knowing what a "true" open door policy means. It is very difficult to try and lead by example when the operations manager has no problem openly criticizing you or your peers and placing the blame of the system on the field crews. Although we could always use more units and staffing, if we can not keep the current employees, we will continue to take 2 steps back for every one forward. This cycle has been going on here for a while 68 1. bonuses for employees who have low task times at the hospital. (the faster crews drop off patients and become available for calls the more ambulances available in the system). 2. Field supervisors on site at the busy facilities (Harris downtown and JPS hosptial)to help units get available and to encourage crews to get availabe as soon as possible. 3. Contract out non emergency interfacilities transfers to other ambulance services to free up Medstar ambulances for emergency calls. 69 70 This is not my field of work, I can't answer this one.

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Appendix B – MedStar Employee Survey Results Question 9

9. Response time compliance was a major challenge for the previous contractor and remains a continued issue for Medstar today. From your experience, describe three things your organization can do to improve response time reliability? [Please try to consider actions in addition to/other than adding resources and personnel] 71 we need to be able to refuse the non-emergency transport/non life threating ones... i.e. my tooth or foot hurt, or i just need a ride.... this would clear up the system and help reponse times for the true emergencies. 72 Deployment is a fairly basic concept. I believe we make it more complicated than it has to be. Cover the most area with the resources available at that time. 73 Really it seems as though we may need to loosen the road safety system. I mean this by not removal of the system but a modification of the top speed of the system. Also there have been times where a unit is closer to a calll the unit being dispatched, so a look at how units are being dispatched may need to be done. Also better pay is the end all. 74 1. Accountability -- We have a lack of this altogether, and it affects everything. This should start with top management and continue down to all employees. 2. Educate, train, and continually develop our Field Supervisors to lead more effectively rather than interact as peers with their subordinates. Many things that directly affect compliance are perceived to go unaddressed, because they are not addressed and followed through appropriately by first-level field supervisors and even the management level. 3. Place more focus on compliance with both verbal and graphic details and reminders. We really don't hear that much about it, although we did recently celebrate our first month of compliance with cake for all employees. 75 1. I've been involved with MedStar for 17 years and in all that time system status management has NEVER worked. Even when we were making times, we were alloted exceptions that didn't count against the company and there were always accusations of numbers tampering. I think a revised status management with fixed 24 hour stations and an automatic over-staffing plan would work. 2. Revise the shift outline - I don't care if Bob Strickland's numbers say we are doing fine, when you drop from 30+ day trucks to 8-12 night trucks, something is terribly wrong. 3. Revise hiring process - I have never seen MedStar so depleted and in such a crisis we hire just about anyone. We do not have the training programs in place to continue to hire new people with no experience. This is a hard system to learn and that continues to add to the constant turnover. 76 1. change the type of model that we deploy. our service area is too big for ssm due to inadequate resourses. 2. deploy bls trucks for priority 3 calls 3. ditch the so-called cities that we service until they pay something for our services 77 Better efficiency of crews on the street. Less time spent at hospitals after patient care is turned over to facility. I cannot think of any other factors other than being fully staffed that would help in this area. 78 I believe that total revampment of the system status plan and schedule would do wonders. I also am a realist and know that this is not going to totally do it, but by revamping these things would lead to employee friendly schedules that would result in retention and recruitment attraction resulting in increased "rubber on the road". I know for documented fact that alot of blame is placed on street folks that should not be there. This leads into talent in management to be able to identify and correct what is wrong instead of ignoring it with smoke and mirrors. Reallocation of what funds there are , use it wiser smarter. 79 none 80 81 The posting plan needs great inprovement all the post moves are a big problem when one unit gets a call then it seems that they have to move multiple untis around. If they could not move units around as much it is a wear and tear on the crews having to post move all day 82 1) The primary issue we need to work on is correct prioritization of calls. I understand that certain calls are higher priority calls, but we need to not lead the caller into answering questions how we want them to. Example: If someone calls and says they cut their hand with a knife, that is what the problem is. It should be dispatched a Traumatic

MedStar EMS System Review Page 8 © Fitch & Associates, LLC Fort Worth, TX May 14, 2008 AMR 04792

Appendix B – MedStar Employee Survey Results Question 9

9. Response time compliance was a major challenge for the previous contractor and remains a continued issue for Medstar today. From your experience, describe three things your organization can do to improve response time reliability? [Please try to consider actions in addition to/other than adding resources and personnel] Injury. If they say they're not breathing "normally" (being non-medical personnel, how do they know what normal is?) it shouldn't be upgraded to a breathing problem because the person is in pain and is having a natural pain response. 2) We need to take the time to train people correctly in their Driver Training. We need to actually take the time to make sure people know how to read the maps, they know the appropriate routes to take, and they know the appropriate roads to take to get from the scene to the hospitals. Routing errors should never happen, especially when transporting. 3) One option I was thinking about was having response districts, much like PD and FD does. That way the units would be more familiar with their areas and routing errors would be reduced to nearly zero. 83 1) WE NEED MORE CREWS!!!!! 2) We need to be out of those trucks. We need stations. 3) We need to be able to retain employees. None of this will be possible as long as Jack Edes and Dan Brunner are in place 84 You don't want us to say add trucks or hire more personnel...... Our service area continues to expand, when this happens, we need to add more trucks and more personnel. With that being said, we need to do something about the individuals that continue to abuse our system. We have for so long taken individuals to the hospital that indeed doe snot need an ambulance. The individuals that I mean are ones that have no complaints at all and specifically request to be taken for a rx refill, or they just need to get to the other side of town. We are abused as an EMS service, and the public needs to be educated on what is acceptable and what is not. 85 1.) Increase staffing (accomplished by better benefits; paid or reimbursed extra- employer provided courses such as conferences, seminars, higher education and not just the mandatory classes; more equality in treatment without passion or prejudice including enforcement of policy) and efforts to improve retention. 2.) Transition to a true modified-SSM system, which includes providing 24-hour stations outside the primary response area (we make times in Fort Worth inside Loop 820, but rarely outside, it seems.) We should have no less than seven 24-hour stations around the outside of the loop (including Forest Hill, Burleson, Lake Worth, Saginaw, White Settlement, Trinity & 360 - currently at FWFD Station 33, Alliance Gateway - currently at Westport Parkway and I-35W, and consider even more for East Fort Worth around Meadowbrook and East Loop 820 and the Cityview/Southwest areas). Run everything else inside the Loop as SSM. 3.) Increase the reserve fleet so our 42 primary ambulances are not all running around the clock everyday, forcing units down for accidents, maintenance (which also needs to be provided 24-hours, since trucks frequently go down in the middle of the night for headlights and other issues) and so when we do become full staffed, there are not only enough trucks remaining so crews don't have to wait for a truck to come in off- shift, but in case of disaster or "all call" we have units prepped and ready to respond when additional unscheduled crews come in to help. Now we can't do that, and we don't even have the means to transport our additional call-ins to a scene to help there if needed. 86 the closest truck should be sent to a call. not the closest code 6 truck. 87 I wouldnt know 88 Put more truck on the streets. In the past the other contractor did as little as poss so they could make money. it was not about the people we served or who care about the employee it was about, let put much money in the company pockets and do little as possble. I think that you have to make it more like being on the fire dept that you want to work at medstar and that it is some were you want to retire from insted of a stepping stone to a fire dept or to some other service and able to make a good living so we can suport are family and our self with out having to kill your self by work 70 to 100 hrs a week and so you can spend time with family and be a family. For us single people we are able live with out haveing to have a room mate so we could pay the rent and so we could be able to suport a family some day. Medstar should be a family friendly place to

MedStar EMS System Review Page 9 © Fitch & Associates, LLC Fort Worth, TX May 14, 2008 AMR 04793

Appendix B – MedStar Employee Survey Results Question 9

9. Response time compliance was a major challenge for the previous contractor and remains a continued issue for Medstar today. From your experience, describe three things your organization can do to improve response time reliability? [Please try to consider actions in addition to/other than adding resources and personnel] work. If medstar care about us and our family and take care of us we will take care of Medstar and have pride. Have 5 extruck a day put in the buget so when it get bussy (250 to 400 calls day ) medstar 80 could put some extera trucks on the streets to help out and when we are fully staff it will let us to get some OT if we need it. Put more 24hrs Station on the out line areas. 89 1. Hire more medics. 2. Retain said medics with better pay and incentives. 3. Adapt a system which is in direct relation to the FD in order to match response times. 90 pay more to the employees who are working or applying for the jobs here at medstar. the company needs to pay more, give better health benefits, and 401 benefits. if the company became the leader in this area then you would find that they would not lose employees to other companies like the fire dept. also tell the cites we serve to either pay more for our service or we pull out and they can run there own ems system. every city complains on how long it takes medstar to get there but no one wants to add funds to help with staff and equipment issues! 91 To have them make sure that you are the closest unit to the call. To not be worried that you are gonna get a routing error because you went a different way to the call to get there faster, but that is not the way dispatch had planned you going that way. To have more updated maps on the computer progam. 92 1. I think that we would be more effective if we placed trucks in districts and not on a continuously roving patrol. 2. Working on keeping personnel rested and driving with a sharp mind. Most of the medics that work here work more overtime than any other profession that I can think of. And I can count more days in my career that I went without a drink, or meal, than then ones where I actually had an opportunity to eat a balanced one. On a hot day when the A/C in the truck doesn't cool well nutrition is key to keeping sharp and avoiding routing errors. 3. Setting up some sort of precepting process of general non-emergent transfers to familiarize new medics to out system and to our area of coverage. 93 I think the board of directors should review all call and desicions that supervisors make for about three months. Of course this needs to be done with out any employee knowing in the comm center. 94 Increase hourly pay and offer benefits to part-time employees 95 Hire persons who have experience and pay them what they need to be paid. Pay continues to be an issue here at Medstar when we can go to a smaller entity and make more and work less. Give us our vacation time as requested and not deny it because "staffing" its not our fault the company cant retain the people. WE ARE over worked and when the time comes to take our earned vacation time its a struggle to have to find someone to cover our time. If we dont find any one we dont get it. So we have to take sick time instead. We've got to have something to work for and not allowing us our vacation time is a big open sore. 96 get more help to run the call and treat them right so they would stay. change up the weird posting assingment and get rid of the fluid system. add more units schedule because this system has gotten more busy and grown in population but our staff and units hasnt. 97 I wish i could provide more actions than additional resources, but the city is growing at an alarming rate making dfw one of the top ten places to live in the nation. The city is developing to the north so rapidly that no matter how fast our times are it would only be a temporary fix to the problem. With the rising housing prices on the west coast and east coast people are flocking to dfw to etablish themselves. It is our responsibility to meet these increasing demands in the most drastic way. I beleive that the only way this can be done is to develop a permenent fix by becoming equivelent to FWFD, by posting ambulances at fire stations, and requiring rigorous hiring standards to be compinsated with city benifits and pay. Medstar performs critical treatment to ft worth citizens that fire and the police are unable to do. It is only fair that we be treated the same. The EMD

MedStar EMS System Review Page 10 © Fitch & Associates, LLC Fort Worth, TX May 14, 2008 AMR 04794

Appendix B – MedStar Employee Survey Results Question 9

9. Response time compliance was a major challenge for the previous contractor and remains a continued issue for Medstar today. From your experience, describe three things your organization can do to improve response time reliability? [Please try to consider actions in addition to/other than adding resources and personnel] protoocols that dispatchers use to determine priority seem to be less than accurate. The overwelming majority of the calls i respond to go out as either a p-1 or p-2, but turn out to be a completly stable pt. With accurate assessment on the phone, most p-1 calls should be downgraded to p-3. We put the motorists of fort worth at risk by responding p-1 across te city to find a pt who never needed an ambulance in the first place. We have regular pt's who we refer to as "frequent flyers" who we transport on a daily basis that should be refused transportation because they have no complaints other than they want a ride to the hospital. A no ride policy would help with these kinds of pt's. I am completing this survey periodicly in the ambulance while moving from post to post. During this we received a call. The call was a P-2 traumatic injury. We drove lights and sirens across town to get to this pt. We found a 30 yr old woman walking around her living room with a less than impressive superficial laceration to her pinkey. The pt did not even want to go with us. This should have been triaged as p-3. 98 The key word would be reliability, it is my perception that not everyone is held accountable for their actions. Crews can sleep through calls and nothing happens. Dispatchers can continually make mistakes and actions are not taken to correct the problem. There is an incredible lack of work ethic, it seems no one even cares anymore. management could be more united in the deliverence rather than turning against each other. 99 Get dispatchers that know the area and where the ambulances are in relation to the call. Dont be putting one truck on the call and redispatch 2-3 times before some one gets there It takes time to get rolling on a call each time that eats into the response time Crews clearing the hospital as quickly as possible 100 think before posting units just to come back to where you were originally, the posting plan is good but not used like it should be 101 1. ALWAYS looking up our routes and not just saying"Oh, I know where that is" 2. Clearing destinations as soon as we are able. I see meny untis who are able to clear hanging out at facilities. Clearing quicker = more units to respond. 3. Paying attention to the Visi-Net and speaking up when they have better access to a call than the dispatched unit. 102 please try to consider actions in addition to adding resources and personnel? are you kidding? seriously? so why ask the question in the survey when you're going to tell everyone to come up with an answer that has nothing to do with fixing the problem? why don't we look at the way that other cities handle response time compliance - how about across the entire nation and the rest of the world? so when a city grows and response times start to increase, everyone else but medstar adds resources and personnel. but medstar in their infinite wisdom has decided to spend all this money and time on a survey instead of adding resources and personnel. GENIUS 103 More Shifts More Posts Better shift coverage 104 105 works in business office 106 N/A 107 1. Stop EMD. Comm-Center needs to be staffed by field medics who know the right questions to ask rather than a generic card read from. This would reduce the amount of priority 1s and 2s. 2. Develope a program to stop system abuse. Such as a cab voucher for non-emergency rides to a hospital for minor illness. 3. PUT MORE UNITS ON THE STREET! 4. System status management should be the descretion of the controler, not a computer program. 5. Bring back transfer trucks to run P-3, P-4, P-5. 108 The road safety system either needs to be fixed or eliminated all together. I cant stand it because it makes me nervous behind the wheel and sometime is hypersensitive and goes off at the slightest of movements. Its not a well maintained system. Our health and safety coordinator thinks that speed is the leading cause of accidents and that is just not the case. If that is a major concern why not put governors on all the

MedStar EMS System Review Page 11 © Fitch & Associates, LLC Fort Worth, TX May 14, 2008 AMR 04795

Appendix B – MedStar Employee Survey Results Question 9

9. Response time compliance was a major challenge for the previous contractor and remains a continued issue for Medstar today. From your experience, describe three things your organization can do to improve response time reliability? [Please try to consider actions in addition to/other than adding resources and personnel] ambulances that will not allow the ambulance to exceed the desired speed? I can agree that speed can increase chances of an accident, but so does turning on the lights and sirens. 109 1. Please, please, PLEASE put more trucks on the streets at night during the week. WE have enough during the weekend but Monday through Thursday we end up hitting a low level and we never recover because we are getting just as many calls as we do during the weekend but we run them with what seems like half the trucks. 2. Keep more trucks inside of the loop for posting. The vast majority of our calls come from inside the loop, so it doesn't make sense to me why we should have a truck sitting at 36E when we only have a few trucks near the heart of the city. 3.Allow a private ambulance service to come in and take the priority 4 and 5 calls so that we can focus on 911 calls as opposed to pulling a truck off the streets for a patient that only needs to be taken home from a hospital. 110 more shifts more people more pay and equipment that would be maintained a little better AKA the ambulances they have a half ass attitude about keeping the trucks working 111 put more trucks on the street create a separate transfer fleet for P4 and P5 calls stop taking emergency P3 psych transfers in the middle of level 0 times. when system level is low create a policy to transport pts to closest hospital or at least within the downtown area or closest facility for outlying area. we should not be level 1 and transporting to Harris NW, Wise County, or Dallas. If pts are sick enough to go to er by ambulance, they are sick enough to go to closest er. 112 DISABLE ROAD SAFETY... Go back to posting plans similar to R/M (we made compliance with those plans) Do not breath down people necks when they are breaking their back for you, people respond better to being treated nicely than when people are trying to find every problem possible with them so that corrective action can be given. This also goes for EPAB. 113 The major thing is that we need more crews. When the compliance is low they will do a large hire in. The problem with that is the people that they hire are serverly under qulified. I understand that everyone has to start some where, but when you are dealing with peoples lives you have to be able to act without thinking. People who are qulified that do not work for medstar refuse to come and work here because either medstars reputation or they know people who they refused to work for 114 ENFORCE actions pertaining to dispatching errors. LISTEN when Field Personnel talk about dispatching problems. STOP allowing the DISPATCH manager to continue seeing dispatch personnel as "controllers" CHANGE the "control" mentality back to DISPATCH. Look at how Fire and PD dispatching works, compare it to OUR dispatch... and look into the discrepancies. Our dispatching systems leaves a LOT to be desired. For people that get paid MORE than the field personnel (who are the ones that are actually doing the work we are chartered to do), they seem to have NO idea how to make the system actually WORK. Obviously we need more people, more ambulances on the street at any given time. Barring that, we need some actual common sense in dispatch. How many times are we dispatched halfway across town, only to PASS other available units while on our way to a call. And when emails are sent to the dispatch manager, a week later I got a response stating that she hadn't yet gotten time to even read my email. 115 more staffing correct routing error stess sense of urgency 116 There is a peak hour period around 4pm to 8pm where many trucks are going home or coming out from post 4. There has been an issue where there are not enough trucks avail to make a smooth switch over which adds to the problem but I believe they are obtaining some more trucks to help with this but they might consider adding a couple regular parttime shifts from 3:30 to 8:30 to make the transistion time more smooth and assist with the added call volume during these hours or they might offer these as as overtime shifts when other shifts are full in the system. They have tried multiple options

MedStar EMS System Review Page 12 © Fitch & Associates, LLC Fort Worth, TX May 14, 2008 AMR 04796

Appendix B – MedStar Employee Survey Results Question 9

9. Response time compliance was a major challenge for the previous contractor and remains a continued issue for Medstar today. From your experience, describe three things your organization can do to improve response time reliability? [Please try to consider actions in addition to/other than adding resources and personnel] to rearrange the shifts to cover this peak overload time and have been unsuccessful and caused different overload times so they need to consider new options not the same old thing. Night time staffing numbers drop too low! If even a small multipatient incident occurs during this time there are simply not enough personel to cover the system. I know they don't want people sitting around but for the safety of our cities we need to add a few night time shifts. It is nice to say people need to clear the hospital faster etc but in reality charting must be done as accuratly as possible so delays are just going to occur on calls requiring lots of meds or treatments or calls with very short transport times where not much is accomplished enroute. The trucks with 3rd person riders actually seem to get charting done easier but there is no money to add a person for that so delays will happen. delays leaving post 4 occur but maybe if there are 5 or more in a quarter the medics on the truck should be spoken to by the supervisors. Some crews seem to never go out on time but legitimate truck or supply issues should not be penilized or disciplined it just makes for a negative work atmosphere. Instead make it a positive to go out on time daily. Rebidding shifts constantly has been a problem in the past. It disrupts peoples lives and people quit each time it occurs. 117 118 If they allow a "check out" time for employees to have lunch breaks if the truck has been running non-stop for most of the shift, then maybe hospital times would decrease. Perhaps having set "districts" throughout the city for which a crew would normally be sent to reguarly would decrease routing errors. If there were set sections then each crew could get to know their streets and area, and could get around it with ease. They would know about construction, road closes, and traffic patterns during their shift. Another way to get things running faster would be assigned trucks. If there were set crews on trucks, we would know if there were problems with it allowing for less downed trucks for maintenence. 119 better posting plan, more reliable trucks, ability for fd to cancell us from calls that do not require us to make the scene to allow us to get to calls where we are needed 120 Get rid of the system status management plan. Farm out the non-priority transfers. Reconfigure the road safety program. 121 Management philosophy first. I believe whole-heartedly that the current management approach to response time is designed within a vacuum. Deployment plan development is limited by resources alloted to the plan leaving a very precise and lean plan which leads to most of the response time issues. Field staff are exhausted and begging for short breaks; for bathroom, warm food, and a few minutes to stretch. Almost every post has no available bathroom, especially at night. It may be a good idea to place several stations across our area to allow a place to meet those needs, even if only for 10-15 minutes every 4 hours or so. There should be a careful mix of dynamic deployment into areas with decent "break areas". I'm NOT suggesting 24-hour stations or even stations for that matter, simple "break" posts. This will help chute times, I believe. The field staff tend to manipulate their times when they're exhuasted and frustrated. We don't like doing it but we do it or have done it when we go days in and out without a moment to breathe. 122 I hate to say it but...... enforce drop time compliance and start and end times. it only seems logical. If we have all this data on TOD/ DOW call info, shouldn't we be able to design a more efficient plan to cover these calls? The culture of the core of medstar has become one of taking care of one's self vs. supporting each other. This is at the heart of the problem. I see this as a direct result of a failure of leadership. 123 Increase the number of shifts and ensure all shifts are staffed, when special events or bad weather is expected add additional shifts, have supervisors or crew members with no partners go to scenes where there is a large amount of paperwork to be done and assist with reducing those scene time, add another computer to each truck or allow paper release at scenes to be turned in and have billing or light duty staff enter them

MedStar EMS System Review Page 13 © Fitch & Associates, LLC Fort Worth, TX May 14, 2008 AMR 04797

Appendix B – MedStar Employee Survey Results Question 9

9. Response time compliance was a major challenge for the previous contractor and remains a continued issue for Medstar today. From your experience, describe three things your organization can do to improve response time reliability? [Please try to consider actions in addition to/other than adding resources and personnel] into the computer, have 95 assist crews with cleaning up after messy or ACLS calls. 124 I dont understand how you say not to add resources and personell, their is not 3 certain things you can say to make this miraculous change in compliance, it comes down to personnel retention and wages, it has been said way to many times and no one listens, the only way to cover the large service area we have and do it meeting compliance is to staff more units and put them on the street, you cannot keep these units on the street if these people keep quiting, and why do they quit? because they get other jobs paying more money without having to run 13 calls an a12 hour shift with no lunch break, no pee break no time to breath!!! 125 1.) The manager / supervisors over this area need to be on top of late starts. This can be done by reviewing the late staarts on a daily basis and speaking to the crews that we late. 2.) The manager / supervisors over this area need to be on top of getting the units out of the hospitals in a timely manner, by simply watching the CAD view and placing a page to the crew. 3.) Encourage staff to show up to work. 126 More trucks at posts when call are dropping means shorter response times. We will never make response times when we are constantly "catching call" from the hospital ambulance bay. 127 I know you say try to consider actions and not so much staffing but come on. If everyone is saying that dont you think you should really look at that. And then look at why we dont have the staffing. Such as low pay, the work enviroment within the company. But looking at actions look at the old system when they use to make compliance. Why did we make it then. I dont have the answer besides staffing. THAT SEEMS LIKE THE MAJOR ISSUE!! 128 when level "0" start m54 and m33 closer into the city find a different level 1 post besides burleson or start the truck in burleson into the city when system gets down to level "1" teach crews that dont know correct routing 129 holding crews responsible for routing errors/making crews know our service area better - these are senseless lates calls having the ability to staff 1 or more units during the day in the event of overload of emergency calls and/or transfers a better way to facilitate pt drop off/exchange of care at the ERs more time off for employees allowing them to regenerate after long hours/multiple calls in a shift - allowing everyother weekend off to allow some normalcy (regular events scheduled - ie birthday parties, family gatherings FUN) in a somewhat abnormal job 130 1- let the original MICU finish the origianl call instead of figuring wich one is closer. 2- more indians less chief 3- place people in upper management that actually now about 911 system not numbers. 131 as mentioned, in addition to adding resources and personnel, retention needs to be considered....think about it, a person who has been here longer knows routing issues better.... possibly better posting plans (I havent found any one in particular that works a hundred percent of the time) with the addition of resources and personnel, possibly "stations" in outlying areas of the city or county to improve response times..... a different dispatch system needs to be in place, dispatchers who have proven themselves capable of unbiased and competent dispatchers can be given more leeway in how calls are dispatched.... 132 1. Fix routing errors by holding people accountable 2. Enforce shoot time standards (whether to post or call) 3. Enforce drop time standards 133 1. Hire part time staff to cover openings and create power shifts to cover gaps in units able to respond for requests for service. 2. Arrange a Scheduler to coordinate staff for shifts and the ability to place trucks on the street and allow full time staff the flexibility to get off shift and take vacations and make work functions. 3. Employee awareness of the response time compliance throughout the month. 134 1. I believe that this system needs to implement some static posting along with SSM. This system is too busy and short staffed for SSM to be effective without killing the

Appendix B – MedStar Employee Survey Results Question 9

9. Response time compliance was a major challenge for the previous contractor and remains a continued issue for Medstar today. From your experience, describe three things your organization can do to improve response time reliability? [Please try to consider actions in addition to/other than adding resources and personnel] crews. Just 4 more stations of static posting in the far regions of the district would help. Then fill in the core with SSM resources. 2. Utilize the basic units more. Especially for transfers. We are headed in the right direction with the als units but I think we could utilize bls units as well. 3. Shorter shifts to prevent fatigue in crews. 135 We could re-evaluate our deployment plan, educate the public on the proper use of 911, other than those the addition of more resources would greatly improve our compliance. Hypothetical example, 15 people call for an ambulance and we only have 7 ambulances available, that leaves 8 people waiting for help. How can we meet compliance when we do not have enough resources to handle the amount of calls we have? 136 have a greater knowledge of the geography, more intense mapping classes, continuation of testing throughout employeement 137 1.Keeping current personnel at MedStar. 2.Listen to the employees who do the this work daily and would have great insight to what might need to be changed to meet compliance. 3. A better schedule to meet the employees needs so that they are not so tired and have time to spend with their families. 138 reliable vehicles, more staff, consider core 24 hr units along with 12 hr/ 16 hr float trucks. 139 Being in billing it is very hard for me to come up with suggestions to improve response times due to not knowing what dispatch and the crews have to deal with. 140 have com center stop moving trucks all at one time com center could use post that dont have all the trucks on one side of the city have com listen to the feald units when the unit states that the call is blocks from where it is use post that are good for respoding to all of coverage not lev 1 post of 119 aa as a lev 1 post 141 The issues for Rural/Metro are the same as the issues for AMR before them, and are the same issues that seem to confound MedStar today. I used to think compliance was based oncomplete staffing and that is probably close to true. The better we are staffed the greater our chances of making compliance. The issue that management seems to be missing is that we can not keep primairy paramedics. AMR couldn't do it, and Rural/Metro couldn't do it. The question weshould be asking is why is staffing such a huge challenge? It is a challenge because I can go somewhere else and get almost equivalent pay, if not better pay, and have less stress. Maybe at a fire department, or maybe at another private service. The stress level is insane. There are somany people telling you what to do and how to do it. It is like death by a million tiny lacerations. Most of us got into this field because we liked the relative autonomy of it. If we wanted someone breathing down our necks all the time we would get a 9-5 job with a supervisor in the next cubicle. I will be completely honest about this... I would have left a long time ago if MedStar wasn't paying me so well. I'm a 13 year medic, and I can't go anywhere else and get the starting salary I have here. MedStar is competing with fire departments which work 24/48 shifts and run a 10th the call volume and pay at least as well if not better. MedStar also competes with other EMS services that are paying better and better every day with loads less stress and call volume. Also, I've noticed that even when we are level 0 with calls holding that when we finally arrive at a call the FD is there. They are always there. Maybe it is time to look at the SSM model. Maybe we have reached a critical mass and need to change the way we think about EMS in Ft Worth. Maybe it is time to start doing it like the FD does it. It would eliminate the employee retention issues and solve compliance problems. 142 Without adding resources and personnel you woud have to focus on retention to ensure the schedule is full. The bottom line is unit hours in the right place at the right time. In order to accomplish this you need to reduce the number of lost unit hours from lack of personnel. You could also ensure that more MICU trucks are available by ensuring tranfers are handled by regularly scheduled ALS trucks. You would also need to work on the posting plan and ensure accountability for dispatch decisions on calls and post assignments.

Appendix B – MedStar Employee Survey Results Question 9

9. Response time compliance was a major challenge for the previous contractor and remains a continued issue for Medstar today. From your experience, describe three things your organization can do to improve response time reliability? [Please try to consider actions in addition to/other than adding resources and personnel] 143 In the billing office, I really dont have enough knowledge of the field operations to even form an opinion on that. 144 1. The ambulances should be directed by the communication staff themselves instead being computer lead. 2. Improve the morale of the crews the compliance time will improve. 3. Find some way to decrease the high turnover rate. 145 Make field crews accountable. 146 More call takers to ensure the 911 lines are being answered. Hold crews accountable for shoot times Move on post assignments when notified Get rid of the Code 6 rule and go back to holding over an hour after shift to keep calls from going unanswered. 147 pay people better and they would stay longer. consider offering better shift opportunities get away from system status management 148 1) Posting Plan The current posting plan is like a dart game. We throw a truck at the city and hope it hits close to where the next call is going to be. The plan changes daily which is better than when it changed hourly however with some consistency in the plan I feel dispatch would do a better job at assigning recources. In addition field crews would have a clearer picture of the status of the system based on where they were posted. It is hard to fix this without additional recources but with consistency in posts crews will become more famililiar with the routes between posts and to calls. 2) Inexperienced Employees Working Together With the current schedule we have shifts that are so undesireable no one wants to work them. The few shifts that actually allow time to spend with family are taken by those with senority leaving new employees forced to work with other new employees on poorly designed shifts. This makes for unhappy employees who leave Medstar who are then replaced with more new employees who fall into the same cycle. If a more employee friendly schedule was used those with more experience would feel comfortable working a larger number of shifts leaving them available to work with those who have less experience. We have been told by management repeatedly that routing errors are the reason we are not in compliance. Although I do not feel routing errors are the main reason for our compliance issues they are a part of the problem and happen too frequently. I believe this can be directly related to inexperienced crews overwhelmed in an understaffed, overworked system. New employees cannot be expected to know every sidestreet and be expert map readers when partnered with other new employees when they have both been given very limited time with a DTO to learn the city. Management should also not post snapshots of routing errors in the crew lounge for everyone to see in an attempt to blame field crews ... Out of characters. 149 well i hear that a general rule of thumb is that you should have atleast one ambulance per every two fire stations. i would imagine that there are around 50 fire stations in our service are and last i hear we have fort worth and 15 member cities that would make 16 cities. with that being said i would imagine that we might be falling short alot of the time since i think we have fewer than 15 ambulances most nights. i think that with less ambulances then we have cities and not near close to 25 wich would cover the rule of thumb you just cant expect to come close to compliance. we run most of our calls in fort worth and yet we put a truck in burleson for level one coverage i realize that polictics is the reason for this but i think that we should be alittle more concered with pt care and less about politics. i think that we need to pull in the north station and 33 when the level starts getting low around 2 to 4 instead of waiting for level o. i think they should go back to the posting plan that rural metro was using. they can say what they want but i think that we were alot closer to making compliance with them than we have been since the athority took over so i think we should look back and see what they were doing right. 150 tempering U call,we haul. With is it medically necessary to use A) an micu,B) a hospital 151 Scrap our upper management - they are woefully out of their depth and have no idea how to retain employees, nor give the system the attnetion it deserves - they are mainly concerned about their own jobs. Scrap system status - it doesnt work - that is

Appendix B – MedStar Employee Survey Results Question 9

Appendix B – MedStar Employee Survey Results Question 10

10. While most people can identify several opportunities for improvement in your workplace or the operations, often there are a few specific issues that are creating the majority of your frustration. What are those issues for you? 1 when an employee asks several management personnel the same question after being denied no consistancy with management responding to employees (it's about who you know and how loud you stomp, determines if you get the answer you want) 2 Dealing with an entitlement mentality, negative attitudes, failure to hold people accountable. 3 Lack of Leadership. Ineffective and inefficient Operations Manager. EPAB over-stepping their boundaries and undermining what the Leadership Team is trying to accomplish. EPAB is inconsistent with policies/procedures. No communication between Management and Field employees. No positive publicity for MedStar. Lack of community involvement with our System. 4 1. People should be held equally accountable. Here some people get away with things that others (who do the exact same thing) would be terminated for. 2. When issues are brought to higher management about some of the middle managers, NOTHING is done. The perception is that he does not care and is not going to do anything to change things around here. Most people are giving up as a result. 5 Lack of follow through by management. Lack of accountablity accross the entire company. The company is currently being held hostage by the employees and it is time for management to take it back. 6 Big frustration is nothing has been fixed. We have done survey after survey and nothing has changed and we keep loosing people. We had a survey and it showed most people thought we needed new managment yet they are all still here. I dont understand how we can opely show they cant get it done yet they are still leading us to nowhere. We still have a command structure were everyone is equal and no body is responsible for anything. They get away with murder and nothing has changed. 7 Failure by Some members of the leadership team to remain part of the team The show of disrespect of management peers Mistrust and the feeling of a hidden adgenda from peers 8 Incompetent leadership; failure to accept responsiblity; failure to give credit when and where due; leadership in denial 9 Management making decision that fall short from the core values. Department heads feuding and trying to sabotage their respective departments. Poor decisions that create bigger problems for the organization as a whole. 10 The current leadership team creates more frustration than anything. It seems they don't work as a team to accomplish goals for the organization. Lack of communication to the organization is extremely frustrating. We have e-mail and we need to ensure all is reading them. Also we need quarterly staff meetings. They have attempted to help with this but have failed in my opinion. IT issues are a daily frustration. The inter- departmental wars are sinking this company. Examples are constant he did this she did that between the communication center and field staff is making us fail as an organization. There is no teamwork within this company. There's only cut throat moves being made and everyone needs to understand that when one area fails the whole organization fails. We need to work more as a team. Blame game doesn't work. 11 The most frustrating thing to me is the inconsistency of our managers in all departments besides billing and HR. They all have the same power and when they disagree, they get all tangled up among themselves and this type of stuff runs down hill. Bringing in an Operations Director is a very good thing and has been suggested for the past two years. I feel this will put a stop to this problem. 12 Low Pay Disciplinary Consistencies Well Maintained Equipment Chain of Command-Too Many Chefs not enough helpers. Employee Retention Hiring A person instead of Hiring a New Employee. Respect Gratification for Others Bigger Uniform Allowance 13 1 pay is too low 2 our EPCR's shutdown sometimes and we're unable to finish our charts 3 fort worth mayor and council members to care less about us and just wanna cover their butts just enough to satisfy the public. 14 1. We do not have the support of the various city councels. They want the most service

Appendix B – MedStar Employee Survey Results Question 10

10. While most people can identify several opportunities for improvement in your workplace or the operations, often there are a few specific issues that are creating the majority of your frustration. What are those issues for you? for the cheapest price. Then they complain when we have response issues. 2. We do not have the support of the AMAA board members. 3. We need real differential week-end pay. We need night shift differential pay. 15 The major issue for me is upper management. They are very inconsistant and a few have such a bad attitude towards everyone. Chris Cebellero likes to get into peoples face to get his point across. This should never ever happen. 16 1. SALARY is horrible. I can make the same amount in retail and have benefits just as good or better with much less stress and will have an adequate knowledge of exactly who my boss is and who I am supposed to answer to versus getting scolded from every member of management for the same issue because none of them know what the other is doing and are always trying to "one-up" the other 2. SSM in our system is ridiculous. My partner and I keep up with mileage and in a 16 hr shift we average approx 150 non patient-loaded miles per 16 hr shift and are lucky to make it to a post for the first 8-10 hours of our tour of duty. 3. Fleet maintainance is virtualy non-existant in our organization. Our trucks have bad brakes, leak diesel fumes and exhaust, air conditioning does not work, shortages are rampant in the electrical wiring (siren malfunctions), light bulbs are out, trucks have excessively high mileage, the trucks are FILTHY in the patient compartment. When these issues are written up and submitted to supply and fleet you will be in the same truck a week later with the same issues. For instance MedStar 47 has a short in the wiring/swithc that allows the rear load lights and pt compartment lights to flash on and off. I personally have reported this issue 3 times in writing via the proper method/form. This issue is yet to be resolved and creates a danger in blinding a driver behind us who might think that we are signalling that we are having an onboard emergency and I have had members of the general public note that it looks like we are playing while driving down the road. 17 All 24hr stations need to be on a Tone System for the entire 24 hrs they are on, only using the main channel for traffic that pertains to the call (i.e. when toned, crews turn to main channel and state their number and waiting for call info, etc. until they return to their Station. 18 Dispatch- they don't always give the call to the closest unit. Non-emergency transfers...... let someone else do them so we can focus on 911. We need better pay! I am barely making ends meet with the cost of fuel and no raise! 19 I believe the majority of my frustrations is that management thinks we field crews are stupid. they believe we believe everything they tell us when they keep making promises of improvement. i wish they would just be upfront and honest. they might actually be suprised by the reaction they get if they told us the truth about things instead everything being a secret. For example, the last survey was edited alot before they sent it to all the employees. why, for what? why edit out what everyone was saying specifically. why not leave all that in. we employees knew alot of bad stuff was said about upper management, specifically jack and dan. another way of medstar lying to the employees. 20 upper management is the worst i have ever had to work with or for. Clinical dept is non- functional once someone is out of the training process. HR is very inconsistant in how they follow through with issues. Often mgmt has out right lied to the crews. Pay and benefits!! Properly maintained vehicles 21 communication and pay 22 Scheduling, training programs, and pay are major frustrations. Also inconsistency of treatment of employees is a major problem. Some employees are given extra chances that other employees aren't. 23 Lack of communication from management to field personell. It is still an issue that has not been resolved. Medstar still focuses on the negative that its employees do, not the positives. 24 Management that will listen to ideas and thoughts, and the balls to do something right. Lets get rid of the "Clinical people who run their classes like the military. 25 When I need an answer from the clinical dept. they are hard to reach and they never

Appendix B – MedStar Employee Survey Results Question 10

10. While most people can identify several opportunities for improvement in your workplace or the operations, often there are a few specific issues that are creating the majority of your frustration. What are those issues for you? return your phone calls unless it is convenient for them. EPAB has way to much authority over our careers. We need standarized protocols given by a Doctor and leave the rest up to the Medstar Clinical Department after the qualified personnel are in place. QA/QI should be done by Medstar and not EPAB. EPAB should only furnish the protocols. Whats up with all of these managers and departments. We need a better chain of command set in place before any of the future changes will work. I dont mean get rid of some individuals but put qualified people in the positions that are currently in place and take some of the rank away from these so called managers and make them supervisors of the departments. Manager is a big word to use for some of the positions some of these unqualified personnel hold. We need a bonified President and Vice President and CEO and CFO and all the normal titles a modern corporation has. 26 scheduling Pay Lack of medstar involvment in the community. I don't think we should just be the "ambulance drivers" I think think if we want a better name for our selves we need to be more involved with the citizens in all the citys we provide care too. 27 Managers interfering in departments other than their own. Worrying about how other managers are running their department. People who are not qualified to perform their job relying on others to pick up the slack and then blaming those same individuals when there are problems. No communication to the "middle management" besides, these are the decisions made for the organization and it is our responsibility to explain and support these decisions without understanding the decisions made by the Leadership Team. Inconsistency amongst the management team to support their own decisions. Don't decide on a policy that you aren't going to enforce and then expect others to adhere to that same policy. Always asked for feedback or opinions but not getting feedback as to any results/resolutions. Not getting the support/backing from the management team when doing what has been asked of us (consistency) when someone else doesn't agree with the outcome. 28 1) Inconsistency in application of policies. 2) Employees "shop" until they get the response they want. 3) ALL of management needs to work together. 29 Im not really frustrated with any specific issue. Mostly i come to work and do my job, then go home and forget anything that upset me the day before. 30 For me it is currently pay... In the almost 5 months I've been in paramedic school with medstar, I have lost everything in my life I worked over the past two years for... I'm on the verge of losing my home because I cannot work overtime, nor can I make it on 800 every other week. I think that is part of why we loose people to Fire Departments, versus other EMS services... The pay/work ratio is very diffrent.. 31 Upper management does not listen to what the field crews have to say. They expect us to go above and beyond for them on a daily basis without showing us that they are willing to do the same. They need to come out in the field and actually see what we are doing. 32 see number 9 33 management salry equipment malfunctions 34 not enough trucks on the street, and i think we need to be paid better for what we do 35 dont have any issues as of now 36 communication within the company. many times i have been told that i need to talk to "this person" with an issue, they tell me that i need to talk to "that person" who tells me i need to talk to someone else. originally we were told that when the authority took over the contract, that we would be able to speak to management or ask a question and that we would receive feedback in a timely manner, now you constantly have to keep asking in order to receive an answer. management also wanted to know what some of the ideas employees had to improve the system. now it seems like most of the employee suggestions get tossed into the trash. 37 Again I must say that PAY is the biggest problem within this system. There is simply no reason for paramedics in general much less in this system to be paid so poorly. I think that if we all come together and prove our worthyness then we can get the pay. The reality of the matter is if I were to go to FWFD now I would increase my pay about

Appendix B – MedStar Employee Survey Results Question 10

10. While most people can identify several opportunities for improvement in your workplace or the operations, often there are a few specific issues that are creating the majority of your frustration. What are those issues for you? 12000 a year and run less calls. Not only that but if you look at the stats for FWFD you can see that they only run 2000+ fire calls a year and over 50000 ems calls. So why are they getting paid 12000 more a year to run a couple of fires and less ems calls? This is a question that I am bringing up in the meeting with Jack on thursday. When you step back and look at the reality of things you will see that money will make or break a paramedic. I love my job and I wouldn't trade it for the world but I also have to feed my family and here at medstar I am finding that not feasable. I just in the last couple of months had to force my wife to get a job just so we can make the bills. I made a promise to her when I married her that I would let it allways be a choice of hers but now that I am here I have to take that option away. When you don't pay your people enough to live decent in the area that you serve then you are going to get the people that will settle. Those are not the medics that you want in a system. You want medics that want to be at work and don't have to worry all shift if they are going to make the bills that month or not. I spent 3 hrs with a newer employee in the er on sunday night that didn't realize that working 7 days in a row at the star can literally cause physcial harm. He found out the hard way and I am sick and tired of having to preach that our pay here is just not cutting it. Overtime here is not a option for too many employees as it is a nessissity. (sorry doing this at midnight after a 16hr shift.) 38 Managers, do your job. Rather than focus attention on doing their own job well, many managers choose to "solve" the problems of other departments and undermine the efforts of others. Examples: 1) EPAB has made repeated efforts to change the SSM. 2) They intentionally shortened a proven academy (which is the responsiblity of the clinical department) to "get more people on the streets". This decreased the quality and training of new hires, and then they attack the clinical department when these employees take longer to train. 3)The operations manager and HR manager consistently interfere in clinical issues. Staffing. The HR department has 5 employees, while Clinical has 3. Similar size systems have between 7 and 15 FTE's doing the same clinical job. Our HR department wastes money on additional personnel simply because the manager is unwilling to do her own job properly. Lack of results. 1)This is the second survey we have done recently. No measurable results have been achieved. What are we paying for? 2)The operations manager has done nothing to improve this system. He delegates unrelated duties to operations supervisors who should be on the streets and creates "admin truck" schedules where entire departments are depleted for multiple days per week. EMS is the only industry where his level of incompetence would be tolerated. 3) EPAB boasts "high patient care" yet does nothing to support training. They force the operation to purchase equipment that is not necessary while undercutting the clinical department and training. Quarterly CE's do not reflect clinical advancement, only new "toys" and verification of skills. 39 Wages- Start paying the people what they need to be paid. I recently found that a person that a high school grad is making more money than me and is a clerk at a business. this person started less than a year ago at this business. I have been in the field for over 10 years. Why is that? We have to know medications, we are out there trying to save lifes for pennies. Policies - start using the policies equal with everyone. It is not good for one but bad for another. If one is married to another employee no matter how long they are here. they need to aplly all rules equally. maybe even get rid of policies that limit family members working in different deptments. Attendance policy - I think that medstar needs a policy on this. However the policy that we currently have is in no way a working standard. I believe that if you have the time to take and you or your family is sick then you should have that right to take off. Have it like school. have after so many unexcused absences the person is released. There are a lot of persons in this field who are single with kids. When their kid is sick and needs to be home... the employee has to be there. Medstar needs to understand that Over all improving how upper management treats their employees. You want to make this work, cut the amount of chiefs and add more indians. There is way to much fat upstairs. stream line it and make it a chain of command not a dept against dept attitude.

Appendix B – MedStar Employee Survey Results Question 10

10. While most people can identify several opportunities for improvement in your workplace or the operations, often there are a few specific issues that are creating the majority of your frustration. What are those issues for you? 40 Bad attitudes from some crews,supervisor not working towards the same goal, and managers not taking responsibility for their superviors. managers can make it happen! 41 1. to be frank, we have certain managers who have an idea how their department should function but are not good leaders or managers of people. 2. most of our managers have very little knowledge/ training or experience in their field, and are not good leaders or managers of people. 3. our "leadership" team, and i am referring to the managers, are more interesting in protecting their turf and stabbing each other in the back, rather being a team that they are ineffectual. from the top down there is an apparent decision making disorder, that is unless your idea of a decision is a knee jerk reaction made without consulting anyone affected by the decision or involved in the situation. 4. i am often struck by the thought that they have attended several hours of demotivational training. it seems that they will make decisions that are designed to make the day as emotionally/ mentally exhausting for our crews as they possibly can. most manager meetings usually involve sitting around the table listening to the managers of the comm center, the supply department and fleet blame all the problems of the world on the field crews while the clinical manager is convinced that the solution to these problems is to make the field crews work harder, idle hands being the devils work and all. of course the operations manager attends these meetings too, he's the one with all the knives in his back. 42 1. Calls 2. Crossing trucks 3. EMD system needs to have personal disgression 43 As a system, not only do we micro-manage our people, but we also push them to work harder, faster, longer....instead of hiring more people and creating a satisfied work force....we constantly work short handed, and then just push the people we DO HAVE to work harder, run more calls, move faster....but "don't get sick", "you're not a team player if you take time off". We "beat" these people down, we "kick" them when they do go down, and then....when they have finally collapsed, we "sell them off to the glue factory". It sounds rediculous, but we treat our people like they are expendable.....we seem to have lost sight of the fact that these are human beings, with families, and lives, concerns and feelings.... 44 1. Accountability by Management- All managers want to do is point blame at other people rather than take responsibility for their own mistakes. 2. Communication- This survey points out a huge problem in this area. It is e-mailed out to all employees but only 40% of the company check their e-mail so nobody knows about it. 3. Inivisible Management- The only time you deal with a supervisor or manager your in trouble. All they do is sit behind a desk and make up policies to make things difficult. 4. Management structure- I have no organizational chart or chain of command. I report to 22 different supervisors or managers and they all have equal power so nothing ever gets done. 5. Lack of direction from the AMAA Board- This board has no idea what we do on a daily basis yet makes decisions that impact our job. They are clueless and have been lied to for the past 2 years so they have no clear picture whats going on. 6. Finances- Without the money we can't have the people or resources we need to make this work. 45 our equipment that we have to work with MONITORS!!!! i miss our lifepack 12 constant post moves.. if i'm not running calls then i'm driving around the city. wow! do i really want to come back to this place. 46 There is no structured command for MedStar, there is one executive director who has 8 managers of equal status that all have their own agenda which is fighting for the top spot of who is in control of MedStar which is no one and no one person is in charge of running MedStar. There is no unified front, there is consistent inconsistancy with the MedStar management. MedStar is in complete diseray and discombobulated with no control. 47 Fairness Sometimes, supervisors can be rude and not willing to help when you are having issues. Treated equally. 48 Not being able to call in sick in fear of losing my job, when I have the sick time. The supervisors are more interested in finding fault against employees. Example, we get a

Appendix B – MedStar Employee Survey Results Question 10

10. While most people can identify several opportunities for improvement in your workplace or the operations, often there are a few specific issues that are creating the majority of your frustration. What are those issues for you? phone log every Monday to highlight our personal phone calls. We are like robots. The supervisors have their computers set up so when we get up, they can look over their monitor and see what we are doing. Isnt that micro-managing? 49 Being treated like children. our phone calls are monitored and checked weekly, our emails are read; we are constantly being watched by supervisors. 50 Lack of communication between the supervisors/employees. Rudness of the communication from the supervisors. They say we are all suppose to be a whole company, but the business office is treated differently then the Field side. We cannot go to the HR department with our frustrations, due to the supervisors will retilate against the employee. We all have seen this happen first hand. 51 billing office unit rotation is a frustration. everytime we switch we get behind and just as you learn and improve your daily totals they change you again. We work hard to get money in the door and are doing a wonderful job doing it. It just seems like a mind game getting it done. 52 We have out grown the building and many people are working in spaces that are extremely cramped and hard to work in. In my department I have no office and it is very hard to concentrate and be productive. Supply is very cramped and hard to organize and keeps things orderly. 53 1. People that work here don't seem to care about the job enough to do it well the first time and then spend so much time gossipping about why they had to correct the mistakes. 2. It seems that so many want to work over time to get the higher pay that they are not putting forth the effort to getting tasks done in a timely manner. 3. Morale is low and that lends to the above problems, most feel we are being micro-managed by our office manager and the supervisors and there is not enough delegation of responsibilities or trust between management and employees. 54 I have no frustrations 55 Work structure in the billing office. Cross training is great, but switching positions so oftem causes us to fall behind. We should be allowed to stay in the areas where we are the strongest. 56 I feel there could be some changes in the way attendance and tardy points are given. If a person is late because of a accident and it can be verified, then a point should not be given. If a person has to call in and there is no more than the 3 people out a point should not be given (business office). If a person needs to leave early for any reason and its 2 hours or less for the day to end maybe a tardy point can be given if they are over the 3 allowed that are out. 57 58 1. The way that we are unable to communcatate among ourselves in the business office. 2.The way that we fall behind in work and then in one week try to play catch-up and get behind all over again it is a never ending cycle. 3. There is suppose to be an open door policy that seems to be always closed. What I go an tell HR should stay with HR and no one else. We have a trust issue and it does not seem to be going away. 59 MANAGEMENT. The current upper management of MedStar, to exclude the "front line" supervisors, have their heads in the sand. The organization is struggling to keep staff while these managers sit on their pedastals and blame some other manager for the downfall. There is very much a "good-ol boy" mindset here, if you ever get on a managers bad side, you can bet your days are numbered. We need new leadership becuase the current group of those with a MANAGER title, are so caught up in their agendas that they are completely unable to change their ways. It's been taught to them, bred into them throughout the years, and I believe it's beyond repair. We need new leaders in these positions, with some documented leadership skills and training to get this company back on track. We need a new Executive Director, a new Business Office Director, a new Clinical Director, a new HR director, and a new Ops Director. The current leaders mentioned above are completely incapable of changing, they all are against each other when it benefits them personally, and there is no leadership or "lead by example" coming out of any of them. They're all like teenagers in high school, yet in

Appendix B – MedStar Employee Survey Results Question 10

10. While most people can identify several opportunities for improvement in your workplace or the operations, often there are a few specific issues that are creating the majority of your frustration. What are those issues for you? positions of power to affect subordinates lives when it makes them feel good. If you piss one off, you can bet that you will be nit-picked to death until you're fired or you quit. This company, in its current state, is not about the employee, it's about the how good the leadership can make itself look when the world is crumbling around them 60 The only thing for me is just the point system because sometimes people get sick and you end up coming in and making everyone else sick when you are contagious. I think it should be there but if you have proper documentation and there was a valid reason for being out then you shouldn't get a point. The only way should get a point is if there's not a valid reason or you don't have documentation from the doctor. (But it isn't a huge issue) 61 62 Having to obtain so many signatures for each patient encounter. Again : HAVING TO OBTAIN SO MANY SIGNATURES FOR EACH PATIENT ENCOUNTER. To complete an AMA, I must obtain 5 separate signtures in addition to mine. A transport requires 4. That's insane. 63 1) EVERYONE IS NOT TREATED FAIRLY, MANY PEOPLE HAVE MORE ADVANTAGES THAN OTHERS. THE RULES ARE NOT FOLLOWED BY EVERYONE IN THE COMPANY OR ENFORCED TO BE FOLLOWED BY EVERYONE. IF RULES ARE SET AS FAR AS DRESS CODE, POINT SYSTEM, TIME OFF, OR EMERGENCY LEAVE THEN THOSE RULES SHOULD BE FOLLOWED BY ALL EMPLOYEES INCLUDING MANAGEMENT. 2) THERE ARE MANY EMPLOYEES WITH MORE EXPERIENCE/WORK SKILLS THAN OTHERS BUT GET IGNORED FROM PAY RAISES OR ADVANCEMENT. MANY TIMES IT SEEMS LIKE THE POSITION YOU ARE IN IS WHERE YOU WILL STAY NO MATTER HOW HARD YOU WORK OR HOW MUCH EXPERIENCE YOU HAVE. 3) THERE IS NOT MUCH COMMUNICATION WITH WHAT IS GOING ON AROUND US OR THINGS THAT NEED ATTENTION UNTIL SOMETHING IS DONE WRONG THEN CORRECTIVE ACTION IS BEING TAKEN. IT SEEMS LIKE YOU ARE COMING TO DAY CARE INSTEAD OF WORK. SUPERVISORS CAN TAKE SEVERAL BREAKS AND LONG TIMES AWAY FROM WORK EVEN IN THE SAME DAY BUT IF AN EMPLOYEE HAS TO LEAVE ON EMERGENCY A POINT IS ADMINISTERED OR IF WE ARE NOT AT OUR DESK BY THE TIME OUR 15 MINUTE BREAK IS UP THEN WE GET APPROACHED OUR BREAKS HAVE BECOME 12 MINUTES INSTEAD OF 15 TO GIVE TIME TO MAKE SURE WE ARE IN OUR SEATS TO AVOID THE SITUATION. 64 One of my biggest issues is the "on a whim" policy production. A while back, Jack decided that only one employee per day could take a vacation day off. He related this to a "staffing crisis." We've been in a staffing crisis as long as I've been here so there was no acute change. This policy was not communicated to the staff so were left to try to find our own coverage when all of our vacation was being denied. It wasn't until I contacted several people that I found out about the one employee per day policy. Another policy apparently has been created this week about parking before clocking in. There was no rationale or notice for this policy. Somebody decided it was going to be a policy so they taped a sign to the door. This kind of haphazard policy establishment and communication creates confusion and extreme frustration. Another area of frustration is the point system. We are assigned a certain number of points allowable for tardies and absences based on our regularly scheduled shift. Those of with 3 16 hour shifts are allowed fewer points than those who work 4 12 hour shifts. This would only be fair if nobody worked overtime and points obtained on overtime didn't count. I can get fired and reprimanded faster than somebody working another shift even if i'm on time for all of my regular shifts because of points earned only on OT shifts. Seems unfair. 65 N/A 66 Management/supervisors lack of knowledge and/or experience in the system. Not being able to look at current policies and realizing the policies don't work, not effective and the negative effect on the system. Not willing to take information/help from experienced employees until something goes wrong, then it's panic mode. Inconsistences between departments and within departments depending on the time of day, day of week and which supervisor is on duty. Having the benefit of earning vacation hours, but not being

Appendix B – MedStar Employee Survey Results Question 10

10. While most people can identify several opportunities for improvement in your workplace or the operations, often there are a few specific issues that are creating the majority of your frustration. What are those issues for you? able to use them without arranging coverage for your shift. This is the 3rd consecutive summer this has happened. 67 Lack of true leadership. Aside from my direct boss (the Clinical Coordinator), there is a different answer for a question from each department. There is NO fair, firm or consitant policy or treatment, it is biased based upon who you know and what your relationship is. Communication is another, what you say in confidence to a supervisor or manager will soon be told to their peers, or to upper managment and so on... Mr Eades counts on his management staff to do their jobs and it appears they all have their own agenda and DO NOT work together to solve the issues at hand. They all want the "power" but not the accountability. THis is not true leadership. The EMS academy building that was bought last year for education, still sits, no one has an answer as to when it will be finished. The Clinical Department is out of room, with the responsibility to educate ALL of the field employees they still rank as insignificant component compared to other departments. Managers from other departments continue to try and "micro" manage employees from different departments when they instead should be focused on the problems in thier own. 68 Doing non emergency interfacility transfers tie up ambulances for a long period of time. I am not above doing non emergency transfers, but I feel that non emergency transfers are very time consuming and our resources could be better utilized for emergency calls. I know MedStar has a membership program for emergency and non emergency transfers services therefore MedStar could not do away with non emergency transport all together. MedStar could contract out to other ambulance services to come in and do some of these non emergency transfers when the schedule is lacking in personal or when the system is very busy. Contracting out non emergency transfers in those type situations would free up our ambulances to do emergency calls. EPAP could require a permit for the private services to operate in the EPAP service area and charge a fee for the permits in order to help off set the cost of the lost revenue. 69 70 Upper management positions are not being filled according to fairness, any other words there are some positions that become available and the job is not posted, which is not fair, this is done because of favortism there is already a person picked for the job, also there are in house applicants that go through filling out the internal application and Mgmt. already knows they are not getting the position. I am not considered for a lot of positions because of no degree, the jobs that are being done in my department was being done by me and another individual by ourselves, it didn't take a degree to do what I was doing, everybody wasn't blessed to have attended college, but I can do just what a degreed person can do and maybe even better. That is my frustration so I just basically come to work and do my work and go home. I was in Accounting for 14 years with 2 of them being an assistant supervisor and 3 being a supervisor without a degree. My job to me is elementary. 71 MANAGEMENT!!!!! the all seeing eye, if they could concentrate and help with work(the real work, QA, verify, billing, collections)we would not be as far behind each month. they are too worried about how many personal calls you make, if you are up talking to someone. they need to help US!!! 72 Attendance. In a diverse work environment, especially where that environment is a 24/7 operation, there are times when people are going to be absent. Even if we have sick time to take, we get punished for using it. Those that have kids, are more likely to miss a day here and there due to family illnesses, yet there is no opportunity for us to make it up, like there used to be. Borders on being penalized for having a family. Pretty hard to swallow in a "family oriented" operation. If my child is sick today, and I have to stay home with him/her, why can I not make that day up with another shift(s) on (an)other day(s). Even if I do get a point initially, the opportunity to work 3-4 overtime shift to make it up and eliminate that point is paramount. Plus, I believe more people would work overtime to make up their absences, thereby making it more likely that someone will come in to cover my absence, as I would do in a similar situation.

Appendix B – MedStar Employee Survey Results Question 10

10. While most people can identify several opportunities for improvement in your workplace or the operations, often there are a few specific issues that are creating the majority of your frustration. What are those issues for you? 73 I have not been here that long but what I hear from most is about the money Medstar receives from subscribing cities and our pay. We are not like the average EMS system so why are we being paid less then the average EMS system? It is a great thing that our per capita is lower then other EMS systems but hows is this benefiting Medstar as a Whole? If we are able to get more from the subscribing cities especially the who not paying at all then there may be room for more resources and better pay for employee's. as far as pay goes, I find it hard to believe that Medstar can't find a way to pay its Field crews more. Its sad when a kid at the mall makes more then EMS professional do. 74 We lack strong leadership especially in our Field Operations area. We inconsistently enforce policy and procedures, and the employees know this. We basically have some rebellious behaviors going on due to lack of consistent policy enforcement and a general lack of accountability. Employees seem to take advantage and never seem to be satisfied, regardless of the efforts made by upper management. They behave as spoiled children who can't be pleased, but this is directly tied to how they are "managed", and in some cases, they are not. We also lack accountability and follow through with our upper management ranks. Many issues and deficiencies tend to go unaddressed, which contributes to the perception that the management team is not unified and not working together. In some cases, managers are following their own ideas and agendas, which don't match that of the team, but yet it is allowed to continue. The addition of a Director of Field Operations has the potential to help a great deal, as long as this person has the qualities to earn the utmost respect and motivate employees at the same time. Rules and policies need to be enforced. This will not cause more corrective action to be issued, but should eventually result in a decrease in addressing employee issues, improved morale, and overall higher employee satisfaction. As we all know, this will impact our compliance and bottom line in a positive manner. 75 1. MANAGEMENT, MANAGEMENT, MANAGEMENT. In all the years I have worked here this is the worst management team I have ever seen. There is absolutely NO support for the field. Everything is based on negativity and fear. We have no CEO and no Operations Manager. Well, we do have an Operations Manager that does not have a clue. The Clinical Department is absolutely at the worst I have ever seen and needs to be totally revamped. Primary Medics fail 67% of the time when they interview with Dr. Griswell after they have been signed off as go to go by the Clinical Department. That is a direct reflection on our poor training program. There needs to be someone in control, a CEO type that is over everyone including Clinical. 76 1. PAY - I do more than what is expected for inadequate pay. The way we work and as busy we are, we should be compensated for it. when i have to work 12 days a pay period to make enough to cover my bills, insurance for the family it tough cause you dont get to see them very much. kinda hard to explain to a 3 yr old that daddy has to work soo much so he can support him. and no i dont live outside my means. i rent an apt, drive a 14 yr old car, dont have cable, internet, home phone or any other luxuries that most have. 2. The company says they are all about recognition for good things but all we see and hear is when we do something wrong. just once it would be nice to hear, i know you just saved this kids life so take a few min to rest not you have been at the hosp for 20 min you need to hurry the hell up and get out of there. we need you to run that transfer. you know what, get a non-emergent service in here to do that crap. 3. Seems that every manager has their own agenda about how the company should run. No one is on the same page. 4. Communication from management sucks. We dont hear shit from them unless its all our fault. keep us informed about what is going on. 5. What exactly does our clinical manager do besides sit behind his desk, have everyone else do his work, and write a book for his own personal benefit? 6. our dispatch center sucks balls. not 2, i repeat, not 2 can dispatch the same way correctly. they always send the wrong trucks, place blame elsewhere when some, not all, is on them. so many inconsistancies make for a long day. and what is up hiring the guy who cant talk right and pronounce an r. it comes out as a w and one day someone is gonna get hurt because of him and it had better not be me cause i will sue the hell out of him and this

Appendix B – MedStar Employee Survey Results Question 10

10. While most people can identify several opportunities for improvement in your workplace or the operations, often there are a few specific issues that are creating the majority of your frustration. What are those issues for you? company. 7. the work schedule sucks. those of us with senority who have been here through good and bad should get a more decient schedule that what we have to choose from now. 1 wknd day off blows. 77 More and more responsibilities being added to duties. Unable to complete job in 40 hours a week. I will work the hours needed to get my job done, but I am sacrificing time away from family. 78 Lack of leadership talent in the upper management. Besides being completely malstructured, the individuals themselves lack the basic leadership talent and people skills . We have the wrong folks doing the wrong things. There are to many supervisors in to many other departments and that money could be spent more effectively in building up the operations supervisor staff so that they can effectively manage the daily operations. Again, reallocation of funds. Sending clinical and dispatch folks to "conferences" out of state like Las Vegas, Come on! Those two departments have alot more to worry about than who got the drunkest, not to mention the other immorality that takes place. 79 management failure to acknowledge its employees . signs ,keychains things like that dont make a company strong it tears it down. 80 81 82 The biggest frustration I have with my workplace is the inconsistancy of management. They say one thing, turn around and expect another. And no one will backup anything they say. As soon as there is any negative impact upon anything or anyone, they pull out as fast as possible. We need some people at work, especially in management, who will stand up for their convictions and will support what they say. 83 1) Staffing 2) Not having the proper equipment on the truck. 3) Post ponging 4) Management 5) Fort Worth fire dept. They really work hard at causing harm to patients and sometimes even taking their life. 6) These surveys. They are a waste of time. Med Star has never and will never make the adjustments needed. 84 No concern or compassion from management. The management staff is quick to discipline us, but slow when it comes to recognition. It seems that the only thing we hear from the operations manager is make compliance make compliance get out of the hospital faster, but when we made compliance in March, we didn't hear anything from him. We run non stop without a break no breaks, dirty bathrooms, irregualr eating patterns, all with low pay and absolutely no recognition unless you win a vote for a prize. Recognize us as a whole and stop recognizing individuals. 85 Backstabbing - I'm tired of presenting worthy ideas to upper management on things we can do to better MedStar, then either ignored or told no, only to have another person go to them a couple weeks/months later and present the exact same idea that is suddenly a great idea & demands immediate action; then the project is tasked to me as someone else's project that I need to do for them. I'm also tired of not getting any recognition for the work I have done/am doing for MedStar while others have received multiple awards several years running for one project or idea that succeeded. I'm tired of managers taking credit for my work & not even having the courtesy to offer a simple thank you in return. I don't do all this extra work, often at personal expense, to have the limelight on me, but I certainly don't do it to have SOMEONE ELSE take credit for work that wasn't theirs to begin with. Then when they want to have me do one of my stolen ideas & I call them on it, I'm just tell me to put things in the past away and move forward, just like it never happened. This has cost ME money I was promised for work completed, earned awards (bonuses and ribbons and eval scores), & countless hours of undeserved grief, all to fulfill a given manager's personal agenda. I apologize if that sounds scathing, but it is far less than my reaping from what I have been sown. Lack of OBJECTIVE evidence in medical oversight - To be demoted & berated based on "feelings" and someone taking a professional matter personally, instead of documented, measurable facts & statistics over trivial issues when others have blatently exceeded their scope of practice and actually brought harm to their patients, and have not gotten so much as a slap on the

Appendix B – MedStar Employee Survey Results Question 10

10. While most people can identify several opportunities for improvement in your workplace or the operations, often there are a few specific issues that are creating the majority of your frustration. What are those issues for you? wrist, & no effort to hide the fact of a friendship influencing the escaping of punishment. Wages - We're paid to be EMT's & Paramedics, but compared to systems that run no more than half of what we do. We're not paid for the quantity of work demanded 86 87 I love working at MedStar and nothing here really bothers me 88 Money and having to work lots of hrs to servie..... the posting plan when you are not running call you are being drivin nut but being move arouned to much. the post pon back and forth. nasty durty trucks, truck that don't run right or they don't bother to fix the little thing or fix it right so the truck that you are in is more of a bucket of bolts in sted of a MICU that you can be proud of. and theys punks that don't care about or equpmint and trucks that the like to destroy and brake things for fun because they don't have anything better to do but to be punks. I want to have good equitment to work with. Also the people that runs Medstar need to use more commonsense. Like the care warsh system that they bout hart in the place but I knew from the start that that was a waste of money and it would cost lots of money to kep up KEEP THING SIMPLE a pressure warsher and a foaming brush like a regular car warsh would have been chepper and better and chepper to maintain and still could have the spot free rinse and waxs all that stuff. Poins. If your kid is sick Do you spank them for being sick or punish them in any way? So why do we get Punish whan we are sick and if you are sick to many time you get fired that SAY that Medstar don't care about you. I am not talking aboutI got drunk and feel bad so I can't come to work I am talking about being sick. I should not have to come on to work and work with pneumonia for almost 2 week. I almost ended up in the hosptial. just so I would not get Punish and get a point. If a medstar 80 see that you are sick they should care and say ahy go home get better don't worry we care about you will not get a point or get punish. If you have a kid or wife that is sick and you have no one that could take care of them HAY we understand take care of your Family we Care about you and your Family because with out you we are not medstar. 89 1. Inconsistant enforcment of polcies and procedures. 2. Working 48+ hours a week; helping to save lives and having to live pay check to pay check. 3. Favoritism. Post assignments, priority 5's, assignments of new trucks, employees of the year/quarter. 4.Running lights and sirens to calls which should not be. 5. Transporting pt's who do not need an MICU. 6. Dispatchers with who CONSTANTLY have attitudes. 8. Bad communications equipment. Radios, computers, paging systems. 9. Procedures being made by individuals who know nothing about EMS. 10. Money being spent on items not needed. 11. Money not being spent on items needed. Stairchairs, more units. 12. Fuelman is very unreliable 13. Constanly getting pages for help while on duty. 90 over worked for little pay! enough said! 91 Lack of communication between office and field. When dispatch gives you 3 p-5 back to back when there are other trucks sitting as close to the call as you are. 92 The constant driving around from street corner to street corner without break. Driving in trucks that don't work, even after having just been serviced. (too many problems to list). The lack of professionalism of the individual employees. The lack of anyone watching out for the shortfalls, and the lack of action for infractions. It is extremely frustrating for me to be treated like I am not a professional because of the last 10 crews that ran with a certain fire crew, or facility that lacked a professional attitude, or appearance. 93 The main issue is that supervisors are NOT paying the required attention that field employees need. There has been many concers that field employees have and when its brought up...... They are put aside. That is not having good managieral skills. This is a huge service. If this is something you guys are really looking into then we should see a difference pretty soon..... 94 The constant hiring of employees with little to experience 95 There are frustrations with my manager. She play's favorites and can get away with it because she is the manager. ex: employee A had an emergency where her cousin was

Appendix B – MedStar Employee Survey Results Question 10

10. While most people can identify several opportunities for improvement in your workplace or the operations, often there are a few specific issues that are creating the majority of your frustration. What are those issues for you? ejected out of a vehicle. She had to clock out and receive half a point for going home. employee B which was a supervisor left for a few hours and didnt clock out, nor was given a point infraction against her. Employee C had a sick child and left an hour before her shift was over and didnt receive a point infraction either. She promoted a part timer whom she frequently spends time with after work for drinks and there childrens functions, to a supervisor position without posting the position or having her test for it. All of the supervisors attended a supervisor meeting and had no clue about her promotion. We have had incidents where we had no supervisor on duty and as a manager I think she should come in and fill the vacancy. She said she was only a phone call away but what can she truly do over the phone when all the equipment that often requires passwords to reboot is at work and not at her home? Our manager retaliates and that is a huge concern /frustration for us. 96 removing the point from sick days because we are human and get sick just like the people we take care of every day.This point system thing is a big turn off and runs people awy from here. (2) we asked to increase the amount of people allowed to take vacations from 2 paramedics 2 emt's weather its day or night.As it stands now its 2 and 2 but thats every body no matter day or night peoples. I have asked why we cant change it to 2paramedics and 2 emt''s off during the day and 2 and 2 durning the night.I dont think that a night person should be able to take a vacation day off from a day person.because that night person is off during the day any way while that day person is to work and thats why that tried to take that days off .the same goes for a day person knoxing a night person off for a vaction day because that peron is off at night any way so thats why we should have """DAY TIME PEOPLE VACATION TIME OFF. AND A NIGHT TIME VACATION TIME OFF FOR THE NIGHT PEOPLE.change this policy please.WE should all be treated as equal no matter what we do and not different. everybody should be on the same page on how people are treated 97 Increasing number of calls and demand for fast times while at the same time more paperwork and responsibility. I am the only paramedic on my truck who can legally treat critical pt's. Sometimes there will be a whole fire crew with no certs higher than emt-b. So i have to provide quality pt care whil in route to the hospital which most the time does not allow me time to document. Once at the hospital I have to transfer care and finish charting in order to leave a complete chart for the physician which will be the only thing protecting me incase of a lawsuit. I am constantly pushed to clear the hospital so that i can respond to another call. Sometimes supevisors will recomend that i finish my chart later in the day, eventhough i was given a written counseling for doing just that. 98 The field crews are offered bonus's to work overtime shifts, while supply and comm center are forced to be on manditory call back. Where is the fairness in that. 99 Transporting patients who really need a cab not an ambulance...... better call taking would alleviate this...... and the ability to refuse transport to a patient that could go to urgent care and not the emergency room, ie call comes in "I have been sick for a week now I want to go to the hospital" or "If I go by ambulance I will be seen faster" These types of calls take an ambulance out of service for some one who could really need our care. Case in point a call went out for an OB call in the an apartment complex near another that was on fire with FD on scene working the fire. A crew was dispatched to the call and the patient went AMA...... while they were tied up with that we had to have mutual aid from another town come take a fire fighter who was hurt in the fire take him to the hospital. 100 the pay, scheduling, post pong 101 To be perfectly honest there isn't really very much frustration on my part. I think this is a wonderful plavce to work. 102 no more surveys add personnel and resources ditch the entire upper echelon of the management team 103 Supervisors Managers Non working employees 104 Lack of communication. Lack of timely communication. Tools to do my job. Continuing education for non-EMS staff.

Appendix B – MedStar Employee Survey Results Question 10

10. While most people can identify several opportunities for improvement in your workplace or the operations, often there are a few specific issues that are creating the majority of your frustration. What are those issues for you? 105 fairness, communication and pay 106 The computer system at Medstar is deplorable. It is slow or doesn't work half the time. The solution from Tim is re-boot your computer or he is going to bounce the server. I have never worked for a company that has such a bad IT department. Does the IT department really know what they are doing? The supervisors really need to remember how it is being a regular employee. When they get promoted it is like they forget where they started. More management training is needed quickly. 107 Many times not having the ability to eat or rehydrate. The seperated levels as in; Lead secondary and Primary Medics. There should be only EMT, Secondary and Primary. Better pay and benifits are always a good draw for experienced people and improve the attitudes of current employees. Develope a better program that gives more people a pat on the back for a good job, commitment and consistancy. We seem to have too many chiefs/administration people. Thin out the supervisors. 108 Attendance Policy: There has to be some built in flexibility. Such as if an employee has to leave for a family emergency or on the job injury or illness, why should they be assessed a attendance infraction? Posting: For a posting plan to be approved in my opinion someone needs to go and check out the location. Other than being strategic locations, there should be facilities close by for food and restrooms. Also safe locations (i.e. 92 D known as crackpheona) This would help response times but cutting down on having to move to other out-of-the-way locations to get crew needs taken care of. Pay: We work our butts off just to have a transfer service who barely runs 2-4 calls tell us they get paid more. 109 1. Getting a code 6 truck should be less of a hit or miss deal. I have seen nights when we are at level 3 but a truck will still get code 6 coverage in Burleson while on another night we will be at level 8 or higher and units are left out to dry. 2. Sending trucks across town to post when it seems completely illogical. For instance a truck clearing from Haltom city to cover a truck at 74A. 3. Wages not keeping up with inflation. Gas prices are getting so high that it is effecting everything, it's almost impossible to pay bills when it costs 100$ a week just to come to work. 110 everytime i come into work they have come up with a new rule designed to make the response time better or to make us work faster and everytime i come in the supervisors spend the time that i can be on the streets working issuing corrective actions or verbal reminders or records of discussion and nothing is consistent 111 A total and complete lack of leadership in all areas of this company inability to convince fleet of mechanical problems so they continue to put problem trucks back in service without a/c, problematic steering, poor brakes etc. a complete lack of capability from the clinical department.. including multiple unresolved complaints against the managers in that department involving hostile work environment, harrasment and even physical threats 112 The small problems are the biggest frustration. Let more than 2 people take vacation in a 24hr period (this amounts to approximately 1% allowed per day). Do not take out lack of compliance on field personnel. Not being allowed to take vacation because one person is off leads to people becoming burnt out and their desire to help make compliance drops! Stop the Comm vs Field mentality. Give us policies that people can use (do not pass policies that there is no intention of letting the people effected by it see). 113 The main thing for me is the pay. If you compare what we make and FD or PD it is sad. All of the situtions which PD or fd ARE INVOLVED a large majority we are onscene with them in the same dangerous situtions 114 DISPATCH. Dispatching is fraught with favoritism and attitude. When obvious discrepancies are brought to the attention of the Manager, she says that her "controllers" have had a lot of training to help them decide what is best for the system. Dispatching trucks past other available trucks makes NO sense. Posting trucks past THREE other trucks makes NO sense. Dispatchers get attitude, short, and nasty on the radio when crews ask for clarification. Crews cannot depend on dispatch to get additional information or do call backs when the field crew requires it. SUPPLY. Small

Appendix B – MedStar Employee Survey Results Question 10

10. While most people can identify several opportunities for improvement in your workplace or the operations, often there are a few specific issues that are creating the majority of your frustration. What are those issues for you? things make NO sense. There are a total of TWO vials of Zofran on the truck including the one in the red bag. There are THREE vials of Haldol. Zofran is used a LOT. There have been times I've had to call for resupply of Zofran two or three times in a shift. And Haldol is a BSP only medication that I might not see used in MONTHS. The field needs to have some input into what is actually stocked on the truck. This might even help turn- around times if we didnt have to sit at the hospital awaiting 95 for items that common sense says should be stocked a little more liberally on the truck. Lets look at the drugs we use MOST and up the amount stocked on the truck. FLEET. Our trucks are ragged out. Fleet needs to drive them every so often and see that pedal MIGHT net 60mph in a full minute. And those small uphills on 35 around I30 are enough to lose 5 MPH. Most of these ambulances are frankly embarassing to drive. THESE surveys. How many of these are we going to fill out before SOMETHING GETS DONE or are we just filling them out to make us think that something is going to get done? 115 overworked 116 IT issues - you are expected to just keep taking calls and try to squeeze in calling IT and correcting IT problems as you are going down the road or to a call. If this does not get accomplished by the end of the shift you are expected to stay and find a way to get this stuff entered in the computer after shift. If we are having serious IT issues let the supervisor determine if we can go down for a few extra minutes at a hospital to get the problems corrected so we are not trying to multitask while driving to calls with lights and sirens. our attention needs to be on correct routing and safety at these times not on talking to IT while our partner trys to do all the navigation. ALSO the 24 hour stations need internet access but it has been 5 months and no improvement in the system the gave us. Quit promoting people who are marginal employees at best. Chris Cebollero has a bad attitude is rude to employees and hospitals and always has been even when working the field. He has a dictator attitude. Yet he just gets promoted and promoted. Now he is never in his office, never returns calls and pushes his work off on Lisa making her look like she never gets anything done either. There are other examples of this but Chris is the most glaring example. GET DEPARTMENTS TO WORK TOGETHER! Dan has "pets" all employers have a few trusted employees they go to but the ones he "goes to" have made several glaring mistakes yet they get no disciplinary action and it is glossed over. Time off issues. There needs to be more flexibility for using "vacation time" One example 24 hour shifts should be able to take just 1/2 a shift off it is no harder to cover 12 hours there than 12 hours in the city. forcing them to take 24 hours of vaction time when they just need 12 is unfair no one else has to use 24 hours of their vacation time for this. You can't put coverage requests in the Net Scheduler until a week or two before the date. Makes getting coverage hard. 117 118 The clinical department tends to play favorites. If you are on the "good list" you are golden, and can do whatever you please. If you "tick them off" you are watched like a hawk. They tend to use intimidation techniques often, and expect complete subordination from not only field personnel, but all personnel. Being that they report directly to Mr. Eades, he only hears what they want him to. Several complaints have been made regarding clinical managers, but it falls onto deaf ears. I feel that if there were a person between the clinical department and Mr. Eades, there would be some ratification to the problem. This, I feel, would provide alot of employees with some "ease" and raise moral overall. 119 traveling too far to make a call in time. leaving a post to go to another only to get a call near where you were posted. 4-5 post changes in just a couple of minutes time, looking like a fool running in circles in front of the public. getting on a scene to find it didn't require lights and siren, or that the call (complaint) had nothing to do with the symptoms on scene 120 1 Lack of cooperation between com center and the field. 2 Lack of cooperation between upper management and field. 121 Management consideration and involvement of the entire staff in making company

Appendix B – MedStar Employee Survey Results Question 10

10. While most people can identify several opportunities for improvement in your workplace or the operations, often there are a few specific issues that are creating the majority of your frustration. What are those issues for you? decisions and process development is a frustration. We want to be involved with our company. Most of us came to MedStar to be a part of the organization for the greater good of our communities. To be pushed aside and threatened when we have an opinion or suggestion gets frustrating and demoralizing. PLEASE involve us, it will help us understand one another's needs. Do NOT assume we're too stupid to understand the limitations of our organization, it's finances, resources, etc. If we work together we CAN be successful, we need one another to make it all work well. Communication is virtually absent. There is a token effort these days that is lacking any reasonable appearance of actual, heart-felt compassion about communicating with the organization. There shouldn't be any major organizational secrets yet all of the management staff are protecting their positions and backstabbing one another to accomplish thier personal agendas. Consistency does not exist at MedStar. From person to person no one is consistent in their message, thier motivations, interpretations of policies, and processes. There are many mistreated and exploited employees by the leadership. It is painful to watch this happen so blatantly and with lack of remorse. Frankly, I think they don't even realize that they're robbing the pride of everyone, even those that are favored. I've never had an issue arise but I've watch many be fabricated to meet the agenda of a manager. Honesty, if our ship is sinking then just tell us that. Please do not sugar-coat or lie to try to overcome our shortcomings and failures. We see them do it and believe that it is okay for us to do it, I've witnessed this as well. Again, poor culture and philosophies. 122 A true lack of leadership. Not management, LEADERSHIP. There is no definitive driver behind the wheel and when things have gotten difficult in the recent past, the employees have been publically blamed for issues accountable to the management group also. This management group has undermined the confidence of the street level employee in their ability to lead and look after our interests. 123 Lack of online resources and up to date information. EPAB, Net-scheduler, payroll, Email, Medstar's web site are all seperate. Employees should have a website that they can sign into and have access to all resources with only one password and an easy to remember URL. We should be able to sign up for CE classes, access forms, have access to On-Line CE classes, sign up for shifts, check payroll deposits, change tax withholding or benefits, request uniform parts, check certification experirations, track our personal CE hours, review stats, review minutes from various meetings, setup our trucks instead of calling the comm center, finish or fix returned charts. 124 As I said in question #9 the frustration at least for the field crews is call volume, we are burning out faster than we should, I believe that every Paramedic that works high volume 911 will eventually burn, but it is happening way to fast, were tired, were stressed, we dont see our families like normal people should because we are to busy living at Medstar working overtime to try to make ends meat and not to mention the toll this job takes mentally and physically on our bodies. Dont get me wrong this is the profession I have chosen and I do it because I love it but Medstar pushes its Paramedics and EMT,s way over the limit, think about it, if I run a pediatric cardiac arrest as my first call at beggining of shift and one at the end of my shift I am still expected to make the same correct,snap decisions on that last call as I did the first call, after running 11 calls in between and driving constantly from post to post in between calls, Im proud to say I am able to do that now, but for how long? I dont want to find out how long we want these issues taken care of before anyone has to find out HOW LONG!!! 125 There is a manager that is always working behind the scense to create their own agenda. This is such a conflict to the other managers and is very disheartening when we are not on the same page. 126 Denied time off requests. It is frustraiting to have vacation time, when you are not able to use it becuase 2 other employees have requested the same day off. This makes it increadible difficult to plan vacations for "stress relief purposes". With so many field employees working this policy needs to be revised. 127 When I worked here before it seemed like up mangement always was on your ass to do

Appendix B – MedStar Employee Survey Results Question 10

10. While most people can identify several opportunities for improvement in your workplace or the operations, often there are a few specific issues that are creating the majority of your frustration. What are those issues for you? something more or better. Add one more thing to everything else you have to do. And in that you feel like they dont relate. Or even care. Do you think while Jack and Dan sit up there in their office making ALOT more money then we are. Do they care that we are working our butts off and barly making any money or getting to barely eat. Yes it comes with the jobs. But look at the old days. They use to bring you boxed lunchs. Not anymore. But wait lets bring you into post 4 to get something to eat when the system is low and we are barely hanging on. Yeah lets see that one happening. Or better yet. What about the night crews. We miss alot of the day walkers fun because one we are asleep and two most things are held during the day. Does mangement actually think by putting a sign up say WOW good just high five that will make us feel better. I do think things are improving. and I do think not all upper mangement is bad. There are a few that really try for us. But there is some that honestly dont give a rats ass about us. They just make the big bucks and go home. 128 need a second dispatch channel so we can limit the traffic on the radio crews are always starting shift late and its the same ones every day 129 PAY staffing people that cannot do the job effectively consistancy 130 their always be comflic between managment, operation and fied crews. as long as we place people in place with not the requerements the issue will not be solve. we can not place people with no school background in this position. 131 biased dispatching constant lack of time to take a quick pick up at a halfway decent eating place (fast food will only go so far, and its unhealthy) consistent late calls, mere minutes prior to the end of a shift when there is a closer unit, all because "we can keep more trucks on the road".... (yes, this was told to me directly from a dispatcher) 132 the lack of accountability in other departments is perceived in other departments which makes things harder for the Supervisors in my department trying to enforce policies 133 1. Lack of flexibility of work environment 2. Employee satisfaction of their employment. 3. Distrust of Administration by the staff. 134 1. Pay..The comm center is not paid wht they should be for the standards they have. There is no agency in this region with the high standards and volume. 2. The field gets paid over $250.00 for overtime shifts as a bonus. The comm center has mandatory overtime and gets no bonus they get paid $24.00 that is not fair. 135 The constant micro-managing by our supervisors in the comm center and out in the field. Staffing and retention in the comm center, we need to re-evaluate our training processes. 136 staffing morale inconsistency in rewards/discipline 137 We are suppose to be one company and sometimes it doesnt reflect that unity that management wants to see because of inconsistency, showing favortism, and being affraid to state a suggestion or concerns without the fear of being marked. 138 low pay, long hours, less than adequate benifits, high expectations, micro management, inablility to eat while at work, inability to even use the bathroom at times, dispatchers with speech impedaments that you cant understand, vehicles that break constantly, having to provide the most expensive parts of uniforms, (ie boots), unfair demerit system used for absences and tardies and a ceo with a poor attitude who has exhibited over and over he is more interested in the bottom line rather than the employees who keep the system running so he can recieve his oversized paycheck, while we are scraping pennies to feed our children. 139 Computer issues, we seem to have to many computer problems which delays our work. I understand the concept of cross training so that everyone can assist in areas that need additional help, but this also disrupts the flow of productivity when we are constantly changing units as some people are better at one area and others are better in other areas. It might be better to assign people to the areas they are best in and then cross train them in one or two other areas so they can assist if needed but to leave them in their assigned area except when they are needed. 140 paging usless info on the pagers( ie: open shifts who is what rank now) post that do not

Appendix B – MedStar Employee Survey Results Question 10

10. While most people can identify several opportunities for improvement in your workplace or the operations, often there are a few specific issues that are creating the majority of your frustration. What are those issues for you? help when lev drops the post are not central com center sending units to multiple post in 5 min post moves not on pagers com not hearing units and having to repeat your self multiple times 141 #1 The trucks are filthy. I cleaned a green colony of bacteria off one of the surfaces last week. The floors are filthy and the cots are filthy. I would love to see some microbiology student come in and cuture the surfaces. I initially tried to keep it clean and neat, but the job is overwhelming. There needs to be a trained team to go through every truck and thoroughly clean and disinfect them. I feel like I'm going to get sick every time I climb in the back of one of these things. #2 Computers and other IT issues. This operation relies on computers and software, and it just barely works. The LifeNet software is buggy and crashes all the time. The black "something has downloaded" box is constantly in the way. Why do I have to press a button every time it downloads something. This is very frustrating and interferes with my patient care. The gateways are constatly going down. The tablets are beat up and are hard to use. Some of the screens are so scratched it is hard to see the display. Some of the screens wont stay open. A lot of the chargers in the trucks are broken. On and on and on. Hire more IT people. As much as we rely on IT we should have 5 or 6 full time IT people. #3 The Documentation Police - Petty Petty Petty. I got a form back to write 3 characters on it, and they had to type up a letter to tell me which 3 characters to write. I'm sorry I made a mistake. Don't waste my time or yours write the 3 characters yourself. #4 It is very discouraging that so many things are broken and/or wearing out. It is even more discouraging to turn in a form that it is broken and it not get fixed. I have enough to do without writing up problems and have the form hit the circular file. I hate that. If I report something fix it or at least tell me why you couldn't. 142 1. Understanding that this is a high performance system, our UHU is still well above what is considered safe and acceptable for employees well being. This goes back to the previous questions and is a large contributor to retention issues. 2. Specific dispatchers make poor desicions and there is often trucks crossing paths and a lack of consistency in post assigments. 3. There seems to be a total disconnect between managment and the field operations staff. Upper management seems unable or unwilling to make changes that would impact morale and retention. 143 144 I actually do not have any at this time.....really 145 That H> R> does not do a very good job. Operation Manager does not have a clue, on doing his job. Flield Crews get the world, while everyone do not. 146 In my department we have mandatory overtime and due to staffing issues we have to commit an extra 4 days a month that we may have to work. When you work a 48hr shift and then get called in that is 60 hours a week, now if you do not get called in you get paid 24 dollars. We work normally 4 on a shift answering calls at least every 2 1/2 mins we are stressed to the point our scores are suffering which ultimatley affects our raises. They offer $200.00 bonus to work OT in the field and we get $24.00? This is a slap in the face and you wonder why morale is low? Because we are a smaller dept does that make us less respected? 911's don't get answered your units go nowhere and our citizens suffer, what a way to instill loyalty in people. You beat them to the ground, expect them to go the extra mile for you, yet you give nothing in return, not even the respect they have earned? You sit here and watch what our teams go through day in and day out then tell me you can do our job when you held to higher standard. 147 pay scale, and shifts 148 The clinical department is a problem with this company. The FTO program is a joke. The department is run by a person who thinks he can threaten people and bully them to get what he wants. He has been at TCC where the Medstar Pramedic program is held yelling at students in the hall. He was yelling so loud that people from other classes in the building came out to see what the problem was. When the Paramedic class wanted to get together and talk to HR about the hostile work place, he told them all that if they went to HR he would disband there class and none of them would ever be paramedics.

Appendix B – MedStar Employee Survey Results Question 10

10. While most people can identify several opportunities for improvement in your workplace or the operations, often there are a few specific issues that are creating the majority of your frustration. What are those issues for you? There are two people that work under him in the clinical department. They happened to be best friends, and were partners when they worked in the fields. Lisa was there first. When they added the 2nd position under him they posted it as a part time job. If anyone who worked for medstar wanted to move into the clinical department they were going to have to give up there full time job and benefits. How convenient that the person who got this job was Lisa's best friend, and had a husband who worked so she did not need her benifets at medstar, she had never been a dto, fto, and had never taught one class at medstar. we will not even get into Lisa'a husbad getting job with phillips after Medstar spent Millions with them. The operation manager poses another issue. He walks around with a cup of coffee in his hand he will smile at you and ask you how things are going if you see him out back smoking, other than that I am not sure what he has done in the two years he has been here. He has not held a single company meeting. He never has answers to questons, he is quick to tell you how busy he is but as soon as he can he will get back to you with a answer, the next time you catch him to ask if he found something out he will ak you to refresh his memory because he is so busy. For someone who is so busy we do not seem to be getting anything acomplished to make things better at medstar. 149 we have an extremly low moral and i don't know how you could fix it but the longer i work here the worse it seems to get. when the athority took over there were lots of promises and propaganda about how things were going to so much beter with them than rural metro. we had alot beter moral then and once again i think they need to look back and see what they were doing right instead of just focusing on what they thaught was wrong. the more and more that there are promises and the i want to know what you think and then we don't see any changes and the feild just gets more frustrated because we are just a number to management and we keep getting more and more hoops to jump threw. most of the people out here love what we do and love pt care but the general consinsus seems to be that all of hate the company that we work for. i stay because i like the protocols and i don't want to go somewhere else that has limited protocols so that i could not continue the level of pt care that i get to provide here.. 150 Favortism,inconsitences 151 Our management team has the "it will all blow over " mentality and carries a reactive stance. We need new management that will be proactive. Upper management is the very cancer that is plaguing this system. It has never been this bad. Clinical is a good old boy system that only rewards each other - there is no way to promote in this company. System status, doctoring response numbers, the schedule, the shifts, and the admin staff is a continuous curse we all have to carry. Emergency transfers which are worse system abusers than the 911 abusers in the field bog the system down, and no one in upper management will stand up to it. I could go on all night...i just dont have the time or energy.... 152

Appendix B – MedStar Employee Survey Results Question 11

11. The quality of frontline personnel is essential to providing excellent service delivery. Medstar is not satisfied with the retention rate of your valuable personnel. From your perspective, what are three things your organization can do to improve employee retention. [Please try to consider actions in addition to/other than increasing pay and/or benefits] 1 employees need to see management care that they are running hard on the streets employees need to see that they are needed 2 Better communication, explaining why things are done. More emphasis on listening to employees and creating an environment where the employee feels MedStar and thereby their coworkers and superiors care about them as individuals. 3 Replace Operations Manager Increase pay to become a LEADER in pay for Paramedics AND EMT- B's, not follow what other organizations are paying. Hire an Employee/Public Relations person that does nothing but focus on employee recruitment, retention, and public relations (not specifically media events, but community education to help increase the perception of value of our EMS service.) 4 1. In crease the number of units on the street so that the crews that are there are not beat down EVERY SHIFT THEY WORK. People can only take so much, and the "front lines" is a very stressfull job. 2. Offer additional comforts (guaranteed lunch, affordable child care, etc.) 3. We are an unhealthy workforce at best, and the front lines are exposed to every nasty thing that comes along, so it really should be no shock that crews get sick. I think a "real" wellness program would help. Obtain affordable gym memberships, wellness education, etc. would help decrease stress, decrease absences, and aid in employee retention. 4. I know you said three, and to consider things other than "pay", but pay is an issue. Why should someone stay and get ran ragged every shift, when they can take a fire department job, run significantly less calls and make at least 25% more pay. That is not a hard choice. 5 We have a split clinical department and it seems to cause issues with the field personnel. We need to establish on Clinical Department under EPAB so that we have continutity with training and clinical accountability. We should model our clinical department after the one in Austin. The work load and technical aspects of the job at Medstar are not considered in the pay. They are leaving for higher paying jobs with less work and less technical requirements. In order to survive they have to work over time or take second jobs. Truly recognize the efforts that they put in ... T shirts with bears on them is not recognition. 6 If people are happy to come to work then they will stay. If medstar would not spend every day looking for all the negative in people and more time on positive then we might be a happier place. Have a managment team in place that you can go to speak with and get answers without getting the run around and getting told they for got this and that. Not have to keep going back and forth to get answers since they have some of the porest communications skills of any company. Stop treating the employee as a number and use there knowledge to fix this place. We have sat and told these people how to fix this place but nobody listens since we are just grunts. Get more funding in the place so that we can have equipment that helps employees not patients but employees. 7 Career advancement Better communication from the organization more pay 8 Be more honest with crew Be more appreciative Have more realistic expectations More positions so everyone is not overworked 9 1. Increase staffing 2. A better schedule 3. Wages comparable with out leading competitors. (Fire departments and hospitals). 10 Look at wages,insurance, benefits, and job security. Look at our competition. Change the things we can. I have answered this I believe on question # 9 or # 8. 11 1. Be consistent with how you treat the employees. A lot of crews being upset is one day we do it this way, the next day we do it that way etc, etc. That is one gripe I hear almost on a daily basis is inconsistency with how things are done, especially in com center. 2. Most employees also want the recognition as the fire/police receive with the media and citizens we serve. Having a PIO person to do this would be good. Anytime something major occurs, the fire/police and ourselves advise the crews they did awesome, but on the news/papers, the fire/police get the recognition. Our employees know they save lives and don't do it for the recognition, but when it is due, it is due and they do not receive it from all around like they should. They still feel like the step children in public safety and get run down all the time. 3. Consistency with our com center is a HUGE frustration and poor retention area. There is absolutely no consistency with how they dispatch and this really needs to be addressed quick. We receive tons of complaints a

Appendix B – MedStar Employee Survey Results Question 11

11. The quality of frontline personnel is essential to providing excellent service delivery. Medstar is not satisfied with the retention rate of your valuable personnel. From your perspective, what are three things your organization can do to improve employee retention. [Please try to consider actions in addition to/other than increasing pay and/or benefits] day on this issue. 12 Respect the employee Listen to employees Stop the endless bouncing from post to post. Get rid of SSM, it makes employees leave and others not want to come here. 13 1 more pay-at least five dollars across the board and raise the cap tremendously. 2 have better health/vision/dental insurance. 3 pay bonuses everytime we work ot. 14 1. Develope better shifts. 2. Stop the mandatory shift bids. It just creates problems at home. 3. Stop dispatchers from harassing feld crews when they are at the ERs writing charts. 4. Management needs to realize that a 20 min ER time is not enough time with the stuff we have to do. 5. Stop the constant post changes. 6. Allow crews time to eat during the shift. 15 PAY US MORE MONEY. 16 1. We are top-heavy with managment. The clinical department never says anything positive about anything that a field crew does. We are constantly harassed about how we are NOT performing right and God forbid a mistake be made because Chris Cebolero will call you a lazy medic TO YOUR FACE and tell you how close you are to him personlly having your patch removed and license taken away. A lot of our management has been here since the Rural/Metro days and things have not changed, the problems still exist that we fight daily. Elimination of some non-essential positions in this division would also free up more money to help with salary. 2. Utilization and upgrades of the IT issues we frequently face as well as not getting updates to the tablets are also another issue. We are pressured to complete calls within a certain time frame and issues are constantly being brought up regarding the errors in the computer programs. We're told over and over "it should be fixed in about 2 weeks". After about 3 months this constitutes as a lie from medical records and IT. Nothing is done and the same problems exist. 3. SSM..... yes the dispatchers are now "CONTROLLERS" and in a lot of aspects this is taken to the extreme. Mary Gilbreath has NO business verbally reprimanding a unit over the radio for not following the route that she deems appropriate. We are a team and should function as a team and the "I am God" attitude received from comm center is a big stress factor in my daily life. Dropping from 28 units to 10 in a 3 hour period with no decrease in call volume is also a sign of mismanagement of assets. When you already are not meeting compliance and you take away units or change the schedule as to not have units available and we begin to suffer even more. 80's constantly telling you that you need to clear the hospital are not helping as well. A lot of the time that is the ONLY time you can get a break and even then you are fighting with IT issues when charting.... 17 Complete Upper Management Reassignment/Replacement, Complete Restructuring of SSM, possibly looking at moving to a districting plan, More responsive compliance and training with WMD/NBRC/Homeland Security items. 18 Back off the attendance and tardy policies, make MedStar more family oriented, and pay us more than what we can make at a hospital in a controlled environment. 19 You say consider other things such as actions, but why do people work. not because its fun. people work for money. why as a medic, i go to school just as long as an rn, have twice the responsibility, can do twice as many procedures, but get half the pay. Okay, some actions. for one, an uninterupted break would be nice. maybe a 30 minute lunch break where could chew my food instead of swallowing it whole. you have to decrease the work load by putting more trucks on the street. we are here to work, how ever with this very high stress job, people get burned out fast after running bullshit call after bullshit call. the company needs to put in place some policy to educate the public and a continuing basis on when and when not to call 911. people get into this job to help people and end up gomer toting a bunch of idiots around who dont need an ambulance. then add the low pay rate on top of that and its not worth it. we do have to go to school to do this job but are not treated like that. 20 Pay benefits better schedules 21 Pay (bartenders make more than some of us) communication and teamwork 22 Pay more, be more flexible with scheduling and management listening to problems that employees are having would be helpful. 23 More pay, better benefits, ability to hire more medics that are willing to stay.

Appendix B – MedStar Employee Survey Results Question 11

11. The quality of frontline personnel is essential to providing excellent service delivery. Medstar is not satisfied with the retention rate of your valuable personnel. From your perspective, what are three things your organization can do to improve employee retention. [Please try to consider actions in addition to/other than increasing pay and/or benefits] 24 1. Better wages and benefits. 2. less BS from managemnet and more positive action. 3. Get rid of the employees who are constantly bitching and grippin about everything, and get ones who want to make the system work. 25 Move the communications center away from main headquarters and hire dispatchers that dont know any of the personnel working in the field. The favortism of crews and good posts is way out of hand. The truck assignments need to be fair and unbiased toward friends of the supply department. If you knew you were going to be hammered today when you went to work because a dispatcher who works the same times as you doesnt like you, would you like to come to work everyday? I know of people who took paycuts to go to a different system because the daily treatment was fairer from a field employees point of view. Make this system a third city service or county service with benefits. Pention also sounds good. Have a step pay system instead of an experience based pay rate. Heres an ideal, make three steps of all positions and each step has a different pay, you start out as a step 1 paramedic for example and reach step 2 after 2 years and your pay goes up by a considerable amount and then after another year of service you are advanced to step 3 where you reach the maximum wage for the position and make it mandatory to have a OJT (on job training module) for the next position in line which would be medstar 80 (supervisor). There is nothing wrong with having a hundred medstar 80's out in the field. Make the positions fair in pay no matter what experience level or time in service you have. 26 To be honest I believe people want to come to work and feel like they do more than just run calls. We get burnt out. I remember a time when we would come to work run calls but have fun. Managment wasnt breathing down our backs Its seems like now managment is so worried about this and that we are no longer able to have fun. I feel like a work muel. I know that I havent answerd your question but to be honest Im not sure. I would like to see tuition reimbursment no matter what the class you are taking Better schedules so we can go to school. A lot of people leave here so they can go back to school the schedules at this time do not allow you to do both work and go to school. its medstar or find another job I would like to have more things offerd by the clinical department. OR rotations, courses, pediatric rotations, to me it doesnt matter how many people go but that thoes that want to go would be given the opportunity 27 Treat everyone the same regarding policy and procedures and ensure they follow the PROPER chain of command (instill a knowledge of what the proper chain of command is) and follow it. Don't allow people outside of the chain to address issues they are not knowledgeable; rather redirect the individuals to the appropriate people so they get the correct answer in a more timely manner. A more flexible work schedule. Allow consideration for individuals travel long distances, single parent, or in school. 12/16 hour shifts may not be what works best for everyone. Follow through....Many times people say they will do or respond to something and nothing gets done or postponed with no explanation. People need to know what is important to them will be heard. They may not always like the answer but at least they have one. And once an answer has been given the response permitted should not be one of, " if I scream louder and to enough people I will get my way". Sometimes the answer is "no" and there should not always be an appeal process all the way to the Executive Director to "get their way". 28 1) Consistent application of policy. 2) Supervisors who conduct themselves in a professional manor and who lead by example. Also, supervisors who are not affaid to hold their employees accoutable. 29 an increase in pay would be wonderful, but also better working conditions. If we didnt have to worry about clinical coming down on us for any small mistake it would greatly improve my want to stay here. But people are going to leave weather or not benefits and pay and working conditions improve. Everyone will eventually move on or retire. 30 Sadly, pay is one of the main underlying problems... I think finally, for the first time people do atleast realize that there is the potential for advancment with things like the Paramedic program avalible now.. 31 (1) Better pay (2) Better schedules (3) Better treatment of the personnel 32 SUPPORT YOUR PEOPLE, BACK US UP, DONT LEAVE US TO THE WOLVES and STOP MICROMANAGING (roland, nunns, and brunner!) -I quit on wednesday so I can use names. yes

Appendix B – MedStar Employee Survey Results Question 11

11. The quality of frontline personnel is essential to providing excellent service delivery. Medstar is not satisfied with the retention rate of your valuable personnel. From your perspective, what are three things your organization can do to improve employee retention. [Please try to consider actions in addition to/other than increasing pay and/or benefits] they managed to run me off. 33 salry scheduling recognition 34 better pay, better shifts, and better trucks 35 without having pay that accomodates the long hard hours you are going to lose personnel 36 1. treat the employee as if they are an asset to the company and not just a number. so many people leave because they find better opportunities with better salary and benefits, alot of them feel like management at other places truly listen and care. in this day with this generation of people we are hiring loyalty to a company means nothing if the employee is not satisfied. 2. spend more time looking at the quality and maturity of potential employees during the application and hiring process. don't just hire people to fill spots on the schedule. 3. spend more time properly training new employees on the medstar system and don't just rush people through the academy because we need people on the streets. 37 WOW I actually had to go out and smoke a cigarette to answer this question. Well, honestly in my opinion I think that MedStar is doing their best at what they can with retention. We have MWR and many opportunities that can come with that. I don't know how to answer this question other than increasing pay. We have good benefits I think. I don't think there is a good enough watch on those employees that are getting burned though. There really needs to be a limit on overtime. However we cant limit the overtime until we actually pay them something decent. Unfortunately the majority of people that I have helped hire and recruit are just coming here for experience to put on their resume. We aren't really helping people become career medics for this system. These surveys actually help me feel better and make me actually think that MedStar cares but there has been no change made from them but more surveys. If I want a pair of socks that are going to last me a while I have to buy a brand name and pay the extra to get them. Or I have to buy a large quantity of the cheap version so I don't use and abuse them so much. I think medics can be the same way. I appoligize that I cannot answer this better. 38 It has to be said that a major reason people leave is because of better pay and better benefits. Since you choose to turn a blind eye to this, I will discuss other issues. First: Hire an operatons manager who will do his job and do it well. Simply having the title of manager does not make one a leader. He is not respected by other managers, the field supervisors or many field employees (and they have said so OPENLY). Choose someone who will spend his time being successful instead of trying to undermine the work of others. Second: Hire people worth keeping. In the past, the hiring process chose people who had clinical knowledge, professionalism, skills, and ability to do the job. Field employees had a direct say in whether or not an person was hired and they took pride in choosing the RIGHT candidates. Not everyone was hired, but for the most part, those who were hired stayed and did well. As for now, the HR manager chooses people based on their ability to "fit in" to MedStar. NO consideration is given to the knowledge, experience, or opinion of the field employees. Add to this that she chose to remove the true clinical assessment of the candidates. Stop forcing people out. Dan Bruner and Mike Shelton are notorious for this. On numerous occasions, they have taken actions against employees that were clearly and publicly a vendetta for some past "wrong". In one 2 week period, these two were responsible for the loss of 14 employees... Many of whom had done little more than dissagree with a manager (Dan). In one case, they went back through the road safety data to FIND a reason to fire an employee. When caught in a lie, Dan refused to back down and holds a grudge against that employee and his spouse to this day. (They are both seasoned paramedics who want to come back). 39 Wages- Start paying the people what they need to be paid. I recently found that a person that a high school grad is making more money than me and is a clerk at a business. this person started less than a year ago at this business. I have been in the field for over 10 years. Why is that? We have to know medications, we are out there trying to save lifes for pennies. Policies - start using the policies equal with everyone. It is not good for one but bad for another. If one is married to another employee no matter how long they are here. they need to aplly all rules equally. maybe even get rid of policies that limit family members working in different deptments. Attendance policy - I think that medstar needs a policy on this. However the policy that we currently have is in no way a working standard. I believe that if you have the time to

Appendix B – MedStar Employee Survey Results Question 11

11. The quality of frontline personnel is essential to providing excellent service delivery. Medstar is not satisfied with the retention rate of your valuable personnel. From your perspective, what are three things your organization can do to improve employee retention. [Please try to consider actions in addition to/other than increasing pay and/or benefits] take and you or your family is sick then you should have that right to take off. Have it like school. have after so many unexcused absences the person is released. There are a lot of persons in this field who are single with kids. When their kid is sick and needs to be home... the employee has to be there. Medstar needs to understand that Over all improving how upper management treats their employees. You want to make this work, cut the amount of chiefs and add more indians. There is way to much fat upstairs. stream line it and make it a chain of command not a dept against dept attitude. 40 APPLY POLICIES AND PROCEDURES EQUALLY ACROSS THE BOARD REGARDLESS OF STATUS. WE NEED TO LET THE BAD APPLES GO REGARDLESS OF OUR NEED FOR EMPLOYEES. 41 1. provide management that has some modicum of respect for the employees, this is a problem with every department!! 2. find some way to build consensus amongst the managers, several of them have built up such a wall of resentment that they may never be able to really be an effective leader at this organization, replace them! 3. it is interesting that my pay has increased by about 6 dollars per hr since the authority assumed operational control, i am much more frustrated and unhappy then i ever was under rural- metro. in fact, i would say the disfunctional enviroment has driven me to the lowest state my morale has ever been in the 17 yrs i have been in ems. 42 Decrease the amount of system abuse 43 1) They HAVE to decrease the work load. We lose good people to places where they will make less money, but be treated better, with less workload. We have new hires quit because they put a few days in on a truck and are overwhelmed by the workload. 12 hr days are not the norm in the American workplace, Texas workforce commission requires breaks and lunch for an 8 hr day, but we do 12 with no lunch, no breaks...and mgmt pushing/telling us to go faster, work harder... They used to provide "snack-pacs", knowing we couldn't get time to buy food, but then took them away because they were "too expensive", which just sent a message that "we were not worth it". 44 1. GET RID OF ALL MANAGEMENT: Nobody wants to work for people that have tarnished our reputation. 2. Increase wages: Pay people what they are worth for the amount of work is done. Our wages attract KIDS fresh out of school that have no idea what a high volume EMS System is so they are not here very long. In order to attract professional employees you have to have a professional wage. 3. Restructure the Organization: Once everyone is gone hire a CEO and then a Director of Operations to hire his own staff and make this something worth working at. Here's a bonus #4. 4. Lack of Direction: The last survey was supposed to fix this yet nothing was done with it. I have yet to see one thing addressed since the survey results were released. 45 46 I consider pay and benefits to be decent and comperable. MedStar can develope a command structure starting with a Chief of the Department with EMS command experience. Develoop a EMS Training program to keep a influx of EMS personal, and Hire and develop a PIO person the employee takes pride in seeing his department in a positive image in the public eye. 47 To be respected by our peers when you have been here more than 8-10 years. 48 49 Not being quite a strict. Relax a little in the office where people are not so tense. Some employees are afraid to get up from their desk. Its a very stressful situation 50 The benefits/pay are wonderful at MedStar. To improve keeping employee's at MedStar is the simple fact that management just needs to improve on their communication with everyone. I think if the employees had to give their supervisors an evaluation, MedStar would find out who should and should not be a supervisor here. 51 To be more leanient to Tardies. Its almost better tocall in sick if it looks like your going to be tardy. Its better to be here most all of the day then not at all. Give a corrective option. If your 1-5 minutes late give option to make it up though the lunch period. Instead of giving tardies that way the compony still gets all time the employee is required. If that person is on phone rotation give there call to voice mail or to another rep then when they get here give them the extra call to balance out calls coming in.

Appendix B – MedStar Employee Survey Results Question 11

11. The quality of frontline personnel is essential to providing excellent service delivery. Medstar is not satisfied with the retention rate of your valuable personnel. From your perspective, what are three things your organization can do to improve employee retention. [Please try to consider actions in addition to/other than increasing pay and/or benefits] 52 Increase pay, times are getting harder and wages are the same. People are going to leave if they can make better money and take care of their families better.This is the main reason people are leaving, when they can not survive, it causes financial and family problems. 53 1. Most would say, "don't micromanage" 2. Little stress relievers every once in a while, we do the "heads and tails" games about 3-5x a year, and the email trivia we did 2x last year, those were fun, didn't take much time and got everybody buzzing in a positive way. It doesn't always have to be for a prize, can be trivia about the job as a reminder or refresher on policies or something. 3. Allowing everyone to contribute to things that we have going on- (I.E.-other than making one supervisor order lunch for this meeting or that function, rotate to the employees that have a knack for it at one time or another.) You might suffer on their productivity for one day, but they will feel better about their job and knowing that they made someone else's day. Kind of like one act of kindness for someone else makes your life better and your job more satisfying. 54 55 I think that the continued education program is going to really help with retention issues. 56 57 Medstar has made several improvements to retain staff. 58 1. Stop focusing on the negative, we do a lot of good but are very rarely commended on the good. 2. Tell us what is going on good or bad we there is so much whispering going and most people jump to the wrong conclusion. 3. Stop mico-manageing. We are adults, let us do our jobs without worring about lossing it because we use the phone a little longer than we were suppose to or took a few extra minutes on our break etc...... 59 1. Change upper management. Without solid leadership (and this means changing the current leadership, not just sending them to a class), retention will continue to be an issue 2. Consistency -- employee A should be treated the same as employee B, regardless of who their supervisor is 3. Communication - why do we not have company wide staff meetings that are mandatory? We hear only what managment wants us to hear, and most of the time, we hear that managers version of the story 60 61 62 Increase availability of 24hr shift schedules. Put float, or flex shifts, back into the schedule. This was done in the past. A full-time employee would be allowed to sign up for whatever shifts they could work that week, as long as their hours totaled the same as a full-time employee on a static shift. 63 1) treat employees fairly 2) be more understanding and acceptable to emergency so employees will not fear losing their jobs to attend to a sick child or themselves. considering we are in the medical field we should know more than anyone that emergencies happen and we can't control it. 64 1) Let us get out of the trucks. If we had a station at our more commonly occupied posts, 63E, 78H, 92T, etc, we could get out of the trucks and maybe watch some TV, heat up our food, stretch our legs. I get so tired of sitting in a cramped truck being forced to warm up my food at whatever gas station we happen to be at. It would reduce stress and make a lot of people a lot happier if we just had somewhere to get out of the truck for a while. It would also save gas, which must be getting expensive, if we could turn the trucks off while we were at these stations. 2) Help us out when we're extremely busy. Rural metro was a pain but when we got extremely busy, Mike frequently bought us Jason's Deli or pizza or something to say "hey, i know you're getting your butt kicked but thanks for your hard work." it was nice because a lot of times we may not have had any other way to eat. 3) Open up more 24 hour stations. There is a large group of people here that would be much, much happier with a 24/48 schedule. It also improves our relationships with the fire departments that the shifts would coincide with. I'm not sure how much more or even less it would be to rent a small area as a station vs leaving a truck idling for 24 hours with diesel at $4.20 a gallon. 65 This is not a problem with the Business Operations staff

Appendix B – MedStar Employee Survey Results Question 11

11. The quality of frontline personnel is essential to providing excellent service delivery. Medstar is not satisfied with the retention rate of your valuable personnel. From your perspective, what are three things your organization can do to improve employee retention. [Please try to consider actions in addition to/other than increasing pay and/or benefits] 66 Management should treat the employees with the respect they deserve, whether they're a new employee or 20 year employee. For some employees Medstar is just a stepping stone to other opportunities. There a few employees who have choose this as their career. Provide at least a cost of living hourly raise to topped out employees, plus the lump sum performance evaluation pay. 67 Hire upper managment staff that will be FAIR FIRM CONSISTANT no matter who you know, are friends with or dislike. Put a stop to knee jerk reactions from the managment staff in order to increase moral, upper managment must be trusted, they are not as well as some supervisors. Human resourses: Has a problem with micro management, yet has difficulty recruiting qualified personnel and per the HR manager "we dont have a qualified recruiter". Risk managment constantly has the same person(s) on light duty for the last 3 years Operations has a weak leader who has been demoralizing and demeaning to employees Clinical has a lack of communication from their manager, yet still has the ability to continue to train and remediate employees with limited resources. Field personnel will leave if they are given no respect, they can work somewhere else for the same money and 1/3 of the workload. the employees who stay are here for the city, the people and the area, not for management. 68 Opportunities for advancement. 69 70 1. Quit having favoritism and treat everybody equally, don't fire one employee for something and keep the other that did the same thing with no action done. 2. Get rid of the nepotism. 3. Get rid of the points if there is a Dr.'s note for being out sick, you might be out a week and get only one point my thing is you are being punished for being out sick noone has any control over that, I have heard so many times from the medics, that they are around sick people all the time and is punished when they get sick, I don't agree with that at all. Sometimes they around very very contagious diseases putting their own health in jeopardy. 71 Appreciate the employee that have been here. if you have an employee that has tenure and a position comes open for a management position, you still don't get considered over a person who has been here a little over a year. what is the incenntive for that employee w/tenure to stay with the company since there is NO room for advancement??? the point system is not good if you have children, do don't have children??? now the id badges, you get a point if you forget it, might as well NOT come to work if you're gonna get that point! 72 1. Loosen the leash. EMS is an Alpha personality line of work, and the more you fight it, the worse it gets. EMS personnel are stubborn, and everyone knows, the more you whip a mule, the less likely you are to get the results you want. The majority of us know what we're supposed to do, just let us do it, and educate those that do not. 2. Let us relax somehow. Not everyone is leaving the system due to money. Plenty are leaving because the are going to another agency that have the opportunity to get out of their ambulance, and sit on a couch for a moment or two. Sitting in the cab of an ambulance for 12-16 hours wears on you, physically and mentally. Place an alert tone of some sort in the trucks, so that in the event that a crew decides to doze off, as we all need to do occasionally, we can be alerted individually to a call. 3. Get rid of the nepotism policy. Once again, everyone is being punished for the ill actions of a few. There are a lot of good medics, and other employees that have had to leave, or not be hired on due to this policy. Enforce the favoritism issue, with regards to one supervising another, but otherwise, it is a useless policy. 73 Something has to be done about Field crew, Controller, and Supply moral. Management actually paying attention to the grunts. Better equipment, I am always told that back in the day Medstar was to EMS what Paris is to Fashion. We were the trend setter, we really need to get back to that. Oh and did I mention BETTER PAY. 74 1. RECOGNIZE! Supervisors and managers tend to focus on surviving and reacting, and therefore, they are not thinking about recognition. They need to change the way they think about this and make this effort as much of a priority as surviving. We have several awesome recognition programs in place, and three in particular which are completely spontaneous. In some departments, particularly the Field, these programs are going completely unutilized -- even after reminders and a little bit of pushing. 2. Provide security to employees by applying

Appendix B – MedStar Employee Survey Results Question 11

11. The quality of frontline personnel is essential to providing excellent service delivery. Medstar is not satisfied with the retention rate of your valuable personnel. From your perspective, what are three things your organization can do to improve employee retention. [Please try to consider actions in addition to/other than increasing pay and/or benefits] policies and procedures consistently and effectively and timely addressing deviations. Employees need and want to know their boundaries, and they want to know that those who disregard the policies and procedures will be addressed. 3. Train all leaders (managers, supervisors, and all training officers) on communication and trust, particularly how to deliver both good and bad messages and following through with what they say to employees. We are lacking in both of these areas. 75 1. Go back to hiring personnel with a little experience. That would make any EMT or Paramedic's adjustment a little bit easy and we wouldn't lose those that feel so overwhelmed or those that just can't cut it because of the lack of experience. 2. If you back your employees up with a strong support team (Management Team), rather than a group that does not support the field at all, your employees will be happier regardless of the pay. Employees in the field have to feel like Management has their back, and unfortunately your guilty until proven innocent here. 3. Realistic schedules and shift assignments. These 16 hour shifts and these every other weekend off shifts - sound great but in reality those that are working the every other weekend off have to work 6 out of 7 days just to get those 2 weekend days off. The sixteen hour shifts basically get hammered to death the whole shift and yes you have the next day off, but not to be able to do anything but to recover so you can do it again the following day. Do you really want someone working on you that has been up for 18 hours working on you and by the time you get off go home it's usually a 20-22 hour day. Get Real! 76 1. create a better work schedule. for those of us who have been here for awhile still are stuck working crappy schedules. we all put our time in on weekend nights when we started. that was what was expected of you. you knew that before you were hired. nowdays they get people in here saying they offer flexable hrs when we all know thats crap. tell the newbies up front how it is. do your time then you can get a better schedule. 2. let us wear uniform shorts and tennis shoes. it gets hot as hades here in the summer time. we are the ones out there on the streets every day burnin our asses up while mgmt sits in their nice a/c offices. we all know that our trucks dont cool for crap in the heat of summer so at least compromise with us. 3. fix the damn a/c's in the truck. when you check to see if the a/c is workin, dont put the damn thermometer inthe vent. we all know it will show it cooling. place it up by the radio speaker and leave it there then tell us how well its cooling. that really chaps my hide and makes me fuming mad. 4. get rid of the current mgmt that is here and bring in people who have not worked here but have run a successful service before. there are too many agendas here and of course none of them are consistant. 77 More opportunity for community involvement Better pay for field(this would probably only work for a little while) 78 Again, effective leadership talent. If they are not eliminated and replaced, Upper management needs to listen and learn from the true leaders of this organization. Treat folks like professional adults, THEN expect them to act like it. It wouldn't hurt to learn who generation "x" and "y" are and learn (apply) leadership skills appropriate for managing them. You can send some to school and buy their books, but if they don't have the talent necessary to act on what they were suppose to learn then you have wasted alot of money and time. This is our problem. Concrete structure. Write the book, give a copy to everyone, honor it yourself, and then hold everyone else accountable. Leave no question of what is expected of each and every person form day one until time to move on. 79 salary 80 81 Top managment should get out and meet with the employees more and know them on a more personal level such as know who you are when you are seen at the office Put a plan in place to get the crews out on the streets time to get food 82 1) I understand that we are supposed to consider other actions than increasing pay, but that is really the biggest reason people leave. They get absolutely hammered during a shift at MedStar, and they walk around with their head held high because they made a difference today. They get one of the most complex medical patients anyone at the 'Star has seen in years, and they are proud to have run it and figured out what the problem was. But come payday, all we think about

Appendix B – MedStar Employee Survey Results Question 11

11. The quality of frontline personnel is essential to providing excellent service delivery. Medstar is not satisfied with the retention rate of your valuable personnel. From your perspective, what are three things your organization can do to improve employee retention. [Please try to consider actions in addition to/other than increasing pay and/or benefits] is how our lives could be so much less stressful as a fork-lift operator at Home Depot, for more money. If pay was increased, retention would skyrocket. 2) One of the things about working at MedStar is we expect large call volumes. Highly intense days, filled with back-to-back calls. But when we get our tails handed to us day-in and day-out for weeks at a time, it can get very tiresome, both physically and mentally. This would lead to an increased chance in making a mistake, either in a diagnosis, medication admistration, or general treatment. Which, of course, would be detrimental to the patient. In order to alleviate this, we would have to add more personnel onto the streets. 3) SSM. We need to get rid of it. Sure, it may save a little money, but in the long run, the fatigue and health problems experienced by the crews is immense. They've done studies (most notably one in Canada) on how sitting in a running unit causes horrible stresses on the backs of the medics. Also, being able to have somewhere we can have food other than fast-food would increase our general health. Being able to get out of the ambulance for extended periods of time and relaxing would do great things for morale and retention. 83 Get rid of management. Find leaders and go to a government third city service 84 UNfortunately, although you would like us to elave pay out of it, that is not possible. Field employees are leaving for the following reasons: Better Pay Less Work More appreciated 85 Terminate and replace the Clinical, Operations, SSM, Communications, Fleet, Logistics, and IT managers and the Executive Director for no less than dereliction of duty. Medstar has a duty to respond adequately to the needs of its constituents, and while other cities (IN TEXAS) cry about having no ambulances available for two minutes, we gaff off the reality that we do that almost every day for hours at a time. In a coutroom, they call that "patient abandonment" and field providers would lose their certs/licenses for this. Actually seeing management outside of federal business hours is also a good start. If you don't want to improve wages, fine, then offer a better paid benefits package and include that with an income equivalency. Example: You make $10.00/hour and your paid benefits include XXX and YYY for a cost of $N.nn per year, so you'll make an equivalent to $14.50 per hour with benefits factored in. Include ability to have paid education (not just cost of class paid for, but time at classes, both internal offerings and external - i.e., conferences and seminars; and quit requiring us to work a 48 hour schedule and come in quarterly on our personal time off to meet your education requirements. Do like FD and PD and factor it in to the scheduled hours - you might save some in wages for overtime too!). 86 nothing you can really do. you're going to keep the people that can complete the training here, and the ones that consider this place a "good" place to work. 87 88 whan you are sick and you have sick time and you call in you get a point. and they use it against you or fire you. If you are a single parent and your kid is sick and you have no one to take care of him/her because they are sick you get a point. If your wife is very sick and need some one to take care of her and the kids you get a point. If you vommit on Medstar 80 desk and go home you get a point. I call in one time because my grandmother was in the hospital and we did not know if she was going to die or not, I was told that I would get a point. that is telling me that Medstar dose not care about me or my family and I am being bad for wanting to be with my grandmother and suport my mother throw a bad time. Most company that I have work for would have told me to go and be with my grandmother and family and not to worry ( we undestand and we care. ) It is one thing to get a point because you got drunk the night before and have a hang over or to call in for some BS reason but it is another when you are sick or have a good reason to call in. Making you work with some that you can't stand or don't want to work with that person for a good reason. It make for a long and hard day. I am able to work with most any one but their are a few that make a shift hell. I am not one to make trouble any one or hurt some one feelings so I don't sign up for any shift that they are working on. If medstar 80 is wanting you to work with them and you tell him that you do not want to for persnal reason he should respect that and understand that you have a good reason and leve it at that. ( It is one thing if you can't work with anyone or get along with anyone ) USE COMMONSENSE ABOUT THING. 89 1. Pay these "frontline personnel" the money they deserve. why is it that dispatchers and supply

Appendix B – MedStar Employee Survey Results Question 11

11. The quality of frontline personnel is essential to providing excellent service delivery. Medstar is not satisfied with the retention rate of your valuable personnel. From your perspective, what are three things your organization can do to improve employee retention. [Please try to consider actions in addition to/other than increasing pay and/or benefits] techs make more then the EMT's and Paramedics who do what makes this company run? 2. Hire more medics. By doing this the average unit will run less and therefor reduce the workloads on personnel. 3. Adopt a FD based posting system wish allows crews to have a station of sorts to have down time in. being in a truck for 12+ hours is straining. 4. More flexible shifts which allow people with families to be home more often at decent hours. ie: Fire based 24/48's or a 12 hour shift which goes 7a-7p for all shifts. having a constant number of units staffed at all times. 5. Learn from other systems as to what works and what doesn't. there is a reason why MOST EMS systems do not use SSM. 90 better pay and benefits, communication, leadership! 91 Better pay, because there are other companies that will pay you more but with less of a workload. The point scale for your absecenes, and tardies. Just because you are sick one day you get one point. Its not only yourself you are looking out for, but your coworkers and patients as well. Better pay. 92 See the previous few questions. I think improving on those things would greatly improve employee retention. 93 Better Pay is the first one..apparently the person in charge of reviewing our pay scale is comparing this service with our surrounding services that: 1) We are not a small service and these other services dont run near as many calls as MedStar runs and they are transfer services MedStar is not.2)Upper management needs to be evaluated.....3) changes make a great different...... 94 Benefits to part-time employees, higher pay, 95 Take a look at the persons in management positions. The retaliation and bending of rules for employees who go and party with there manager are different for those who dont. The moral is low when you feel inadequate by your managers presence. 96 FRIST START TREATING PEOPLE RIGHT LIKE ADULTS AND NOT KIDS AND GIVING RESPECT. MORE MONEY BETTER SHIFTS AND TIMES SO YOU CAN STILL HAVE A FAMILY LIFE AND SPEND TIME WITH THEM. WE NEED TO START HAVING COMPANY MEETING AGAIN TO KEEP THE EMPLOYEE'S INFORM ON WHAT GOING ON WITHIN THE COMPANY. 97 The majority of people who work in the field at medstar have no intention of staying. What they want is to use medstar as a stepping stone in order to develop experience so they can sell themselves to either a fire dept or flight service. Fire dept's are appealing because of the 24-48 shifts, the excellent city retirement benifits and the better pay. Also the prestigious feeling of being part of the city. I think medstar has a bad reputation from all the previous years of being ran by a private service. It is hard not to talk about pay or benifits because ultimately thats what we all want. The name medstar has a tainted reputation amongst potential applicants as well as residents of fort worth. I think a more appropriate and prestigious name would be Ft. Worth ems. the name medstar sounds like a transfer service which is not appealing to potential applicants. 98 How about fairness. Like the bonus shifts. Being able to utilize vacation time. I know that is a benifit, we are alotted vacation time although we must find our own coverage to take it and then we must be at minimum staffing. General moral is at its lowest. Not being able to utilize your benifits is very discouraging. Mangers and supervisors need more training. It is hard to lead when you don't know how to. I do not have confidence in our management team. 99 Listen to the field crews and take action. We arent always right but we are the ones out there not sitting in an office crunching numbers. Field crews can be fired by just about every manager. Other departments are not held to this standard they only have to answer to their department manager. Where is the fairness there? The changes in pay scale has helped. But we are tired of our voice not counting. 100 treat the field crews like you appreciate them not just saying it but by doing something, pay is a big deal and treat everybody the same, stop all the playing favorites 101 Having been in EMS for 15+ years and at the manager level for 5 years I have seen this same issue in every EMS agency I have worked with. In the majority of all the exit interviews I have done it comes down to 3 things. a. They can get higher pay at an ER or FD. b. Retirement is offered at FDs c. Too many calls. ( I generally relate this to then person that doesn't want to

Appendix B – MedStar Employee Survey Results Question 11

11. The quality of frontline personnel is essential to providing excellent service delivery. Medstar is not satisfied with the retention rate of your valuable personnel. From your perspective, what are three things your organization can do to improve employee retention. [Please try to consider actions in addition to/other than increasing pay and/or benefits] work very much and therefore not a huge loss). I know these fall inot the pay/benefits area, but they are the main reasons. More oppurtunities for advancement helps retention, but having good retention automatically stifles advancement. 102 no more surveys add personnel and resources ditch the entire upper echelon of the management team oh, and increase pay and/or benefits 103 104 1) Re-educate personnel about the point system for tardies, absences, etc. This system bothers a lot of people. 2) Company-wide uniforms. 3) Tuition reimbursement for education. $1,000 doesn't begin to cover expenses for an associates or bachelors degree (or certification for non- EMS personnel). 105 better leadership, communication and values 106 One of the biggest reason for the low retention rate is because of management or the lack there of. They all need to take management classes. People are not born good managers they learn management skills. The human race is naturally selfish and people that are put in a management position have to stop thinking about themselves and start thinking about the other guy. Also, management has to be equal in every aspect of the employees they manage. Employees talk and they know when an employee get favors and others don't. 107 Pay and benifit increases are a big issue among everyone. 1. Don't beat down someone for a minor mistake or oversite. Reward them more often for all of the good things they do. 2. EMS is a field that always has had retention problems and probably always will. Until the pay and benifits increase that will continue. (Sorry for mentioning that, but it is the biggest issue). 3. Improve working conditions, as in breaks for meals or an hour to chill and collect your thoughts after an intense and emotional call. 108 Pay employees a competitive rate vs other emergency services. Orthodontic Benefits for employees 18+ Fitness Plan to keep medstar employees in tip top shape and reduce risk of injury. 109 Well honestly there isn't much that can be done, this system gets busy and stays that way which is different from other systems in which crews get to sit at a station and watch TV for a few hours in between calls. This system will chew you up and spit you out of you aren't up to snuff or if you come here expecting to have it easy. One thing that you might try is having units assigned to a fire station as opposed to moving from post to post all night. Some night it feels like we never stop moving, it helps to have a place to go back to. 110 relax on some of the rules I understand that rules are needed but we now spend more time enforcing the rules and worrying about if we have broken a rule and if we are going to be fired because medstar will terminate your employment for anything and there is no job security here you never know if tommorow you are going to make on of the supervisors mad and he is going to find a reason to fire you. higher pay would be nice and maybe TMRS retirment package and also a higher possible salary increase percentage right now the highest you can get is 5% increase and its impossible to get this i now a perfect employee and they only got 4.38% and the average is 3.5% so that doesnt even cover the cost of living increase. 111 all you can do is increase pay and benefits.. until there is management that cares about the employee there is nothing else that can be done. 112 Offer more training to personnel outside of mandatory card classes. If someone needs off for a class that is mandatory, and it is not the last class offered before expiration, give them the time off! It is mandatory that you do this, but you must do it on your time and management will not assist you in making sure that you can work. If vacation is not available that day, you have to give the shift away. If the giveaway does not work, you cannot take the class. If you cannot take the class, you cannot work. If you have to take the class outside of work, you have to pay for it, even though it is MANDATORY. "We offer it so that you do not have to pay for it" but "you have to find your own coverage." This mentality is similar to the following: You have to have wheels on your car, but we only offer the lug nuts on this one Monday between 8:00 and 9:00, if you cannot make it then you have to make your own lug nuts and we will not reimburse you for it. Stop forcing people into these situations and people will not feel like management is setting the rules against them, they will not be as resentful and will most likely provide better

Appendix B – MedStar Employee Survey Results Question 11

11. The quality of frontline personnel is essential to providing excellent service delivery. Medstar is not satisfied with the retention rate of your valuable personnel. From your perspective, what are three things your organization can do to improve employee retention. [Please try to consider actions in addition to/other than increasing pay and/or benefits] care since they are not angry or frustrated with management. 113 The first thing would be to talk to us ask us what we think. They ask us but never use any of our ideas. I do not mean this in a bad way but the way that admin thinks that everything should be done just cant always be. Second I have no faith in our upper managment. On several occasions they will tell us one thing and do another and when asked why they get very defensive. To be honest without the feild employees there would not be a medstar. People do not give there oppions anymore because it is ust wasting breath. Third give crews the credic that they deserve. We work hard for the company that no one has faith in. We do our jobs for the community. The people who have stayed at medstar through all of the hard times have nothing to show for it, and to be honest that is just sad... 114 LISTEN when we talk. And FIX the things we really need fixed. Field Crews are where the rubber meets the road. The Field Crews are the ones who actually DO what MedStar's mission is to do. MedStar's mission is to provide Emergency Medical Service. Yes, all the other departments are definately integral to the operation. BUT... it's the Medic out there in the field that is actually doing the work that we as an organization are tasked with accomplishing. We could not do it without all the support staff..but they are just that. SUPPORT staff. Their job is to support the field as the field accomplishes its mission. When Dispatch gets nasty on the radio, gets caught in a mistake and nothing happens, or when we email their manager who doesnt even have TIME to read our emails... THEN we hear that an EMT working in dispatch makes more money than some of the field paramedics, and is supposedly REQUIRED to take a break every 2 hours because their job is so stressful....while the field gets harassed by dispatch when we try to sneak in enough extra time at JPS to get McDonalds that we will eat WHILE DRIVING..... it's enough to make the field crews field unappreciated. And once again... WHO is it that is doing the actual task that is MedStar's mission? The Field Crew. The field crews who are ignored when we complain, whether we complain to Dispatch or Field Management. The Field has no voice. And after being ignored, or being treated like second-class citizens for long enough, maybe they start thinking it's time to go where they might be appreciated. When the field crew calls for FD back-up for an "interfacility" call that may require us to need extra hands in route.... why are we asked for the "Nature"? Dispatch had a nature when they sent us... The paramedic on scene is responsible for pt care. NOT dispatch. Do what we need done. Period. And why do they have the authority to tell us how we can clear from a call? 115 equal work load more staffing 116 Accept that this is a high stress job where people are going to get sick or require mental health time. ALL HIGH STRESS JOBS HAVE HIGH ABSENTEE RATES IT IS A STATISTICAL FACT. Quit giving "points" for the first 4 sick calls. continue giving perfect attendance awards those are nice but you should not feel guilty or worry about your job if you get sick. We feel we have to come to work sick and we expose our partners to illness and our immune comprimised patients to illness which isn't fair to them Make vaction more accessible so people don't feel forced to Call in to make important events. Encourage outside interests and activities most of those people who have outside interests and activities instead of constantly being at medstar deal better with the stress. get rid of the frequent schedule restructuring. It just stresses people out and they quit. If you need to restructure some do a limited shift bid of only the shifts that have been assigned over the past 6 months and work with those shifts to tweek system coverage there is no reason to stress everyone out by forcing them to re-bid. Consider discounts at area health clubs or maybe cover enrollment in one TCC physical activity class a semester to help people cope with stress and maintain their health. 117 118 Stop the fighting between departments. There are many good ideas from many good people, but the "blame game" gets old really quick. Everyone fights to be superior, and is way too busy to pay attention to the needs of employees. People pick up on this very quickly, and decide it's not worth it. Perhaps if there were some consistancy with the policies. There are people who get a slap on the hand for the same infractions that others get terminated for. If there are policies in place, they are there for a reason and should apply to all employees. When new employees come here they see this, and employees who have been here experience it, which makes this a

Appendix B – MedStar Employee Survey Results Question 11

11. The quality of frontline personnel is essential to providing excellent service delivery. Medstar is not satisfied with the retention rate of your valuable personnel. From your perspective, what are three things your organization can do to improve employee retention. [Please try to consider actions in addition to/other than increasing pay and/or benefits] volatile place to work. Opening up more shifts would be beneficial. Not everyone wants to work rotating weekends, or 4 days in a row. If there were more of a variety in the shifts available, perhaps we could retain more people. 119 a chance to eat a meal, in order to take medication on a timely schedule. concideration of the fact that we carry sick people in a small area, and we get sick ourselves, but can't miss any shifts without risk of termination. 120 1 Change work hours from 12 to possibly 10 per day. 4 days a week. 2 Fix broke down trucks totally instead of just geting them on the road. 3 positive fedback from management instead of negative all the time. 121 Truly appreciate everyone in the organization. I'm not talking about gifts, rewards, and other fluff. I'm talking about including everyone in the building of our organization, treating everyone respectfully and fairly, and removing personal agendas. Retention is factored by employee delight/happiness, fair pay and benefits, and sense of well-being and job security in the workplace. I believe pay is relatively fair but a sense of well-being and job security is absent. Designing the organization as a profession and not assume that everyone or anyone for that matter, is moving on to something else. By this we need career development paths for anyone interested and willing. Even if that career development is for another industry. 122 Create an atmosphere in which employees can do more than run their legs off and go home. I has been and continues to be proven that it is not about the money. IT is about feeling appreciated and respected and valued enough to do he little things. Good management accomplishs that. 123 Pay and benefits can't be overlooked since it is the primary reason I have heard people say they are leaving. There needs to be long term goals and opportunities for people so that they can see the company is investing in them. Send people to training or conferences outside of our system. Have career counseling available that can offer opportunities like the ability to work toward an RN, PA, etc. without leaving the company and increase the pay and responsibility for people who obtain them. Survey the people that are leaving the company and determine why they are leaving, where they are going, what are they doing in their new job and what would have kept them from leaving. 124 Please try to consider actions in addition to/other than increasing pay and/or benefits] THEIR ARE NO OTHER ACTIONS, INCREASE PAY,BENIFITS AND OUR WORKING CONDITIONS AND YOU WILL KEEP PEOPLE...PERIOD..ITS NOT THAT HARD TO FIGURE OUT!!! 125 The employees need to have more one on one contact with their supervisor / manager. 126 127 The enviroment in which we work in. When people are happier we are more likely to go out their and bust our butts just a little harder. If mangement maybe took care of us then I think things would get better with the ones left therefor when people came in they would SEE what a great place this is to work. Anymore you feel like you have a giant thumb on you pushing harder and harder with no release. 128 do more cook outs at post 4 commcenter needs to have a bonus for working overtime commcenter needs to have no less than 5 onshift at a time 129 PAY since operating hours are 24/7, better time off allowed for employees to have some quality time with family/friends PAY, pay not penalizing employees when they use sick time. Sick time is offered as a benefit - only after an employee uses all their sick time should disciplinary start - we work in all kinds weather/around ill people - we are going to have exposure more so then the normal 9 - 5 office person 130 the problem we always have is being pay and benefit. as long we have other companies paying more and better benefits we will never compete. we must raise pay and find better benefits to keep people and not use medstar as a stepping stone 131 aside from increasing pay and benefits, something has to be done about morale.... field medics (both primaries and secondaries) are constantly feeling like they have to watch their backs around management and certain supervisors (whatever supervisor that may be for a certain person) inconsistent policy enforcement needs to be dealt with... quite possibly, easing up on

Appendix B – MedStar Employee Survey Results Question 11

11. The quality of frontline personnel is essential to providing excellent service delivery. Medstar is not satisfied with the retention rate of your valuable personnel. From your perspective, what are three things your organization can do to improve employee retention. [Please try to consider actions in addition to/other than increasing pay and/or benefits] some policies that are creating issues for people to deal with, and of course, if that is taken advantage of, then put the policy back in place. by creating issues for some people, I mean policies that make us feel like we are being treated as if we are still in elementary school. 132 Take back "control" of the organization. By always bowing down to what some employees want (because they complain the loudest/longest) others get frustrated and leave. 133 1. Pay for knowledge and actual work done along with incentive pay for education. 2. Career Ladders and advancement opportunities. 3. Educational assistance for advancement within the organization. 134 1. Pay and beneftis 2. opportunity for advancement. 3. some sort of bonus incentive for tenure. Alot of cities have tenure pay each year. Example you get paid $12.00 a month for every month you are here. 3. Redesign top out pay for certain postions. 135 We need FTO's, DTO's and CTO's that are proficient, professional, know what they are supposed to be and are not constantly bashing the company or other departments. That does not provide a good base for our new employees. They are "brainwashed", if you will, from day 1. There are several FTO's that do not how to correctly clear a call, how can these people train others, when they themselves don't even know how to properly do the most basic things. From some of the FTO's, DTO's and CTO's that I have talked with, they are constantly complaining about this or that in front of their evales, while I can agree on a lot of the points, it should not be presented in front of new employees. 136 being able to use the vacation time benefited to us not allowing veteran employees to abuse the new ones 137 138 fire the ceo... replace him with someone who understands and values the field personnel who "are medstar". otherwise, are you kidding me??!!! increasing pay and benefits is the only way. 139 Treat all individuals fairly. Give them what is expected up front from the beginning and don't try to make it sound better than it is just be honest and up front. Keep benefits as good as they are, and make that one of the highlights. Get them to understand that not all companies have the benefits we have and keep salaries competitive with other companies so that it is not an advantage for them to go somewhere else due to better salaries and benefits. 140 pay better not be so anal on the attendance maintain trucks that are needing major work turn off speaker for road safety 141 Pay a lot more. New hire primary paramedics should make at least 50k per year. Ten year primary medics should make at least 75k per year. Your turnover would drop to almost zero. Set up districts like the fire department. Let people work 24/48 shifts, and have peak load trucks. Get off our backs about all the petty stuff. Hire good people and treat them well and they will care more about doing things right all the time. Recognise that people are human and as humans we make mistakes and don't beat us up about it all the time. The vacation poicy does not work. I understand that it costs more to fill vacation because of the bonuses, but if you paid more the bonuses could go away and people could get vacation approved. Do I have to stop at 3? Sorry I went over. 142 1. Considering the demands placed on the personnel in this system I feel compensation should be well above average for a system this size. 2. Reduce UHU and the workload placed on personnel. 3. Improve benefits such as retirement, career ladder, ect. Not only is easy to keep happy employees but highly compensated employees will think long and hard before leaving. 143 144 Be upfront with new potential personnel about how tough working the streets really is. Hire quality managers with experience as the lay person. 145 Fire the Operation manager, gives special treatment to his favorite crews. Get a new head of H.R., does not like doing her job never has time for no one. Make things equal, with every one, like bonus, etc. 146 Give us the respect that we have earned, come down from the office and associate yourself with those who are loyal to this company, take time to talk to us instead of at us. Be consistent, we know more than you think there are no secrets at Medstar. What you would do for one you

Appendix B – MedStar Employee Survey Results Question 11

Appendix B – MedStar Employee Survey Results Question 12

12. How long do you plan to remain employed at Medstar? 1 I’m in it for the long haul 2 I’m in it for the long haul 3 I’m in it for the long haul 4 I’m in it for the long haul 5 I’m in it for the long haul 6 I’m in it for the long haul 7 I’m in it for the long haul 8 I’m in it for the long haul 9 12-18 months 10 I’m in it for the long haul 11 I’m in it for the long haul 12 12-18 months 13 Less than 3 months 14 I’m in it for the long haul 15 12-18 months 16 3-6 months 17 I’m in it for the long haul 18 12-18 months 19 12-18 months 20 6- 12 months 21 6- 12 months 22 I’m in it for the long haul 23 12-18 months 24 I’m in it for the long haul 25 I’m in it for the long haul 26 3-6 months 27 I’m in it for the long haul 28 I’m in it for the long haul 29 12-18 months 30 I’m in it for the long haul 31 6- 12 months 32 Less than 3 months 33 6- 12 months 34 3-6 months 35 I’m in it for the long haul 36 I’m in it for the long haul 37 12-18 months 38 I’m in it for the long haul 39 I’m in it for the long haul 40 I’m in it for the long haul 41 I’m in it for the long haul 42 I’m in it for the long haul 43 I’m in it for the long haul 44 6- 12 months 45 46 I’m in it for the long haul 47 I’m in it for the long haul 48 Less than 3 months 49 I’m in it for the long haul 50 I’m in it for the long haul 51 I’m in it for the long haul 52 I’m in it for the long haul 53 I’m in it for the long haul 54 I’m in it for the long haul

Appendix B – MedStar Employee Survey Results Question 12

12. How long do you plan to remain employed at Medstar? 55 I’m in it for the long haul 56 I’m in it for the long haul 57 I’m in it for the long haul 58 I’m in it for the long haul 59 3-6 months 60 I’m in it for the long haul 61 62 I’m in it for the long haul 63 I’m in it for the long haul 64 I’m in it for the long haul 65 I’m in it for the long haul 66 12-18 months 67 I’m in it for the long haul 68 I’m in it for the long haul 69 I’m in it for the long haul 70 I’m in it for the long haul 71 72 I’m in it for the long haul 73 I’m in it for the long haul 74 I’m in it for the long haul 75 I’m in it for the long haul 76 6- 12 months 77 I’m in it for the long haul 78 I’m in it for the long haul 79 Less than 3 months 80 I’m in it for the long haul 81 I’m in it for the long haul 82 I’m in it for the long haul 83 Less than 3 months 84 3-6 months 85 Less than 3 months 86 I’m in it for the long haul 87 I’m in it for the long haul 88 I’m in it for the long haul 89 3-6 months 90 I’m in it for the long haul 91 I’m in it for the long haul 92 I’m in it for the long haul 93 I’m in it for the long haul 94 I’m in it for the long haul 95 Less than 3 months 96 I’m in it for the long haul 97 12-18 months 98 I’m in it for the long haul 99 100 I’m in it for the long haul 101 I’m in it for the long haul 102 3-6 months 103 I’m in it for the long haul 104 I’m in it for the long haul 105 I’m in it for the long haul 106 Less than 3 months 107 I’m in it for the long haul 108 12-18 months

Appendix B – MedStar Employee Survey Results Question 12

12. How long do you plan to remain employed at Medstar? 109 I’m in it for the long haul 110 I’m in it for the long haul 111 I’m in it for the long haul 112 3-6 months 113 I’m in it for the long haul 114 6- 12 months 115 I’m in it for the long haul 116 I’m in it for the long haul 117 118 6- 12 months 119 I’m in it for the long haul 120 I’m in it for the long haul 121 I’m in it for the long haul 122 12-18 months 123 I’m in it for the long haul 124 I’m in it for the long haul 125 I’m in it for the long haul 126 12-18 months 127 I’m in it for the long haul 128 I’m in it for the long haul 129 I’m in it for the long haul 130 I’m in it for the long haul 131 I’m in it for the long haul 132 I’m in it for the long haul 133 I’m in it for the long haul 134 I’m in it for the long haul 135 I’m in it for the long haul 136 12-18 months 137 I’m in it for the long haul 138 I’m in it for the long haul 139 I’m in it for the long haul 140 I’m in it for the long haul 141 I’m in it for the long haul 142 I’m in it for the long haul 143 I’m in it for the long haul 144 I’m in it for the long haul 145 I’m in it for the long haul 146 I’m in it for the long haul 147 I’m in it for the long haul 148 I’m in it for the long haul 149 3-6 months 150 I’m in it for the long haul 151 Less than 3 months 152 I’m in it for the long haul

Appendix B – MedStar Employee Survey Results Question 13

13. What’s one thing that would result in you deciding to terminate your employment at Medstar? 1 my boss stays the same 2 Failure to believe that what I do is worthwhile. 3 I'm getting too old to physically work on an ambulance. I've done this for almost 15 years now, and my back, knees, hips, and neck won't make it much longer.... 4 I hope to retire here, but if a position opened with a stable company with a function similar to what I do now, that had better pay, better insurance (quality not necc. price), or better retirement, then I would probably take it. 5 What happens with the new organizational structure. The job discription for the new deputy director is very disturbing. There are many qualified people in the job market that have strong leadership and company turn-around skills and the job discription is excluding them. I am afraid that we will just get more of the same thing and that we will be no better off then we are currently. If that happens, I will not stay. 6 I have been here to long and have no were to go so I am stuck. Sad to say but I am Things keep getting worse and worse but if we do not have a drastic managment change then people will fill out of the place. we have to show things are trying to change. 7 The operations manager 8 If the clinical department was my immediate supervisors 9 Inconsistent management decisions. Failure to act on critical issues. No sense of urgency. 10 If we don't have REAL CHANGE in this organization in the near future I will be looking for other employment because it is extremely stressful under the current day to day operations. I'm sticking it out and have done several things to help the organization. I just want a organization that functions correctly. I'm optimistic and hope that Fitch and Associates recommendations will be implemented. I believe if it isn't we will have mass exodus and be in the same situation we have been every year since I have been here. 11 One thing that would result in me deciding to terminate my employment at Medstar is knowing that we are not stable. When all this first started and the thought of Fire taking us over, I almost quit. I look at my future retirement wise versus day by day. At times, not knowing if we will be here for 20 more years is not a good feeling. People want to know their job is stable. With families to take care of, stability is a must in a work place. All this that has been going on has scared a lot of people into wanting to go somewhere else where they know that as long as they remain a good employee, their job and company as a whole is safe till they retire. 12 There is not just one thing, but once the breaking point is reached, from the constant job stress and other factors here at medstar(namely managment or the lack there of) then I would decide to just call it quits. 13 medstar mgt dragging their feet to help us and give us false hope just to keeps us hanging. 14 A bad shift. 15 if i found something that paid more money for less work, and consistant upper management... 16 continuation of the SSM plan 17 Current Management remaining in control. 18 If I found a position where I could work less hours and make more money...... IE children's hospital 19 after my 7 yrs when i am 100% vested in my retirement, if nothing has changed and things are not already on the way to getting better, i am leaving. 20 UPPER MANAGEMENT 21 Pay mainly 22 I don't know. 23 The lack of communication, and the feeling that the management at medstar still only focuses on the negative. The only time that we here from our management, is when we have done something wrong, enpecially from the Clinical Manager, Chris Cebollero. 24 Wages and management 25 Make it intolerable to work here and management thinking its not broke so nothing ever gets fixed. Leaving the current personnel in place including the upper upper management, if it didnt work in the past its not going to work now no matter what kind of paint job you put on it. 26 IF my schedule doesnt change then I will be the employee that leaves so I can go to school. 27 After all of the previous consultants MedStar has had over the years, if nothing changes and no

Appendix B – MedStar Employee Survey Results Question 13

13. What’s one thing that would result in you deciding to terminate your employment at Medstar? actions are taken, I would have to look elsewhere. I need to know that I work for a team and not for a company that says they want change but all the actions are "we have always done it this way". WE need a change and to embrace the changes as a team. 28 If it ever went back out for bid and a private contractor were to be brought back in. 29 being micro-managed by someone who has never worked in the field or hasnt worked in the field in a long time. 30 31 Increased pay from a home business 32 realizing that it's been this way for 26 years and no fitch and associates survey is going to change it. It will have to become FWFD EMS division to be any different, maybe then I will come back (I left a nice goodbye note in case I do.) 33 better paying job, better schedule, more family friendly environment 34 pay 35 if i get hired on the fire department i want 36 if i feel that things are not going to change after giving it ample time for improvement. 37 Persuing my career in EMS. I know that if I stay here too long that I will end up like alot of the burnouts. I don't want to put my family through that. I think if MedStar makes some big changes then I might consider staying a little longer but I ultimately don't like Texas Heat so I plan to move a little further north. I really love this service and see so much potential, however even in my short tenior here I have to say that I am begining to feel much like the older ones here and wonder if change is ever going to occur. 38 There are 2: 1) Dan Bruner being promoted in any capacity. 2) EPAB taking over the clinical department. 39 I love medstar. I love helping the persons of fort worth. I think that a job is just that a job. I think I would have to cut ties when medstar starts to cut into my family time and limit my time with my family. I am a single dad with two kids and it is hard when your kids get sick. They do not get sick at the same time. The attendence is a big one for me. There is no reason to fire someone if they are honestly provide a dcotor's note for each they are sick or call off for a sick kids. There is no reason for medstar to get rid of a person for that reason. You give us sick time to take off when we have too. Change the policy to state if you do not have sick time you can't take off. However, if you have the time and you are sick bring in the doctor's note. 40 More money 41 i say that i am in it for the long haul, but that is because medstar has always been a place with alot of potential, im afraid that it will never realize that potential. i recently entertained a job offer but because it would require a move to the austin area i turned it down. im concerned that all of this hullabaloo will blow over and we will be in the same position we are in presently. that is what seemed to happpen with the previous surveys. the most recent survey caused alot of hand wringing and worried faces amongst the management team... for about two weeks, then it was right back to business as usual. so, what would it take for me to leave medstar...i want to stay but i evaluate my opportunities every morning. 42 1.Losing my shift that i am currently on. 2. Not working with school schedules 3. Not feeling wanted or needed 43 Honestly....if you allowed a/any current Medstar Mgr to obtain the new postion posted for Director of Field Operations....not ONE of our Mgrs. has made Medstar a priority...and they never will. They have proven that by not only failing us over the past 2 years, but....since the first survey was made public....they STILL have not put Medstar first. 44 If there was no Management change. If Jack, Dan, Chris and all the managers are still here in 6 months I'm gone. The only reason most of us have stayed is to see if there will be changes. The last survey spoke for itself but it wasn't used. If this is handled the same way then there will be nothing left. 45 46 The inconsist attitudes and behavior with the management staff from the executive director to the Supervisors. 47 When they fault with everything you do; it's time to move on. 48 I am completley fine with my pay, that is not the problem. When supervisors walk into the CS

Appendix B – MedStar Employee Survey Results Question 13

13. What’s one thing that would result in you deciding to terminate your employment at Medstar? room, my stomach gets in knots from fear that I am going to be called in there to be written up. I cant work like this. I'm not trusted to do my job well. I dont feel that my manager is a micro manager, but I do feel it with my supervisor. I have never worked in a place like this. And I do not feel that other companies are ran like we are. 49 its too structured and strict. 50 I love my job at MedStar! I just feel that we get nit picked on to much and it has lead me to feel like looking else where for employment at times. It mostly depends on who you are and who you know in the way that you are treated. Some get away with more than others. 51 Money, 52 financial problems 53 If I felt that I weren't doing my all for Medstar and Medstar agreed. 54 If there is no room for growth 55 ??? 56 Start giving points for unnecessiary things that are out of employees control 57 At this time I can not think of anything that would make me leave Medstar! 58 1. No room for advancement and no pay raise. 59 the lack of care and compassion for the employees. there is no solid leadership here. they want to throw money at everything rather than realize they are ineffective as leaders and are the cause themselves of most of the problems at medstar. 60 If my family got to a point that I didn't need to work. 61 62 Putting the system back into the hands of a for-profit contractor. 63 the disrespect that we receive. medstar itself is a good place to work but unfair with the treatment of employees versus management 64 Better pay 65 If Jack or Joyce left the organization. If Dan Brunner stays with the organization! 66 I'm able to start my own business. 67 Over the course of the next 1 or 2 years, it will be money. I took a $11,000.00 pay cut to educate our employees and with the cost of fuel and living going up at an alarming rate, i may need to research higher paying positions. Aside from that would be if my boss left or was replaced, she has great communication skills, has guided me through "political correct" issues and is a fantastic boss. We need leaders like her to help make this a better place. 68 Requiring more mandatory CE (classes) than already mandated. mandatory call schedule. 69 either a better job opportunity or MedStar fires me. 70 If i'm just stuck as a file clerk, which was not my job when I first started, i'm used to a lot of data entry, I was used to keying in telephone orders making about 8.00 more than what i'm making here WITHOUT A DEGREE. 71 they have to fire me, as MUCH as i would love to leave, i need a job 72 Continuing to see HR take the side of management, irregardless of whether or not the manager was right or wrong. I believe that an HR mediator should be an outside individual, not someone who sits across the hall from the rest of the management. 73 My fiance getting a job in another state. Besides that I don't believe I would find a place quite like the Star. Medtstar does have its quirks about it but all and all this place is kinda like herpes, yeah there treatment for it but you can never get it out your system, and the treatment for Medstar is working here. In other words I find a good place to work. 74 There are actually two things: 1. More flexibility with my schedule for kid purposes (work from home with slightly less hours) 2. Relocation to my home town 75 The continuation of this company with the lack of support and the lack of a true management team. I am already exhausted and would probably look for other work, but I built a house in Fort Worth and so I am trying to stick it out. The sad thing about this company is it could be awesome, but not in the current direction we are going. 76 if after all this talk that you, fitch and associates, are gonna come in, evaluate, and change things dont happen. if things continue the way they are now, i will leave even sooner. i am leaving in november but would leave tomorrow if noting gets done.

Appendix B – MedStar Employee Survey Results Question 13

13. What’s one thing that would result in you deciding to terminate your employment at Medstar? 77 Becoming physically unable to do the job 78 If it continues in the direction it is headed now. Why in the world would someone promote another when there have been documented identifiable issues from day one of their employment, and continue to enable them more. I personally spend a majority of my time leading folks to stay and continue hope, but I am about done after seeing what takes place day in and day out. I say I am in it for the long haul now, but that is only because I am in that mood today, who knows what tomorrow will bring. It is getting old. 79 the management that is here stay and run this company further in to the dirt. 80 81 not staying up to date on pay 82 Honestly, if I could get a job at another EMS system (hopefully not fire based) that paid more. MedStar, overall, is a great system, but if I could find somewhere that paid more, I'd be gone. 83 Management has made that decision. I filled a complaint against a supervisor and was told in a meeting with Dan Brunner that I would be reprimanded if I chose to follow through. 84 This is the second survey we have completed with your company. We would like to see action rather than talk. So far all we have seen is a second survey. We are tired and we are ready to see promised changes. I would stay for the crappy pay, crappy hours, and running my butt off if I saw jsut a little appreciation from management 85 Tired of all the crap & beat-downs I take for this place because of the personal agendas & cliques, & laying all the blame squarely on the field employee (heaven forbid that stupid computer might think it was wrong!). Tired of never being recognized. Tired of the society of mutual admiration. Tired of the ribbons that were designed to reward the field & comm personnel, but more than half of the allocated awards went to middle & upper mgrs & administration. Tired of MedStar mgmt & clinical going in to medical control reviews & ganging up on the employee, who is represented only by himself. Tired of mgrs who allowed others to take credit for the job done & said nothing to correct the injustice. Tired of mgrs who live by the "Do as I say, not as I do" motto. Tired of MedStar never standing behind the field provider & always erring on the behalf of the complaintant. Tired of mgrs and supv's who sincerely act as if they can't be wrong, & will enforce that belief. I have never once heard a supv or mgr apologize for making an oversight or mistake. They feel the need to present themselves as infallible regardless of cost. Tired of mgrs who profess to being walking-talking Christians, but can't live according to a biblical standard (a.k.a. Hypocrites & Pharisees). Tired of mgrs who demand respect but will never reciprocate to anyone who isn't on their A-List. Tired of being lied to about bonuses we were promised two & a half years ago, in writing, from Dan, Ernie, and Jack. Tired of billing getting paid collection bonuses for field providers' charting while being told we have to chart better. Tired of no planned equipment replacement - the crisis & shortage never ends when there is no reserve to back-up the daily demand. Tired of no disaster response - you can't run an MCI out of an ambulance that maybe can provide enough for three people; certainly can't do it while running only 8 trucks for 850,000 permanent people. Tired of NO support for on-job injuries; just too bad! 86 i would have to evaluate that situation when it arose. im sure that if i got in trouble for something, and was continually persequted for that one mess up, i would probably find somewhere else to work. 87 If I get a good job in my field of work after I finish my Bachelors degree. 88 I don't don't know at this point. More money or to make a better living for my self and family. and maybe a slow pace or some thing easer on my body if it get to that point 89 Getting on with a fire dept. These departments have better pay, and benefits. They allow the employee to be a part of a team where MedStar breeds individuals. Greater respect from managment and fellow employees. 24/48 shifts which would allow me down time to be with my family and not constantly at work. Less pressure from managment to stay with in time limits for response times/ on scene/ destination. Better moral overall within the organization. 90 i have advance in this company as far as i can go. going to school to do something else. the stress level in the company is way to high and it should not be this high! 91 Nothing at the moment. 92 I have always liked working here, although this is not a system to keep working full time. Most

Appendix B – MedStar Employee Survey Results Question 13

13. What’s one thing that would result in you deciding to terminate your employment at Medstar? of the employees that leave here leave for jobs where they don't have to work 100 hours a week to pay their bills, and don't have to constantly be on the clock to get somewhere, or do something. Everything we do is on a time-clock. So much time here, so much time there, hurry up, don't stay here too long, you got to move, so don't eat that, or get out of the bathroom, you have a call across town, or post move across town etc. There is never a deciding factor to terminate employment here, it is just a decision to leave full time and work somewhere with a decent retirement, or somewhere you can slow down and be treated like a professional. 93 Low Pay...... 94 If I do not get an increase in my pay. I have been here for almost 8yrs and I make less than some people starting here. 95 Just waiting to here back from a few agency's and will go work for them if the pay is right. Better pay, different work schedule as far as vacation being granted and no requirements of being on call back without compensation. No mandatory over time. 96 AFTER 20YEARS NOTHING COULD TEAR ME AWAY FROM HERE NOW .IAM HERE TILL I DIE. 97 A job offer at a fire dept. 98 If I win the lotto. 99 When I see changes are being made to correct our problem. Make disciplinary action equal quit playing favorites 100 if I keep being passed up for the primary slots 101 MedStar starting to put $$ before patients and employees. 102 if I have to fill out another one of these surveys if they don't hurry up and add personnel and resources if they don't ditch the entire upper echelon of the management team oh, and if they don't increase pay and/or benefits 103 A fire department job 104 I would leave if I felt that I wasn't contributing to the success of the company any longer. 105 106 I'm sick & tired of being treaded like a second class employee when the other employees in my department have more & better equipment to work with than I do. Other employees in my department make personal phone calls at all times during the day and never get called upon the carpet but I make one call to my doctor to make an appointment and I'm called out about it. There is so much favortism to 3 or 4 employees that it isn't funny. 107 Finding a better paying job that I enjoy with more benifits, that has less stress. 108 An offer from a Fire Dept that offered better pay and benefits. 109 being offered a better paying job with a good fire department closer to home that would pay for my medic school 110 If the supervisors keep the same attitude that they have i had one the other day that without any evidence or any just cause approached me affter i left the hospital the other day because i was there to long and accused me of sitting there will it was time for me to get off and then issued me corrective action i have never had this problem and i cant beleive that after one incident this supervisor would do this. 111 Allowing any of the current managers to be placed in sole control of this company 112 I am tired of being pushed around by management and having managers double talk employees. I am tired of management saying that they are concerned about employees and then do the opposite and prove they are only worried about losing their own jobs. I am tired of the managers saying "There is nothing else we can do, it is up to the city to give us more money so that we can do our job." I can live with the calls and how busy the system is, I am tired of dealing with management. I want to see a management department that does not offer favoritism or promotion based upon a quasi-nepotistic system in which who you know plays the largest part in promotion into management. 113 If the disrespect towards me and my fellow feild employees 114 If I continue to be treated as second best to dispatch. If dispatch continues to believe they are "controllers". If my complaints, criticisms, and suggestions continue to be ignored. I'm sick of filling out these surveys.. and saying the same thing over and over and over ad nauseum. I know that nothing will come of this. Nothing came out of the LAST one. I wonder if we keep getting surveys so that it will appear as though something is being done. Our management staff

Appendix B – MedStar Employee Survey Results Question 13

13. What’s one thing that would result in you deciding to terminate your employment at Medstar? MUST know what we consider as serious problems. And what has changed since the last time? On the issue of pay... Jack Eades told the city council last fall that he believed it was a pay issue and that we should be paid comparable to Fire and PD. And yet, in an employee meeting when this very subject was brought up less than a month after Jack said that.... the HR manager told us that MedStar had done extensive research and that we were being paid "competitively" with other like EMS services. Management tells city council and the Star Telegram one thing... and its own employees something totally different. Lets stop ASKING the field questions if we aren't going to do something about it... and STOP telling us something different than we are telling the public. 115 a job with better hours and same compensation 116 loosing my 24 hour shift We need someone from outside to come in and be the new director. If many of our current management get promoted but Chris Cebollero in particular gets promoted to that spot I would seriously consider leaving. We need someone who can get supply, opps and dispatch to work constructivly together. Someone who is positive and willing to look at what is working then make appropriate changes not just status quo or throw everything out and start again. There was a time when you were very proud to work here despite seriously low pay we need to maintain competive pay but also gain that pride back. 117 118 I'm waiting to see if there is any improvement or change on the horizon. If all of these surveys are really going to be heard, and things improve I feel that the majority of the current employees will stay for many years, and bring a bunch of new faces to our doorstep. The way it stands, many will probably leave in the near future, and definately won't recommend this company to anyone. 119 can't pay my bills, and drive back and forth to work on my pay 120 Failure of management to recognize the big problems and try to fix them. 121 No change, evolution, or growth within the ranks of management/leadership. Remaining stagnant and "business as usual" will be a large disappointment and I fear that I'd be faced with finding a more employee-friendly organization. They exist, I came from one. 122 Reduction of my ability to treat patients in the manor allowed by my medical director. Patient Care is still what drives me in this profession. 123 Not really sure. 124 Burn out, knowing in my heart that I to the best of my ability can no longer provide 100% of the pt care that my pts deserve, then for my pts sake I will leave!! 125 Not making a change in a specific managers work ethics. 126 work load to pay ratio. 127 i left once for about 4 months and came back. Yes Medstar has it's bad points but it also has it's great points. Overall you cant bet the experience that you get working this system. And this is what we were trained and wanted to do. Get down and dirty in the 911 world. and well Medstar gives it too you 100%. I dont mind the little pay I didnt get in this job to make money. But sometimes with the way the world is going you have to stop and look at what is going on. I think that if Medstar would have kept going on its original path and not tried to change anything I would have bailed. Right now I see that they are trying good or bad they are trying. And with that gives you hope. 128 people backstabbing instead of going to the person to correct the problem or medstar punishing everybody for one persons mistake 129 better pay - hours somewhere else 130 as a part time i will always be here. but the reason i moved on to a beter company is dut pay and benefits. 131 being stabbed in the back by management one time to many..... so far, I've been able to rectify most issues I've had with management, but it could possibly become an issue for others... 132 I don't know. 133 I am wanting more of a pay for advancement for the type of work I do than what is in my job description because the two dont match. 134 1. Better paying position with more advancement opportunities. 135 Right now I feel that we are heading towards a fork in the road, one way leads to good things

Appendix B – MedStar Employee Survey Results Question 13

13. What’s one thing that would result in you deciding to terminate your employment at Medstar? the other leads to the further decline of what was once a premier service. If we start to head towards the good, then I will more than likely stay, if we continue down the path to "the dark side" then I will have to really reconsider my status here. 136 contiuation of low morale and the inability to use vacation time 137 138 if in the next year there arent some changes for the better, im tired of doing these surveys, im tired of empty promises from management. the last time they supposedly did a survey of the average pay most of my co workers, including myself recieved letters saying we made enough.... well, enough according to who??? i dont care where the imformation came from,, how about surveying our citizens, asking them how much they think we should make. thats who really counts. our tax payers that we serve. not what some fat cat in an air conditioned office thinks is the bare minimum he thinks he can get away with paying us. 139 Benefits reduced and salary not competive 140 141 If I were offered better pay somewhere else. 142 Without significant changes in the philosophy and management style at MedStar I would likely leave for better oppotunity. It seems that surveys don't produce quantifiable change at MedStar. It seems that it is just a feel good exercise. 143 144 Slander 145 Really havent thought about it, love working here at medstar, just tired of seeing a bad operation manager not doing his job 146 I won't. If I have to jump up and down, beat the street for change I will. This is our Medstar and I am loyal to those I work with and the community I serve. 147 When they loose focus of the big picture, taking care of the employee so they can take care of the pts 148 If anyone form the current Management team get the new Operation Director Job. 149 i am curently looking at getting out of ems or atleast going to a different complany so that i can make a resonable salary 150 When I get too frustrated watching the favorites get the warm fuzzy to soothe their feathers. It royaly irks me and soon I will be full. 151 If all this hype with fitch and associates pans out to nothing. Also, If upper management - anyone in upper management, most of all cebollero, lisa bennett, angela wiemer, dan brunner grab a promotion or move up in any way and the good ole boy system gets a leg up in any way shape or form, i will terminate immediately. 152 moeny

Appendix B – MedStar Employee Survey Results Question 14

14. Recently, MedStar contracted with Whitney Smith Company, Inc to conduct an anonymous employee survey. In your opinion, what is your level of agreement with the following statement? The employee survey asked me the right questions to accurately capture a snapshot of my feelings about our workplace. 1 Agree 2 Disagree 3 Disagree 4 Agree 5 Disagree 6 Agree 7 Agree 8 Disagree 9 Agree 10 Agree 11 Strongly Agree 12 Disagree 13 Agree 14 Disagree 15 Strongly Disagree 16 Disagree 17 Agree 18 Strongly Disagree 19 Agree 20 Agree 21 Agree 22 Agree 23 Agree 24 Agree 25 Disagree 26 Agree 27 Agree 28 Strongly Disagree 29 Disagree 30 Disagree 31 Agree 32 Agree 33 Agree 34 Agree 35 Agree 36 Agree 37 Agree 38 Agree 39 Strongly Agree 40 Strongly Agree 41 Disagree 42 Disagree 43 44 Disagree 45 46 Disagree 47 Agree 48 Agree 49 Strongly Agree 50 Agree 51 Agree

Appendix B – MedStar Employee Survey Results Question 14

14. Recently, MedStar contracted with Whitney Smith Company, Inc to conduct an anonymous employee survey. In your opinion, what is your level of agreement with the following statement? The employee survey asked me the right questions to accurately capture a snapshot of my feelings about our workplace. 52 Agree 53 Agree 54 Strongly Agree 55 Agree 56 Agree 57 Agree 58 Agree 59 Agree 60 Agree 61 62 Agree 63 Agree 64 Agree 65 Agree 66 Agree 67 Strongly Disagree 68 Agree 69 Agree 70 Agree 71 Disagree 72 Agree 73 Disagree 74 Agree 75 Agree 76 Agree 77 Strongly Agree 78 Disagree 79 Disagree 80 Disagree 81 Disagree 82 Agree 83 Strongly Disagree 84 Agree 85 Disagree 86 Agree 87 88 Agree 89 Agree 90 Strongly Disagree 91 92 Strongly Agree 93 Strongly Agree 94 Disagree 95 Agree 96 Disagree 97 Disagree 98 Disagree 99 Disagree 100 Agree 101 Agree 102 Strongly Disagree

Appendix B – MedStar Employee Survey Results Question 14

14. Recently, MedStar contracted with Whitney Smith Company, Inc to conduct an anonymous employee survey. In your opinion, what is your level of agreement with the following statement? The employee survey asked me the right questions to accurately capture a snapshot of my feelings about our workplace. 103 Agree 104 Strongly Agree 105 Strongly Agree 106 Strongly Agree 107 Disagree 108 Strongly Disagree 109 Agree 110 Agree 111 Agree 112 Agree 113 Agree 114 Agree 115 Agree 116 Agree 117 118 Agree 119 Agree 120 Agree 121 Disagree 122 Agree 123 Agree 124 Agree 125 Strongly Agree 126 Agree 127 128 Agree 129 Agree 130 Disagree 131 Agree 132 Agree 133 Disagree 134 Strongly Agree 135 Agree 136 Agree 137 Agree 138 Disagree 139 Agree 140 Agree 141 Disagree 142 Agree 143 Agree 144 Agree 145 Strongly Agree 146 Strongly Agree 147 Agree 148 Agree 149 Agree 150 Agree 151 Strongly Disagree 152 Agree

Appendix B – MedStar Employee Survey Results Question 15

15. What did the Whitney Smith Company, Inc survey not ask you that you wish it had? What would your response to the question(s) have been? 1 2 3 There is not a general understanding of what our "Chain of Command" is. It seems that every Manager or Admin person handles situations that one would not "under normal circumstances" be their job. Some duties are "repeated" throughout our Organization and I believe this caused confusion with the Whitney Smith survey because they did not specify Manager vs. Supervisors and who that would be for me. They also didn't ask for our input on how to fix OUR system. 4 I don't think I would add anything, I have just been disappointed that nothing has come from the response that was give to the survey, yet here we are taking another one. This is why people are giving up. 5 The structure of the survey was poor and resulted in people responding with negative answers. I think that the timing and questions were poorly planned. It was based on field personnel and there should have been surveys developed for the various departments that make up Medstar. I think that we would have seen different results if this had been planned better and we would not have seen such a negative response. This survey set us up for failure and did not help the relationship between the employees and management. 6 It should have broke down each department and listed each manager for questioning. I think to many of the questions got lumped into field operations and this makes the operations manager the fall guy for everything. So there should have been direct questions about these people and there job. My response would have been we need a change from the authority board all the way down. Except for Joyce brown,David Lamb and Stacy Rayborn. 7 8 Our office was not included in that survey. Many times our office is not included; roundtable meetings, certain 'company-wide' emails, etc. We are made to feel like the bad guy. 9 Allowing for comments on each department and the individuals in charge. 10 I believe the language in the survey was confusing. Otherwise it was ok. 11 The survey was a long time ago and cant remember all the exact questions, but I feel the questions asked were enough to get the point across of where we could decifer our weak areas versus our strong areas. 12 I cant think of anything at this present time, get back to me later and i will think of something. 13 nothing at this time 14 The survey questions were generalized and non-specific. They should have deeloped questions specifically for MedStar. 15 Are you happy with upper management? 16 people were complaining about gym memberships not being available and this INFURIATED me. I am not here to socialize and suck all the freebies that I can from my company. I am here to help people while being a productive employee. 17 I can't remember a specific question. 18 How I felt about may specific supervisor. At the time I was very disappointed in the way he micro-managed his employees. I also feel like management as a whole only cares about how much money we make, not the people who are out there everyday working too hard. It has become too business minded, when we are in the business of taking care of others. 19 none at this time. 20 I would have like it to have been more dept specific and break apart upper mgmt from field or middle mgmt 21 cannot remember 22 23 24 I dont remember the survey 25 Is running 6 or more calls a day worth your pay in a system that doesnt believe in team work or advancement? NO 26 I think the survey was fine.. 27 To correct the changes mentioned how long would I anticipate it would take to implement and see the changes taking place. 3 months - 1 year

Appendix B – MedStar Employee Survey Results Question 15

15. What did the Whitney Smith Company, Inc survey not ask you that you wish it had? What would your response to the question(s) have been? 28 None 29 I dont really remember the survey so i cannot accurately answer this. 30 31 32 "Please select from the following list which employees you dont know what they do" and "Please select from the following list which employess don't do anything for the company but suck up money and need to be put in field or fired" (I know the last one was bogus but the first one is actually a real request) 33 34 its all good 35 didnot take th survey 36 i honestly do not remember the questions asked. i do remember that it did seem like a very broad survey. 37 Honestly, that was way to long ago to completely remember what was even on the survey. From what I can remember though I liked it overall. I don't know that it was very medic oriented and if it is the way I remember it seemed more business world oriented. 38 Do you think the AMAA has violated it's charter and related city ordinances by not replacing members when their terms expire? Absolutey 39 I feel the survey asked the right questions... I just fear that upper management will not listen and move along like normal with no changes to the system. 40 41 i wish i had it in front of me... i dont really remember but i remember being disappointed when i had finished it. 42 43 I am unsure of which survey you are referring to...we've had so many. 44 The survey was not department specefic. The flaws and lack of attention from the Clinical Department were not noticed because EPAB got good reviews and stole the glory but Chris is doing that. Nobody really knows if it worked or not because we have not had any changes. The two things written about in the star telegram were employees were not satisfied with their pay or workload but nothing has been done. We got lucky in March when the call volume went down and we made compliance thanks to overload but that won't happen again. If the survey worked then we would not be 33 people short going into the busiest time of the year. This management made that survey a waste of time because of the lack of progress and change. 45 46 It was not clear as to which department they were talking about so it created confusion. 47 NA 48 I feel that there needs to be a seperate survey for each department. 49 I feel they asked the appropriate questions 50 How would you rate your supervisor? My supervisor has no knowledge of my job. If I had to rate her it would not be very high. 51 I can't think of anything. 52 nothing off hand 53 I think it asked all that it could, it is hard to be honest because not having been here as long, you don't see as much of the scope as others have seen. 54 it covered all angles 55 56 57 58 59 it didnt ask if we knew that jack is related to someone at whitney smith, and that our answers (even though we were told they were confidential) were not confidential at all. I have seen employees face some retaliation because of the survey....snide comments made by managers here & there to an employee, actually repeated what the employee put in the survey. 60

Appendix B – MedStar Employee Survey Results Question 15

15. What did the Whitney Smith Company, Inc survey not ask you that you wish it had? What would your response to the question(s) have been? 61 62 63 64 65 N/A 66 67 since the survey was so long ago i can not remember any specifics, however most of the questions were "politically correct" questions and we live in the real world where people drown their babies, put them in dumpsters, beat their grandmothers to death, get behind the wheel of a car and kill a family of 5. were not much on the political correct statements and frankly we feel you should say what you mean and mean what you say! The survey was none of that. When the people came here to do interviews, the people that were picked were either the political players or they were real people who were made to feel like they were boring the interviewer or there were rushed with their answers. so to answer the question: DO you like your job? Why? Are you planning to leave? Why? What will make this an effective work place? WHy? What is broken?Can you help us fix it? 68 none 69 70 Can't remember 71 i can't remember, there's been so many surveys recently. but a good question is how do WE rate OUR suprevisors. they have the power to effect our pay rate increased based our our preformances we should be able to do the same since they are supposed to be here to help us and the customers we have to deal with. 72 Not sure 73 74 75 First I think the survey was should have been broken down into categories. I also think some of the results were skewed due to fact we have so many new hires that really don't know what is going on here. Do you think the field employees should be more involved with management meetings? Yes, although we have round table meetings, management only allows two employees from the field to attend to ask questions. Also, if they do not like your question or believe it to be negative, management throws out the question. 76 its been so long ago that i completed that survey and i have slept since then. all i remember is that mgmt got the list but i havent seen any changes to how things are done here. 77 78 I don't think it asked the right questions because they are not aware of our real structure. It was WAY to generic. I believe the answers were skewed because of this and the blame for many things fell onto the wrong person or people. As a matter of fact, in my opinion there were more not right questions than right questions. Perhaps this is why the right focus has not been established. It is either this or there is a great cover job taking place. 79 did no good to ask anybodyanything because nobody will do anything about it 80 81 82 I believe the right questions were asked, and it actually did a thorough job of finding out what the problems were. But, MedStar didn't respond to the issues like they needed to inorder to solve the problems. Honestly, this all comes down to money. We don't get paid what we deserve for what we do. Now, I know they say we're "competative" for our service, but we don't need to be competative. We need to be leading the industry, not only with our medical direction, or quality of medics, but in our pay as well. If MedStar appreciates us as much as they claim to, they sure have a funny way of showing it. Medics living off food-stamps is no way to show it. 83 It was not really the questions that they asked. It was nothing was done with the survey. Just like this one. It will be swept under the carpet. As soon as the media left Med Star all went back to normal. SNAFU!!!!!!!! 84 Its been too long since said survey to recall questions that were or were not asked. 85 Q: What would it take to convince you/make you confortable enough to want to actively help

Appendix B – MedStar Employee Survey Results Question 15

15. What did the Whitney Smith Company, Inc survey not ask you that you wish it had? What would your response to the question(s) have been? recruit new people to MedStar? --A: See previous answers to this survey. 86 87 88 89 90 ? 91 92 I think it did well without being too long for people to get bored and not finish. 93 Will this change anything or is it just a waste of time? 94 -- 95 96 ABOUT OUR FEELING AND WHAT WE THOUGHT COULD HELP MAKE THIS SHIFT RUN BETTER.GETTING OUR IN PUT,IT SEEMS AS IF WE ARE LEFT OUT OF EVERYTHING BUT MADE TO FOLLOW THRU WHAT EVER THEY COME UP WITH. 97 the questions that have been asked in this survey are adequate 98 I can't recall the exact questioning, however I did not feel very satisfied after completing the survey. 99 100 101 102 how about we get rid of the upper management. the people that keep sending out the vibe that we need to have consultants and surveys and all that crap. How about we get rid of them, and pay the people that we've got working in the field a little bit better, and get people some better hours and better schedules. 103 104 What type of education reimbursement would you like to see? 75% reimbursement for tuition, books, fees, etc. for all work-related/degree related courses. A passing grade of B or better would be required for reimbursement. 105 106 107 More personel responses and questions. It was too generic. A survey needs to ask for ideas to improve not to gripe. 108 I felt it was invalid to those who had just came on board whom were new to the system and couldnt say anything really good or bad because they were learning the system. 109 My race is Hispanic/Latino but the option for it was not in the field of answers for the first part of this survey so I picked the closest to having the same color skin as me. 110 i do not recall this survey 111 Do you think any of these suveys will do any good? Not one bit.. you can ask all the questions you want, but untill Mr. Eades decides to act on any of them, they are nothing more than the same grumbling you hear in front of post 4. 112 Do you have faith in the abilities of management at MedStar? No, there has been no proof in the past three years that management at MedStar is competent in their positions. No person in the office has proven they can lead, some do not even talk with employees (clinical) unless you have made a mistake. Negative reinforcement is common practice at MedStar. The staff that is currently in place does not instill convidence from field staff. The positions are respected because of the positions and not because of the people in those positions. 113 114 Frankly, I don't even remember much of the survey. I know that my biggest complaints at the time was that it kept asking me about my faith in my manager and my upper management. The way the survey was set up with the questions it asked did not match well with our organizational structure. I have complete faith in SOME of the 80s. I have little faith in the highest of upper management. 115 116 I would need to look at the survey again to answer this question

Appendix B – MedStar Employee Survey Results Question 15

15. What did the Whitney Smith Company, Inc survey not ask you that you wish it had? What would your response to the question(s) have been? 117 118 119 120 nothing they covered the bases. 121 I feel that you have covered the majority of what I wanted to say in this survey. My overall feeling is that the leadership focus is not on the organization's employees but of that of the selfish few among the top ranks. Quality measurements and benchmarks are absent and that goes for every aspect of the company. Employees are viewed as replaceable and treated as such. We have a person here who I believe is BEST suited for these necessary, positive changes, Kyle Roach. His philosophies and background support a fair and inclusive work environment. He makes few decisions without science and fact. He is straight forward and honest, yet respectful and elloquent. He directs others well and coaches others to "fish" rather than simply feed them. He contains most outstanding leadership characteristics and behaviors that this organization needs. 122 I cannot think of anything at this time. 123 Can't remember at this point, it was too long ago. 124 125 na 126 127 I did not do the survey sorry.. 128 is your equipment adiquite? no....some of the trucks need to be updated and the commcenter needs to be updated 129 it has been too long ago 130 this is not the first time we had a survery and the problems have not change 131 I would have to look at the survey again to see the questions.... and refresh my memory a bit more. the issues I have had with the survey is that nothing seems to have been done with the results 132 I would have liked to see some of the questions worded differently. 133 There is a severe disconnection between the staff and Administration and the communication and interaction is lacking. 134 I think it asked alot of the right questions. 135 136 I was not here when the survey was conducted, but from the outcome I can tell the questions were thorough 137 138 it didnt give me the opportunity to put my exact feelings down like this one. i felt like it ended up being a waste of money that could of been given to employees that risk and give up thier lives daily for an unappreciative management team. 139 140 141 I think I was too new at that point to really form many opinions about MedStar. But, since you are asking... I feel that the orginazation is TOO top heavy. Rural/Metro got the same poor compliance with far fewer managers. I know that there were other issues, and I am happy to have a stronger HR and supply department. But, how many "Managers" do you need. Let Mr. Eades run the AMAA and have ONE manager run MedStar and let EPAB worry about themselves. Put the clinical department under EPAB and let the MedStar "Boss" work with EPAB. It isn't that difficult. I feel like a lot of time, effort, and money is wasted by all the Clinical/EPAB fighting. EPAB is in charge of clinical ultimately. So let them be in charge of it from the get go. Let the MedStar "Boss" run the operation and work wih EPAB and AMAA like it was originally designed. It worked well for a long time, and Mr. Eades didn't have to go on TV to explain whey compliance was in the toilet. I've been a manager in EMS. I know that after the first few months of enthusiasm it is all to easy to start building your office and hanging your awards on the walls. You get stuck in the details of unimportant things. I did. After 6 months behind a desk you couldn't make me run an ambulance call. And, that was my greatest failure as a manager and my greatest regret. I forgot what we were about. I believe that our managers have done the

Appendix B – MedStar Employee Survey Results Question 15

15. What did the Whitney Smith Company, Inc survey not ask you that you wish it had? What would your response to the question(s) have been? same thing. They are majoring in the minor things, finding ways to look busy and protecting their jobs with reports to show what they are doing and why it is valuable. Give me a break. I've been there done that, and I didn't make things any better for the people in the operation that really mattered. The ones taking care of the patient. Shake up the management tree. Get themout into the streets and make them remember what we are here for. 142 I wish they had broken down certain questions by specific departments. It is difficult to effectively evaluate the proper function of the organization without this breakdown. 143 I wasnt a permenate emplyee at that time and didnt take part in the survey 144 Do you think this survey will change anything? No 145 146 It was complete 147 148 149 150 Do you think Medstar is a humane employer? More no than yes. they drive the field ops too learn more,test us more, quicker time, quick to accuse without following paper trails that Medstar itself created. 151 not so much the survey, i thought it was rather thorough actually. It was the interviews held by Fitch. You all interviewed 2 whole people from the field - 2! and we (me and the other lucky medic whom i have known for 5 years) were the only ones talked to on a face to face basis, and we were bullied out by cebellero because his appointment was at 1000 am and we were dipping into his time. Why on earth didnt you get a more vast field perspective - were the unhappy and worked to death people here. I was severely let down by the person to person interviews. a total of 32 mins were spent with with field crews. this was unacceptable and a tota let down. I knew after this happened that this was all fluff. 152

Appendix B – MedStar Employee Survey Results Question 16

16. Organizational communication (management to frontline employee and visa versa) is always a challenge in any workplace. How would you describe the current quality of two- way internal communication? 1 there is communication between management and the frontline employee, it's just not consistant 2 3 Poor. 4 Slightly better than it was, but it still has a LONG WAY TO GO! That statement includes both directions. Management is making an effort, but communication has been so poor for so long, that "the front line folks" don't make much effort because they feel it is a waste of time. It will take time and a lot of effort on the part of management to overcome this. 5 Its not the the communication ... the employees get the information ... they challenge it on every front ... the lack of accountability and the inconsistant handling of issues creates the problem and the personnel claim bad communication. If we would put a QC process in place we would see that it is working for the majority. On a daily basis I see the majority of the employees come to work and follow the rules and are knowledgable about the company and what is going on. It seems that the vocal minority cause most of the issues and claim that we are not communicating ... this is an excuss and we allow it. 6 poor very poor nobody talks around here and you have to pry information out of people that has been the case for years. 7 No respect from frontline supervisors toward managers in following policies 8 Not good; too many hidden agendas 9 Could be better - Department managers need to be accessible and the only form of communication is email and memo. An occasional face to face can only enhance communication. 10 VERY VERY POOR!! Need more staff meetings and make it mandatory to check your e-mail. 11 I feel it is ok, there are so many employees and not all of the employees in our type of business can all meet at one time. We put up Memo's, send pages, emails and place statements etc on our internal Tv's for employees to read. We also have a roundtable meeting every month that employees can attend. We also have an open door policy that crews utilize. I feel we communicate quite well actually. Some employees chose to not utilize or deny those tools. 12 Completely One sided, specifically from the lower employee side. Specifically, emloyees talk or communicate with management but management doesnt seem to listen. 13 depends on who is supervising at the time. some supervisiors just disappear and when you call for them to arrive on scene they don't show. like roland, he wants you to call him so he can decide wether to show up or not. 14 Poor. There is too much "communication" via the pager system. The company e-mail system is not used properly. There is very poor feedback when concerns are voiced. 15 all in a nut shell, it sucks. 16 virtually non-existant. Lisa Bennet only sends pages notifying us of upcoming classes and will not answer emails when questions arise. Dan Brunner will dilligently go out of his way to answer an email and has no problem meeting with you face to face over coffee and cigarrettes if needed to help you make it through the day. We are required to initiate a comm form for any request or problem we see and except for Dan or Medical Records you never get a reply... EVER especially from Angela Weimer, Chris Cebolero, or Lisa Bennet. 17 Poor, at best. I feel that management has not done an effective job of communicating ALL info as it pertains to the progress of the Fitch and Associates program. Furthermore, I believe that each individual manager has their own personal agenda, and will do anything to accomplish their goals, up to and including backstabbing and lying to get their way. 18 I personally talk to my supervisor every shift that he is on duty. As far as upper management goes, I only see them when I am in trouble. They do not go out of their way to be seen. 19 employees and thier direct supervisor communication is good. beyond that, i havent seen upper management in months. they dont come down from upstairs and interact with the employees that are working for them. they seem to have completely cut themselves off with non management personel. this is absoluty no way to run a company. yes a boss is a boss, but you should know who he/she is and not have a fear of going to them because they never mingle other than to discipline someone. 20 Poor, Mgmt is only interested in talking at us, not too us and they certainly do not listen, even

Appendix B – MedStar Employee Survey Results Question 16

16. Organizational communication (management to frontline employee and visa versa) is always a challenge in any workplace. How would you describe the current quality of two- way internal communication? when we seem to yell!! 21 sux 22 Some managers are better about answering questions and resolving problems. People often receive different treatment from the same manager... extra chances at training, etc, where others don't. 23 It is very poor. Still it has not been fixed. The channels are open, but no one is listening from the management side. 24 very poor and when it comes, is usually trying to sugar coat things 25 Open door policy is always the best policy. 26 Hard to say... I don't really speak to managment a whole lot. I speak to supervisors and some are better than others.. Chris and Popp are the best in my opinion they just shoot strait. the rest are to "political" I don't really like that.. ITs like when your sick you want the dr to tell you truth not some bs answer because he either dosent know or dosent think I can handle it. 27 There is minimal face time from upper management to the frontline employee. Many times the decisions made by people far removed from the field are relayed to the employees through middle management who has no say in the decsions but are expected to relay it to the frontline with no explanation as to why the decision was made. Many mangers never even respond to fellow staff much less field employees in a timely manner. I have experienced this frustration myself and have heard of field employees waiting well over 5 days to a response to an email or voicemail. 28 Email is the companies "official" form of communication and many employees don't read their email. 29 All I know is management says they have an open door policy but I have never found any need to use mid to upper level management. 30 I think person to person it is fine... If I ask, they will give me an answer, but as far as group to group, it seems to have its ups and downs, thats hard with any large organization though.. 31 We, they frontline employee speaks, nobody, being management, listens! 32 when you do finally get the kite string between the cans stretched far enough to hear anything it's apparently opposite day. 33 poor 34 i havent had any communication with supervisors 35 dont kow 36 37 The quality of communication really relies on someone willing to listen to someone that is going to talk. I think alot of the problem with the communication around work is there is no one willing to listen. Everyone is tired of management saying the same thing and the management is tired of people complaining all the time. No one is actually sitting back and listening to each other. I personally have no problems with talking with management. I have had a great repor with all but one of the managment employees. One of the employee surveys stated something about not having Dan B. available to talk. I actually found it to be humorous because I haven't found a time yet when I wasn't able to just swing by and chat. 38 What communication? 39 the comminucation has got a little better over the last few months. however, there still remains a need of improvement. Upper management sometimes forgets that the field persons are the money makers of this company. it is not the pencil pusher that brings in the money. It is the two medics that walk into the danger, the two medics that lift heavy patients and still cry out for a better stretcher. It is the two medics that no matter how long and hard the day was comes back the next day because they love helping the people of this city. Help those two medics with better money, better policies, and add more of them to the street. 40 there has always been an open door policy, however the bigger question is how much do they truly listen? I see alot of blame and not enough action again this falls back on management. 41 they do try to communicate effectively, however we still have managers who put out the "effective immediately" memos with little or no explanation about why change is happening, we often change procedures several times in a row without adequate notification, and then we are

Appendix B – MedStar Employee Survey Results Question 16

16. Organizational communication (management to frontline employee and visa versa) is always a challenge in any workplace. How would you describe the current quality of two- way internal communication? shocked when they dont follow the latest and greatest procedure. 42 Any time in need to communicate to a manager or supervisior they always seem to be very friendly and helpful. 43 The e-mail system we have in place is practical in this large setting, but we have many who are unable/unwilling to participate. Many folks have difficulty accessing the website, and others just have a bad attitude, which has developed over time with Medstar at its current rating. I believe that better employee relations/morale would garner a better attitude towards employee participation. 44 The quality of communications is poor or non-existent. The only time I communicate with a manager or supervisor is when I'm in trouble and that's it. I don't know when the last time was I was told I did something good. Nobody checks their e-mail yet that is the sole form of communication we have. Communications is not an issue. MIS-MANAGEMENT IS THE ISSUE AND THEY ALL NEED TO BE FIRED. 45 46 Upper management is very poor and a couple of the supervisor communicate well with their individual employees. 47 Needs improvement 48 I know that I can always speak my mind, and I do. But I have the fear of being written up. And it has happened. I had a problem with my supervisor and I went to HR. In turn, my supervisor found something against me and I got written up for. Not just a verbal, but written up. Medstar seems to bypass the verbal and goes straight to a write up. This has happened to me twice. 49 We do not have very good communication with management 50 Communication is not good at all between the supervisors and employees. 51 excellent. 52 not too good 53 Not very good. Some of the supervisors seem to act like queens lording over the serfs. The employees take great offense to that but fear retalliation or job loss if they stand up for themselves. 54 it is great 55 Sometimes it's good, sometimes it's not so good. 56 In the business office I feel there are only maybe 1 or 2 supervisors you can really go talk to and not worry about whats going to happen to you because of what you said 57 Medstar has several ways of communicating, I personally like face to face. 58 We have no internal communications maybe management to management but not management to employees 59 Its getting better with the company wide emails from whatever her name is in HR, but I believe the picture is skewed to what management wants the employees to hear, not what is really happening 60 I think it works pretty well 61 62 Good. The roundtable meetings, and the dissemination of the info exchanged via minutes in our e-mail box is a resounding success. 63 not enough communication. too many secrets and things withheld from employees that effect our work environment 64 65 N/A 66 Very poor. Management seems to have alot of meetings, but very little information comes out of there. The info they give is filled with alot of fluff, no subtances. Or the info is so old it is not relative. Communication from employees to mgmt, appears to fall on deaf ear. 67 I feel as a frontline mgmt person as well as a field employee, we are told to do this or that with little or no information or explanation. there is an expectation that we as a whole should do what we are told and dont ask questions or you will offend someone, just put you head in the sand and do what you are told, feeding you tid-bits of information as needed. This is not good leadership or good communication.

Appendix B – MedStar Employee Survey Results Question 16

16. Organizational communication (management to frontline employee and visa versa) is always a challenge in any workplace. How would you describe the current quality of two- way internal communication? 68 good 69 70 71 they communicate w/us thru e-mail and what they say the law.. if we are asked our opinion it's taken but then that the last we hear on it. 72 Bad. When I hired here, there were notices, as well as a policy that stated that Email was the primary source of communication in the company. However, the paging system still seems to be used most often, even though, if an individual has their pager turned off, or an abundant amount of pages is sent that cycles the memory, those pages are lost, and the individual never receives them. Along with this, some communication is very delayed, sometimes by weeks, or an individual is left out of the loop altogether. 73 I have not had much communication with the higher ups so I would not know. 74 Not very good. Management has made several changes in the way we communicate with employees and we have consistently applied these changes. We communicate via email (with a structured format focusing on what, why, when, and how), wall monitors, bulletin boards, and coming very soon, departmetnal intranet pages and quarterly "state of the union" messages by Jack. We are also open to new ideas to continue to enhance this. The problem is that many employees openly admit that they don't read their email and have no desire to do so. Even though they have been told that this is MedStar's primary means of communication and why (due to our various schedules and comings and goings of employees), they do not feel any obligation to do so. As a result, many employees still complain that communication is bad. Some just aren't willing to receive the communication. 75 You either get in an email or not at all. Other CEO's here at MedStar have always had an open- door policy. Here it is very difficult to go sit down with Dan Brunner or Jack Eades due to there lack of availability or their lack of ability to answer questions directed to them when you do finally get a meeting. As far as using email, it is a pathetic way to communicate, especially when you have as many IT issues as this company does. 76 i send emails, call offices, even try to see them when my schedule allows but hardly ever get a response. there are times when you send an email or call a phone, leave a message and wait a month or sofor a reply. it totally blows and that makes it hard. 77 Much improved from previous communication efforts 78 If it weren't for the operations supervisors there would be none. Upper management speaks at the employee and the operations supervisors speak with the employee. 79 not worth the paper things are written on 80 81 not good 82 Very poor. We express our concerns as field employees, and it's "taken into consideration". If it's even considered. Most of the time, when we go with a concern or an issue, it is "going to be handled" and nothing ever happens. Yet, we're expected to jump when they say jump for anything they say. And I'm getting tired of the old excuse "we can't do that, it costs too much money". They spent all that money on that car-wash, instead of putting it somewhere we needed it. Like shift-differential for secondaries, or buying more supplies, or upgrading our comm center. The hose and brushes worked just fine - and better, actually. 83 There is none 84 Horrible. The only constant form of communication is through email. most of us work so much that we can only check our email at work. We are so busy at work a lot of the time we do not have th eopportunity to check it. We are too tired at the end of the day to sit at post 4 and read and retain the 15 emails we get a day. Why can't we post bulletins? Why can't we have company meetings. We have done employee meetings with every contractor, but our current management staff says it won't work becaue no one will show up. If one person shows up then it was worth it. They won't even try it. 85 It leaves much to be desired. Effective communication requires Egalitarian dialog, not monologue. Refer to these links: http://en.wikipedia.org/wiki/Dialogue#Egalitarian_dialogue ******************************** http://en.wikipedia.org/wiki/Dialogue#Obstacles

Appendix B – MedStar Employee Survey Results Question 16

16. Organizational communication (management to frontline employee and visa versa) is always a challenge in any workplace. How would you describe the current quality of two- way internal communication? ******************************** Current communication involves mostly management monologue and silencing dissent, even when the dissent could be productive. 86 i dont really communicate for my shift. 87 Great. Everything is through email so you always have a chance to go back and re look at it if you didnt understand the first time 88 89 Terrible. You never get straight answers form managment. you get an answer which they feel will satisfy you for he time being, then drop the issue until you initiate communication again. 90 they have no clue what they are talking about! in other words this company says it has a chain of command policy, and an open door policy. you cant have it both ways. this is why the employees run the company not the managetment team. 91 I think it can be improved. Alot of times you dont have time to talk to them because you dont wanna go out with a late code. 92 It works okay I guess. I wish the email was used more so there is a record of communication though. The process of writing a comm form, or calling 80 and them forgetting is a little old. However I understand the problems of the email communication. It is just frustrating taking the time to write a comm form, or calling in about something and never seeing the result. 93 There's no person to person communication ALL IS DONE BY EMAIL....Employees want front communication... 94 Very poor. Management makes decisions and gives us no adavance notice of the changes and if we the workers agree or disagree with them 95 Its not very good. Policy's change day to day. I was following a company policy and my supervisor and manager came to me and in a not so nice fashion tone of voice scolded me. It took an additional supervisor to step up and tell them both that I actually WAS following the policy as written in our current SOP's. I believe there is so much bend and change that nobody is on the same page. Plus, items are being discussed in supervisor meetings but are beind dissemenated to employee's below them, or if it is, its misconstrued 96 WE DONT HAVE THAT HERE .THEY TALK WE LISTEN AND DONT TALK BACK SO I GUESS YOU CAN A CAN CALL THAT A ONE WAYCOMMUNICATION 97 Too many cheifs, not enough indians. 98 I'm not sure I understand the question. 99 The open door policy has too many doors that close after you express your concern. So if they arent going listen why bother. 100 its extremely lousy, even when some people act like they are listening, as soon as you walk away they have forgotten about you 101 Very open and functional. Information is actively passed from management to crews by multiuple means. The oppurtunity for the reverse is also readily available if the emplouyere chooses to use it. I feel employees that feel communications is bad are not taking the effort to utilize the available resources. 102 I wouldn't. 103 excellent 104 Not at the top of management's priorities. Late. If you don't ask the right question(s), you don't get the information. 105 need to try to balance the needs more for open communication for the employees 106 There is NO two-way communication in the department I work in. If you go to a supervisor or manager and express you feeling then what ever is said will be used against you later. There is no one in Medstar that I can talk to about problems in my department, because other managers wouldn't believe what I was saying and take up for the manager I was complaining about. 107 Poor. You do not know who to trust. 108 For the most part it is ok, my points have been recieved. I have no complaints. 109 The relationship with medstar 80 and the field crew is great 110 There is none all of the managers are too busy fighting beetween themselves to communicate with us 111 They speak alien, we speak human.. no communication at all. the only thing company

Appendix B – MedStar Employee Survey Results Question 16

16. Organizational communication (management to frontline employee and visa versa) is always a challenge in any workplace. How would you describe the current quality of two- way internal communication? communicates is more surveys and MWR events.. 112 The communication is TERRIBLE, especially in the realm of policy/procedure. NO company should operate without a P/P manual. MedStar has had three years to develop a manual and there has been no apparent work on this until 6 months ago. Communication is only functional when corrective action is occurring. Managers go for days and never answer personnel when emailed a question or concern, if ever. When the manager is confronted, they say "I never got the email" when on the email that was sent, a delivery and read-receipt was sent to the employee that show the manager did receive and read it. 113 Their is not a two way communication. supervisers and admin do not care about what we have to say or how we feel. Their are only three superviser that even concider the idea that feild employee may have a oppion. 114 There is NO effective communication. I and most of the other crews that I have talked to feel as if nothing we say has any weight. Upper management does not communicate with us at all other than by telling us what our "reliability" is. The 80s are friendly for the most part and willing to chat with us.... but don't seem to have any more clue than we do about what is really going on at MedStar at any point in time. 115 sometimes there is a lack of sharing new information or updated policies 116 bad, horrible, awful. It is some better with email but there are still things I find out about late because I did not have access from home or the station due to IT issues. 117 118 There is none. Management stays upstairs, crews stay downstairs. The only communication to either is if there is a problem. We see EPAB, and direct supervisors on the streets, and around the station more than any of the managers. It's a great feeling to have EPAB or one of the 80's show up on your scene just to see what's going on, and to make sure your crew is okay. It's nice to know that they are there for you if you have questions or concerns, whether it be on scene or in the office. It's very moral boosting to feel as if they want to be a part of what's going on, not just call you upstairs if something is wrong. 119 my supervisor is very good 120 Needs to be more positive. We only see management if we'vemessed up. Very few time do they come out and say "good job" There are maybe 2 sups who do this. We shouldn't dread to see the sup vehicle come to a scene or on post. 121 Weak at best. I described this in a previous question. 122 Cold. The downside to internet driven communication is that the personal touch gets lost. 123 Improved but still has room for improvement. 124 I still believe that a majority of mgmt to employee communication is non-existent, their are a selected few people in mgmt that I trust and do communicate with but for the others their is NOTHING!!! 125 There are so many opportunities for communicaation that it is now up to the employee to take action on these. 126 The M80s are stuck in a constant battle as the only link between the field and admin. They have the sole responsibility of attempting to keep the field employees satisfied while being "handcuffed" by the administration. 127 Communication to the 80's is great. but after that it is lost and falls on deaf ears. Upper mangement really doesnt care about the field staff 128 it seems that certain people go to the upper managment to get their way....and managment seems to come down harder on certain employees than others 129 good 130 we will always have a problem in the filed with communication. the problems we have is about to much paraegos. let field crews due their job and communication just their job. communication asnwer radio and phone and field do patient care 131 chaotic and inconsistent 132 133 This is a problem but with company email, Marquee presentation of employee information and recognition programs, this seems to help alot.

Appendix B – MedStar Employee Survey Results Question 16

16. Organizational communication (management to frontline employee and visa versa) is always a challenge in any workplace. How would you describe the current quality of two- way internal communication? 134 1. I see a huge improvement in this area in all departments. I am very pleased with the communication I get from my manager. The only thing I have an issue with is ....it seems that top management is only addressing field issues not communications or supply. Those of us in these departments feel that we are secondary to the field. 135 sometimes it's better than others. 136 one sided.. management will pass down information but rarely as for input. when approached with issues, management often ignores it rather than make efforts to fix it 137 I think the roundtable meetings is a great start as long as everyone keeps an open mind. 138 dan really does have an open door, chris likes to play the intimidation card, human resources seems out of touch with what its really like on the streets, and jack, well, dont expect anything from him except a cold uncaring disposition... he has denied several co workers time off to go to important family functions (including funerals and graduations) his reason given was that it might cost the company more money to pay someone to work the shift instead.... WHO CARES?? my family sacrifices alot for my job!! my child gives his mother to medstar everyday and can only hope that when he kisses her goodbye she comes home again! 139 One a whole we can go to any supervisor or our office manager and discuss any concerns we have, but there are time that they do not appear to keep us inform of what is going on with the company. In fairness though that seems to be improving some, still needs a little work but getting better. 140 com needs all personel to speak clear n radio managment needs to enforce rules to all employes managment needs to talk to employes other than in e~mails 141 I have no idea what is going on upstairs, and they would rather pay 100K to do a survey or hire a consultant than come down stairs and listen to us. Good for you. Bad for MedStar. 142 Communications seem to be a one way street here. Directives come from the top and we follow them. Even after reading the minutes of the roundtables it seems that issues are glossed over with prepared responses and no significant changes have been seen. 143 good 144 I do not have a problem communication to any of the managers. They all have an oopen door policy. 145 146 Between us and our Manager is excellent, in this sense we are fortunate. 147 poor between 80 and field, always pointing out the negitive and not the positive 148 Communication? There is no set communication. Some times it is e-mail, sometimes it is pager, or you may see something on the tv in the crew lounge. This has been an ongoing problem. 149 they always want us to write comforms about anything and yet even though i have check the reply requested box i have only gotten an answere or any comment one time in almost five years. i have gone to dan with what i felt was a large problem and explained that i thought it was and was promised that he would get back to me via phone call within 48hrs. i was never contaced about it. 150 Depends who u are and who you are talking to on what day and the phase of the moon 151 Our internal communication sucks like a gigantic vaccuum. It is non existent. Upper management is a secret society that can squash us into oblivion, and they only tell us what they want us to know. Communication is non existent here. 152

Appendix B – MedStar Employee Survey Results Question 17

17. Employees at Medstar have high hopes and expectations for what will result from the Fitch & Associates study. For you, what do you hope most will result from the findings of the consultant report? 1 there will be a constant answer to questions, the shift outline will be better 2 Identifying opportunities for improvement. Recognition of the good things about MedStar. 3 A more effective and efficient Operations Manager that is not afraid of making decisions. I hope the client cities understand that they cannot expect a product or service of a 5 star Steak House on a McDonald's budget. We need more resources to do the job we need to do. We need LEADERSHIP. 4 I hope there will be changes in management. There is one particular person that is at the root of most all of the problems. From what I can see the man has never accomplished anything here other than to destroy tradition, and spread hate and discontent. I hope the consultant will suggest his replacement. I know it won't fix everything, but when you remove the biggest obstacle the smaller ones are easier to get around. 5 That the system is under funded and we need more resources, a new facility and accountability. I also hope that this survey will show that we are doing many things right and that we have a strong core group of employees that support Medstar. 6 Hope that someone will finly listen to what we have to say to fix this place. I hope it will continue to show we need change in managment and the change acually happen. I hope it shows we have no funding and that we can get these citys to pay. I hope this will result in better company wages and retention. 7 8 That the real problems will come to light and be addressed and corrected. 9 1. Solid plan for improvement 2. Improve the training of the current managers or find replacements. 3. Short/long term goals. 10 The need for drastic changes in leadership and operations of the overall system. Basically an overhaul of the entire system from the ground up. 11 I hope they find out that we were on the right track, but needed a litte adjustment here and there. One of my answers would have been to hire someone that is between our Executive Director and Ops Manager which is currently under way, hurray. Other than that, what I said above. 12 A drastic change up in our company specifically in the upper management. Morale here is at a all time low. We need some type of huge shakeup. 13 That each employee here will get a much deserved raise and better benefits. Somehow to also get those people on the council and mayor of ft worth to listen up. they're already complaining about the budget being in the hole. well, that's what they get for not handling EMS like they did their PD and FD by making it a city job. 14 Hopefully, the City councel members will realize that they are part of the problem. 15 get rid of the upper management people that dont need to be here. 16 That this survey does not turn into a "wow MedStar is really doing good" survey. We need to face facts that we are wounded and have been wounded for a long time. You can only lose blood for so long before bad things happen and we have been operating in a crisis mode for too long now to keep doing the same things over and over again. removing inneffective managers making pay better reducing stress level (a little goes a long way) modification or discontinuation of the SSM plan 17 Change that will benefit not only the employees, but the citizens we serve. 18 I hope we find a solution to make the system work without a contractor. I would to see a better variety of shifts, and a better rate of pay. 19 CHANGE 20 I have no hopes, it keeps me from getting disappointed. This will be the second major surbey and still nothing has happened. And when you have upper mgmt making statements like "we are not worried about anyone else taking over because the cities are getting a great service for a cheap price" it leads me to believe that they will not even attempt to make the needed changes until the threat of losing their jobs comes up again. 21 Not sure 22 I'm not really hoping for much. Things haven't changed much in the time that I've been here, except for minute increases in pay.

Appendix B – MedStar Employee Survey Results Question 17

17. Employees at Medstar have high hopes and expectations for what will result from the Fitch & Associates study. For you, what do you hope most will result from the findings of the consultant report? 23 That one of the issue at medstar are the managers that are in place. It is all about the politics. I still would not trust them as far as i could throw them. 24 better or new management better wages better working conditions a better radio dispatch system and better controllers 25 System status management is a thing of the past, we need 24 hour trucks with no less than 30 units on the streets at all times, districts would be better for the team morale with rotating assignments that everyone plays a part in with no exceptions of who is friends, 100% compliance is fair for the community because I believe no one person should recieve different treatment including ample time to get an MICU onscene. If it were your child in our response area wouldnt you want a response that shows we care for your family. 26 I would like to see a happier more fun to work at company that truly cares about the employee and not the bottom dollar. Im not truly convinced that people do care I would like to see it not just be told it. Actions speak louder than words. 27 The organization as a whole will work together rather than defending their own agendas. That individuals will know how to communicate and get consistent answers and the rationale behind the answers. All persons will be held accountable for their own actions and stop creating excuses. I want the field to want to take care of each other and take pride in what they do every day. 28 Validation of what we know needs to happen. We know that late starts, routing errors, chute time delays, total task time and hospital drop time are an issue. We also know that one posting plan does not meet our demand needs. I believe we have tha answers, but we don't have buy-in from the biggest department, Field Operations. 29 Management will get a better understanding of why thier employees have such low moral. 30 I hope to have some peace.... People have been fighting, and complaining for a very long time, and its time for a break.... I also hope this will motivate people to want to make sure that we take this profession to the next level and really join the family of Health Care Professionals.. 31 A change in the upper management and increased pay rate. 32 the second floor of post four comes available for rent. 33 need better top management 34 that we are not paid well enough, and the need for more employees 35 dont know 36 37 Overall I hope that you all see the potential that this service has. I am praying that you can relay that to the cities that we serve and let everyone know that we care and we want to help but we need help to help others. Quite honestly with the questions that were included in this survey I don't see alot changing though. I want the overall perception of value to be passed on to the cities and people that we serve. I know that we can be one of the best EMS services in the nation. I really think that we can in the next few years be able to compete with other services like seattle and FDNY. There is alot of weight being held on this study, however, I just hope someone actually listens to yall. 38 Honestly, -I hope a person is hired to manage the field operations as a whole unit. -I hope Dan Bruner will be removed from the company. -I hope EPAB will be forced to do it's own job instead of medling in the operation. -I hope the member cities will be made to pay subsidies reflective of the service they want and comparable to other systems. 39 I hope the results will make the needed changes to this company. I hope Jack will open his eyes and see that there is more going on then just what his upper management wants him to see. Again, I am affraid that this study will be placed aside and nothing will come out of it. medstar has had the same problems since 1995 or many longer. nothing has changed except company names. persons need to change, policies need to change. 40 That we all learn from our mistakes and make it better. 41 i hope that there will be a new paradigm for management. i hope that mr. eades will be responsible for the business side of things and overall control but that we will have an accomplished, effective director of operations who will be in charge of EVERYTHING east of the billing office.i believe that the field, supply, comm and clinical managers need to answer to one

Appendix B – MedStar Employee Survey Results Question 17

17. Employees at Medstar have high hopes and expectations for what will result from the Fitch & Associates study. For you, what do you hope most will result from the findings of the consultant report? person who knows ems and is a leader... please, notice my use of the word leader. i hope that this person will not be hired from within, the current managers will be either trained, educated and molded into some sort of cohesive team or replaced with experienced effective persons. i hope that we can someday have a meeting where decisions are made instead of scheduling a meeting about when to have the next meeting. i hope that we can stop the mixed messages from upper management. 42 I hope that my shift does not go away and also that my partner and I can stay together. 43 That a new management team will be put into place, a team that knows and respects the value of the frontline workforce, a team that will be committed to Medstar, and will be loyal to everything that "Medstar" stands for. The true heart of Medstar is its people...it's family, it's loyalty, it is a deep love for each other and for the city we serve. Those who truly love Medstar, feel it deep inside when they cross into the city limits...a sense of "belonging". 44 1. Someone to get rid of overload- We can't make 90% with 86 shifts and 2 minute head start in a response with overload so get rid of it. Overload is a false sense of security and does not show true system performance so get rid of it. 2. Increase shifts- A true demand without overload will show how short staffed we are and we need more than 86 shifts. 3. GET RID OF MANAGEMENT- All they do is lie to one another and the board and someone needs to be held accountable for all their mistakes. FIRE ALL OF THEM. 4. Increase funding- We can't do anything with a $2 million subsidy and people need to pay more. With more money we can pay more, have more trucks, better equipment (stair chairs and electric stretchers) and better overall resources. 5. Someone show all the mistakes and flaws that have been done. We were promised when the AMAA took over we would not have a revolving door of employees and that's all we have had. Mistake after mistake has been made over the past 3 years and nobody will do anything about it. WE NEED CHANGE! 45 46 That they recognize the need for a Command Chief and develop a Structured command of the organization. 47 Major changes 48 I would like for management, HR and supervisors to be knocked down to peon status. Then maybe they would see what they are doing to all the people that are bringing in their money. 49 that they need to be a little more relaxed in the office. I know you need structure however, I feel it too structured. No one else that I know or have worked has such a structured environment 50 That management will change for the better. 51 new policies made. Possible cross the board raise for every dept. due to cost of living. 52 Pay compensation and better benefits. 53 That office morale will increase, causeing productivity to go up and people actually enjoying coming to work. 54 I have no high hopes or expectations 55 A more cohesive workplace. 56 More fair and understanding workplace 57 Retaining staff longterm. 58 CHANGE 59 NEW MANAGEMENT....new leadership.....new faces in the upper management positions, ED HR BO Clinical and OPS I think we hope for change that will encourage those like me to stay here...we are dedicated loyal people who are tired of being treated like crap, talked about, stabbed int he back and disrespected by our leaders 60 revision of the attendance policy 61 62 Improved response times. I'm tired of hearing about our failure to achieve compliance. It is constant negativity. 63 that ALL EMPLOYEES get treated the same and that the so called understanding of emergencies becomes a reality instead of a myth that is told to make us feel better 64

Appendix B – MedStar Employee Survey Results Question 17

17. Employees at Medstar have high hopes and expectations for what will result from the Fitch & Associates study. For you, what do you hope most will result from the findings of the consultant report? 65 N/A 66 That the current management is replaced by people that are knowledgable and experienced for each department. 67 Truley the field employees just want to get on with it. they have been waiting for over a year for shift bids, and we have LOST employees because ther was no accomidation for shifts (that is a shame) For me i would hope that there was a change in management in operations, maybe HR, but most of all i hope that the management staff that continues to sabatoge our company realize they are flawed. I dont believe anyone should have to fear for their job if they are doing their job in the most effective and cost effecient manor setting the standards for others to follow. 68 To reconize and address where the weaknesses are in upper and middle management. 69 70 It really don't matter what is found, the key thing is fixing the problem, you can administer surveys all day long, but if there is nothing done to fix the problems then it's defeating the purpose. 71 that We Are Miserable!!!!! and it stems for one person/management... at lease over in the business office! 72 Across the board improvement in quality of the workplace. I believe we have the right people, just not the right environment. 73 I hate to sound like a broken record but, I hope that a substantial pay increase is implimented. Also I hope that we are able to get better equipment and, more PR for Medstar. 74 Support for much needed resources that will help to make our system run more efficiently. Confirmation of needs (or no needs) for changes in system status management. (need to put this issue to rest) Follow through with hiring of Director of Operations. This posiiton is much needed and with hiring the right person, should help ease Jack's level of responsibility and help to foster accountability, consistency, and trust. 75 That major changes need to result in the way this company is being handled. If MedStar was a fortune 500 company - our management team would not be employed. Hopefully this will really open their eyes to the "Big Picture" to be able to see all the problems. This company has so much potential it is a shame that it is being wasted. I have never seen this company this bad in all the years I have been here. 76 that everyting currently being done is done in the wrong way. that you recommend bringing in new mgmt to run the place. that you say we arent paid enough. that you say our supervisors need more training to adequately do their job. that you say we need a new work schedule. that you say we need a new deployment model cause ssm dont work. 77 That changes will be made to the appropriate areas as deemed necessary. 78 Unfortunately I am pretty sure on what is coming and I don't like it. I think Fitch made alot of money, the organization spent alot of money, and life will go on. I had hopes and dreams and I will not spoil it for anyone else that continues to have. That's what America was built on. I hope most for a complete overhaul of the top and then we can look at getting all the other things taken care of. I would like to see talented individuals in place of what is there. I hope we don't waste anymore time training them to do a better job, because we have sent them to Vegas and everywhere else in the nation to "train" and they don't seem to know what to do as it is. There are several very talented and educated folks out there, some even from within. On a personal note - Dave, I know that you know what needs to be done and you are a very talented, experienced, and intelligent man - KUDOS to you. If you can accomplish what needs to be done then you need to run this place. Of course they need to allow you that nightmare. 79 that the management change 80 81 That we should get better pay a better posting plan 82 Honestly, I hope that a change will occur. A significant change. Yes, I would like to make more money, and I hope that this leads to that - but what I really want to come from this, is having a management team we can actually count on to support us for what is actually best for us, and not always bending to what benefits their bottom line more. Yes, it might cost a little more for

Appendix B – MedStar Employee Survey Results Question 17

17. Employees at Medstar have high hopes and expectations for what will result from the Fitch & Associates study. For you, what do you hope most will result from the findings of the consultant report? Product X, but if it works better and is easier to use, why are they insisting on going with Product Y? I understand that we can't operate without money, and if we spend it on every little thing the field wants, we'll run out in the first month of the fiscal year. But they need to take heed to what we are telling them we need. We are in the field every day, seeing what we see and being forced to work with inadequate instruments. They are sitting in their office, not working with these underachieving tools. They should listen to their medics. Now, there wasn't any particular product or tool I was referring to during this, it just made for an easy example to elaborate on. 83 It would be nice if Med Star would take their advice. But, we all know that is not going to happen. This is just a dog and pony show 84 Change in management. New operations manager. Hold the management staff accountable like we are held accountable 85 Realization that this system cannot be fixed due to too many design flaws, politics, and poor public and media opinion. Rebranding is not sufficient. A new agency should be created, and although this survey is a nice token to try to make some improvements, I implore you to face this reality: If the powers that be really wanted change for the better, they would have already been objective and professional enough to realize nothing they have effected has improved public opinion or compliance, and would therefore have resigned and found someone who could do the job right, instead of just patching gaping holes in a sinking ship with pieces of chewed bubblegum in hopes that they will break "The Law of Insanity" (you know, doing the same thing over and over agin and expecting different results each time). It never ceases to amaze me how since the late 1990's this place has been running the streets of Tarrant County and Fort Worth at breakneck speed on bent rims, and trying to correct the problems by frequently installing new tires. This system is fundamentally flawed from the foundation up. It has never ceased to be a company, when it is, in fact, an agency. These two terms, company and agency) carry very different meanings and operational mindsets. Companies make money, agencies yield less concern to budget as to providing sufficient services to jo the job right and still be quick about it. Like the old saying: "Pick two from the following menu: 1.) You can have it fast, 2.) You can have it cheap, 3.) You can have it done right." You cannot have all three so pick the two that give you the most and are both morally and ethically right. Medstar demonstrates it picked #1 and #2. It will take ten years of absolutely flawless operations before we arrive on a scene and quit hearing, "Oh, here comes Medstar..." and start hearing, "Oh thank God, it's MedStar!" 86 87 88 More Money be able to make a good liveing with out working 70 to 80 hrs a week. better benefits , more 24hrs shifts a better work place with better equitment. medstar be family friendly and become a work place that we can be proud of working for. a place were I would want to retired from. and better running trucks. DO away with the road saffty 89 Something poisitive. There is always hope for change but it never comes. One day something will open the eyes of those who can make this system the premiere system they say we can be. 90 high hopes where lost..... the company just talks about the survey.... no action has been taken to fix the problems that was presented..... so the only thing i can hope for is another survey! 91 That there needs to be a pay raise, and the communication between field and office will improve and the trucks will be more dependable and everything will work on the trucks. 92 I hope that there will be some actual thought and attempt to change. So far there I think there has been alot of good change, and we are continuing to improve, but it is an ongoing process. 93 MAJOR CHANGES FOR THE BEST INTEREST OF THE SERVICE AND THE PATIENT...... IT MAKES A DIFFERENCE.... 94 Higher pay and benefits for part time employees 95 People in leadership poistions need to be supervised and trained or hopes of them being booted out of there position. 96 A CHANGE OF THEY WAY THINGS ARE RIGHT NOW.PUTTING TOGETHER A GREAT MANAGEMENT GROUP OF PEOPLE THAT WILL TAKE THIS COMPANY VERY FAR AND RESPECT THE LITTLE PEOPLE THAT ARE OUT DOING ALL THE WORK.MAKING THIS LIKE ONE BIG WHOLE

Appendix B – MedStar Employee Survey Results Question 17

17. Employees at Medstar have high hopes and expectations for what will result from the Fitch & Associates study. For you, what do you hope most will result from the findings of the consultant report? FAMILY LIKE IT USE TO BE .REMEMBER WE ALL JUST WANT TO BE TREATED EQUAL SO WE CAN CONTINUE TO SO ALL THE LOVE WE HAVE FOR MEDSTAR AND THIS COMPANY. 97 A total reconstruction of the company to accomidate for the growing demand for ems. 98 I'm not sure what will happen, I feel that we have a good group of people, if only they could learn to work together and realize that we are all on the same team. If one department has a problem we all have a problem. It is so frustrating to see each manager try and point the finger at another department. I would like to see our management take responsiblity for every department and realize we are all one team. Ask what can we do to help you guys out, rather than pointing the finger and saying well you did this or you did that. I think our management has gotten out of hand, they have lost their focus. 99 True change not smoke and mirrors 100 new management, well certain ones anyway 101 The only thing I feel that will make MedStar better is the improvement of the attitudes of some employees. One bad attitude can make the entire company seem bad, and can infect numerous others. 102 I expect that the results of this survey will be slowly and completely swept under the rug upstairs in the upper management teams' offices. 103 104 105 A stronger vision, mission and values 106 That the managers realize who does all the work around here and that employees are not getting noticed & recognized for the work they do. It is more like a prison around here now that the secutiry locks are on the doors. 107 Of course, better pay and benifits. But mostly more units on the street and a way to reduce B.S. calls. 108 More competitive wages. Become NIMS compliant so we can get federal funds that we are not getting. Better posting. more flexible policies. 109 That we aren't being paid well enough for the amount of work we do. 110 Make it a happier place to work i have always loved working in fort worth on an ambulance but i have hated medstar i hope that they will make it so i will love the company too 111 The need for a well defined and strong leadeship and structured chain of command 112 That the work environment for all front line workers at MedStar will be improved. Stop the management mentality of leading by intimidation. 113 I know what I want and my fellow employeesb is respect fromour peers not just 114 "Employees at MedStar have high hopes and expectations for what will result from the Fitch & Associates study"??? Fitch and Associates should actually ask some field crews what their hopes are. Most of us don't believe that anything at all will come of it. It's been MONTHS since the first survey. And what fundamental changes have happened? 115 116 Some stablilzation of turnover Stabilization of shifts so we are not constantly hoping we don't plan things then have to reschedule due to shift bids etc. A more positive work place 117 118 I hope they listen to what is being said, perhaps with an open mind, and see things for what they are, and not what they think is going on. I feel that if they just listen to the concerns of the employees, not just what they are being told by the managers, and take them into consideration, then we might be able to keep employees, and boost moral enough to draw good, solid new ones. Nothing will ever make everyone happy, but when the majority of a company is unhappy, then things need to change. If the people who represent a company to the public are unhappy, there is nothing good that can come of it. 119 correct the problems that have been identified 120 From the last survey we did, the company asked the right questions but after the results were in, nothing changed. 121 Management change! It's time! We know it would be a painful time but THIS is more painful. Let's endure a new leadership team's vision and direction rather than wade through the blind

Appendix B – MedStar Employee Survey Results Question 17

17. Employees at Medstar have high hopes and expectations for what will result from the Fitch & Associates study. For you, what do you hope most will result from the findings of the consultant report? misdirection under the current management. ALL of them above the lower-level supervisors in field, comm, and business office. 122 I hope management will get the clear message that they have failed us,the employee, and continue to struggle to reestablish credibility. 123 That it is the right system for our service area with possibly more 24 hour stations needed. That benefits and salaries need to be increased to meet those of local Fire Departments especially Fort Worth since they are our primary city. That the facilities that currently house Medstar and EPAB and not adequate for the current and future growth of the system. 124 I pray that the we will not only be heard this time but maybe action will be taken, we have been put on the back burner so many times before that their is no high hopes from the field, we know that we will talk and we will be told " sure we understand where you are coming from and we are working on it" and our answer to that is " we wont hold our breath" alot of us that have been here for a long period of time and have weathered the storm are still realizing the many broken promises, I guess we are just so used to it that the promises almost become comical. 125 The need to have an organizational structure change. 126 Better schedual apportunities at shift bid. 127 For upper mangement to actually listen and try to improve. Both our pay and our morale in the field. You have to take care of the ones already here and working before you fix the new ones coming in. 128 better equiment 129 show the quality and quantity of work that we do does not meet the needs of our pay currently 130 a complete re-arange from upper managenent to field crews. including billing. solution in how to keep field crews.survey inn pay from cost living raise to a deserve rasie. and hope that upper manangement does not take revenge on field crews 131 that something will actually be done about the things that can be fixed. why does management seem to have to be secretive about so many things they do? why is there not more communication or at least better communication between everyone. personally, I'm tired of the US versus THEM attitude around here. managment is not better than field, supply is not better than maintenance, field is not better than supply..etc... you get the picture right? I hope that if our suggestions arent considered, we will at least be told why they werent considered.... instead of being ignored, or have a blind eye turned to us or our suggestions. 132 I hope the recommendations will help us become stronger as an organization and make necessary adjustments to make compliance. 133 The constant stress and work done by Medstar employees is very hectic and constant with other places of employment being less continuous should have the shifts shortened and workload evaluated for pay increases than just market value. 134 1. Better pay and benefits. 2. Even distribution of conern to all departments. 135 That they will realize that we are overworked, underpaid, under funded and under appreciated. And that it will be rectified. 136 that management will actually put into action the recommendations 137 Better ways to maintain our employees and to get rid of the negative feelings many employees have towards management so that we can work as a team. 138 a raise to what our tax paying citizens feel we are worth to them, a change in our ceo, and better benifits, including mental health days, and a more forgiving attendance policy. 139 That this will improve the retention or employees and make this a premier company to work with and make other people want to work here and be waiting in the wings to get here. 140 that we are under paid and post moves to 119aa should be a lev 3 post and make other post moves good for responce times not political 141 That the managers don't file it away like the report given to JPS and try to pretend it didn't happen. That is my biggest hope. That you guys tell them what is really needed to fix this place and they actually do it. Or I should say Mr. Eades does it. It is hard to make changes. Most of the time the only time we really do is when we hit rock bottom. I just hope that we don't have to dig any deeper before MedStar makes the changes that are necessary. 142 Changes in managment, management style, and work environment.

Appendix B – MedStar Employee Survey Results Question 17

17. Employees at Medstar have high hopes and expectations for what will result from the Fitch & Associates study. For you, what do you hope most will result from the findings of the consultant report? 143 I do hope that the views and opinions of my coworkers are taken seriously, I havent been around long enough to be able to really say what's right or wrong but I tend to agree with things that I've heard from coworkers with more time here 144 Management would really listen and act! 145 I hope that the problems will be seen and heard, and then fixed. 146 That we have a problem and fix it so we can do what we have dedicated our lives to do. We want a well rounded secure and consistent company that cares about the foundation in which this company stands upon,,,, the people who work for them. 147 That the only way to fix things is to start at the top change our upper management. 148 I have really just about given up hope that the board, Jack or anyone in the current management team is going to do anything. They did nothing with the last survey. If by chance the board let fitch come in and implement the recommendations there might be a change, but that is the only way I think anything might change. 149 i hope that yall can find a way to fix the moral because i try to be positive but it is hard to with the current state of things and am tired of working in a negative enviroment 150 Fairness across the board. 151 That someone will bring salvation to this mess of a system, kind of like what yall did in KC. It is my greatest hope all of upper management is relieved from their duties and sent packing. That is what needs to happen here - plain and simple. 152 better work place

Appendix B – MedStar Employee Survey Results Question 19

19. What question(s) have we not asked you in this survey that you wish we had? What would you have shared in response? 1 2 3 MedStar is an AWESOME system with so much room for growth and potential. Unfortunately, we haven't done much with our potential because of a lack of funding, lack of interest, or someone in Managment didn't want their "ego" stepped on. I would like to see a Community program implemented to teach our Citizens who we are, what we do, and why they need us in hopes that if we increase our "perception of value" they don't hesitate to vote to raise taxes or support us in other ways. There is no reason your other city services should have budgets in the "double- digit" millions, but your EMS service gets just over $1 million a year. Even the ZOO gets more from the City of Fort Worth than MedStar. The perception of value of the ZOO is much higher than the perception of value for the local EMS service, and we have done nothing to change that. 4 I can't really think of anything specifically you didn't ask, but I want to offer my overview. I think MedStar in general is a great place to work. I really like most of the people I work with, and I absolutely LOVE what I do. I think all management at MedStar would benefit from formal training in how to manage and motivate people, but I think 95% of our problems stem from one manager. This person has done nothing to improve his department, and wants to battle every other manger that presents any problem or even solution to him. As for the retention and response times, I think these issues go hand in hand. We need to stop hireing just anyone we can get to apply first and formost, stop shorting the new hire orientation time to crank employees out faster, and focus on fixing the problem instead of bandaiding it. Put more trucks on the street, even if it means from time to time some crew only run 5 or 6 calls per shift, consider running shorter shifts, so the crews have time to recover before their next shift. Mandate equality, and if a manger / supervisor can't treat everyone equally then they need to find another place to work. More money and better benefits are needed without a doubt, but I really think they are second to the issues listed above. 5 The last set of questions were poorly designed, just like the Whitney Smith survey. I picked the negative choice most of the time, however this is not what is truley in place here. I just don't want someone to think that everything is good based on the poorly written survey. I, like others, want to see action and the only way issues get attention is through answering in a negative way. This is not black or white ... some of our problems are just alittle grey and need some attention, however the sky is not falling. 6 Should have asked the masses if they thought things will change and if they thought all this process with Fitch and Whitney was worth our time. My response is that this is a waste of our time since we have done it time after time with diffrent contractors and managers and the things never change. Nothing changes here because we do not seek funding or have people on a board that know what ems is about and we have nobody with a back bone to get us what we need from these cities. we have lived in the it has always been this away world for ever. 7 8 9 The authority board must also take some heat for Medstar's situation. My personal observation of some members is they do not understand the business of EMS and should not be in the position to navigate the ship. It angers me that Medstar's problem have been in existent for quite some time and nothing has been done to prevent our current situation. The Medstar system wants a cheap service at the expense of our current and former employees. 10 None, I believe it was a good survey. Thank you. 11 1. Obviously if your feeling out this survey you are currently employed at Medstar. What makes you stay here at Medstar? 12 Q. what is your overall opinion of MEDSTAR? A. The company as a whole is in trouble. We are a sinking ship that has several ways to stay afloat but will not choose them. Once ideas are offered up most are rejected or completely ignored. 13 nothing I haven't said already 14 n/a 15 16 opinions of SSM and its toll on the workforce. SSM is outdated and dangerous. Diesel is over

Appendix B – MedStar Employee Survey Results Question 19

19. What question(s) have we not asked you in this survey that you wish we had? What would you have shared in response? $4.00 a gallon and we are killing our trucks. We are posted in the middle of nowhere with no facilities (47Q, 89Q) in dangerous areas where you can watch drug deals going down and crack addicts hounding you for a handout (92D) and you are seem to be punished if you are sent to 89Q because you will get a transfer out of the Southwest hospital district before you are removed from this post. This post IS unsed as punishment. 17 None come to mind. 18 n/a 19 none 20 Really am tired of questions, I just want to see some changes. 21 Are you happy? 22 none 23 24 With regards to the question about the right equipment to work with, many times the trucks do not work correctly and the medical equipment is is dirty and not working 25 none 26 I think the survey was fine. MY only comment is what I get out of work I put in. Work allows me to get things done but only because I have the drive to do it. Work doesnt push me its my own personal pride and desire to be successful. I would think that most people would agree with that. 27 Why do I stay? I am a paramedic first and foremost and I am proud of what I do and who I work for. Although there are many frustrations in my job, I see the results from my job in those I help in their training and education. I have continued to grow in my professional development and am hopeful we are taking actions to make this a place people can be proud to work. 28 None 29 n/a 30 31 32 I love working in fort worth, I love the people, the crews and the calls. But damn I wish Medstar wasn't the EMS provider for fort worth, so I could run ems in MY town and not get run out of here. I hate the management here and the only thing that will change this company is to fire the second floor. 33 34 none 35 pegged them all 36 37 First of all I know that you are getting paid to do this but I do want to say thank you on behalf of the employees at this service and in EMS in general. I don't think that there is any questions that you didn't ask and I could comment on things about this service for days. So I will leave in closing with a thank you and good night. 38 What do you think we are going to do with the survey results? Like all past surveys, this will get lip service and then be slowly, but completely swept under the rug. No action will ever be taken based on it's results. 39 40 41 its so difficult to answer this type of question in this format, i really wish when david williams sat and talked with us it could have been all day, or it could have involved some one on one conversation. 42 43 This was one of the most thorough, thought provoking surveys I have ever completed....outstanding! 44 It's not what you asked it's what will be done. You have all the data to determine a shift outiline and posting plan and that shouldn't be an issue. You have seen the last survey and know nothing has been done about it and now another survey is being done? One thing you have to understand is we have had 4-5 surveys in the past 3 years and there have been NO CHANGES,

Appendix B – MedStar Employee Survey Results Question 19

19. What question(s) have we not asked you in this survey that you wish we had? What would you have shared in response? ZIP, ZERO. So don't be suprised if you have poor numbers for this one. One thing that has to be done is determine which department is pulling their weight and in this case there are maybe 2- billing and supply. From there changes HAVE AND NEED to be made starting at the top. Someone needs to be held accountable for this mess we are in. Our staffing levels and hiring abilities point at management. We can't retain because of managment and we cannot hire because nobody wants to work for this management. It is obvious by our performance that we don't have what it takes to get this fixed so something else needs to be done and somebody else needs to do it. I am tired of being the laughing stock of EMS because I work at Medstar and why should I change because of mismanagement? It's not my fault. You have all the info and data you need to make a change so do it. 45 46 1. Do you enjoy your job? 2. What is your long term objectives and retirement objectives? 3. Do you respect the Management team of MedStar? 4. Do you trust the Management team of MedStar? 5. Do you trust and respect the type of system MedStar system status management? 6. Do you believe in the MedStar system and System status management? 7. Do you have trust in all of the various departments of MedStar? 8. Do you have trust in the maintenance and dependability of the MedStar fleet? 9. Do you have confidence in the Medical oversight of MedStar? 10. Do you trust your supervisor? 11. Who is your mentor? 12. Who is your supervisor? 13. What type of EMS system do you prefer to work? 14. Do you feel confident the current leadership of MedStar is capable of taking MedStar to the next level? 15. Are you Proud to say you work at MedStar as a Paramedic or EMT? 16. Are you confident the Medicine you provide is the best care around? 17. Are you a confident and proud paramedic? 18. What MedStar traditions does MedStar have? 19. Would you be open to building and funding a EMS Memorial to honor the EMS profession such as building a statue in public view? 20. Do you trust your dispatchers to dispatch you on the appropriate priority with appropriate support agiences (ex...fire department, police department). 21. Do you enjoy the non EMS related activies MedStar provides (ex...cookouts, picnics,) 22. Do you trust and enoy working with your partner and if not why? 23. What non EMS related activies would you suggest or reccomend? 24. Are you dedicated do EMS and what have you done to improve the image of your profession and MedStar? 25. Do you plan on retiring from MedStar and if not why? 26. What is your attitude towards MedStar and if not good what can be done to improve the over all attitude of MedStar employees? 27. Does MedStar give you the opportunity to advance and what type of advancement are you looking for? 47 Do you feel you can go to HR with any issues without any retaliation from the supervisors? No, it's not feasible to even try, will not get solved and will make one's life miserable. 48 49 none 50 ? 51 can't think of anything. 52 I believe that everything that has been an issue has been covered. 53 I think that all the wuestions wer valid and complete, I can not think of anything else that you could have asked. 54 none 55 56 57 58 59 60 None. Really I am pretty satisfied here. 61 62 63 There are not any questions that come to mind, but in the question of "ethnicity" just about all majority ethnicities were listed except for mexican american/hispanic. That is my ethnicity. Since it was not listed the question was left blank. Thank you. 64

Appendix B – MedStar Employee Survey Results Question 19

19. What question(s) have we not asked you in this survey that you wish we had? What would you have shared in response? 65 The essay questions are not always a forum in which you will get a oerwhelming response 66 67 Without reprocussions from anyone in management, what is the biggest downfall of this company? Dan Brunner can not be trusted to be fair, firm and consistant Stacy Rataree can not be trusted to be fair, firm and consistant. 2 of the key elements in having a true open door policy and enstilling confidence, trust, and equality to the employees is hindered by these 2 people. 68 none 69 70 Are you satisfied with your work schedule? The answer would be no. I was doing a schedule that I loved we became short handed and I was told the schedule is not working because of the dept. being short handed, well my schedule was changed, and since my schedule was changed there has been nothing major to warrent my being here on the day that used to be my day off, I understand if it's for the needs of the business, the position that was short was a degreed position and there was nothing to that position that pertained to me, I was told that maybe I would be able to go back to the schedule I was on, but I doubt if that will happen, it was originally done to try to accomodate the medics that don't work our 8-5 shifts, I hear it all the time, there is noone here when I get to work or there is noone here when I get off of work, there was a lot of people that were able to get things taken care of because the office was open early. I would even consider working 9 hour days starting out early in the morning and working 4 hours on the day that was my off day, I just feel that if this was another person in the department they would still be working the schedule they wanted. 71 something like do we feel we can speak with the HR department confidentely? NO, everything you say just goes back to the root of our problems, why even have an hr dept?!?!?! she might as well be the HR/Bus Opp Mgr!!!!! also on question # 3 --most majority of ethnicities were listed except for Mexican American/Hispanic, it was not listed, I left it blank. I’m Mexican American, that is my ethnicity and i DID NOT choose the others listed. 72 Good survey. 73 Do you believe you are paid at the industry standard? My answer would be no. 74 NA 75 Does the public realize what kind of service MedStar is providing? I think the public would absolutely be outraged and frightened for their loved ones that may need the services of MedStar. For a company that use to be an elite service, now we are just scrounging by. What a waste. Do I feel Like a change in management would better MedStar? Yes. I think a professional management team needs to be put in place. I think if that were to happen, turnover would decrease and other issues could be handled. Do I feel that the problems of MedStar can be addressed by the current management team? No. I do not believe that any changes made with the current management staff in place will benefit MedStar and us as employees. It is clear to me that I am not a concern of management, except to fill the schedule. 76 i cant think right now but i will tell you this. all hell is going to break loose if you dont do something. 77 78 None, thank you for your time. 79 80 81 82 I think it was asked well, I think I might have turned your questions into what I thought was the spirit of the question, instead of what they actually did - but those would have been the only changes I would have made. I think this has been a good survey, as most of them have - the biggest thing about these is what our management team will do about the results. No offence, but we can survey ourselves until our fingers go numb, but what we need is enough people to fill them out and have management do something to improve. Not that we're flawless, but these surveys aren't about us. 83 To tell us the truth. That this is a waste of your time. Med Star is going to make you fill this out and then they are not going to make any changes. I was given a number from a gentleman

Appendix B – MedStar Employee Survey Results Question 19

19. What question(s) have we not asked you in this survey that you wish we had? What would you have shared in response? from your company and was told that I should call him and report the incident with Brunner. Well, I called several times, but my messages went unanswered. The truth is that no one cares with the exception of a few of us in the field that really try to make a difference in the lives of those we serve. And even that has run out. Most of us are taking the steps to find other employment. 84 no 85 I would ask you to believe that people that already serve in MedStar may just very well have the right answers, and no, most of them are not in management yet. I would ask that you genuinely seek out these people and find out what they have to share. A Bachelor's degree cannot make you a good leader and it does not guarantee you can drive this agency to excellence. It simply means that you can follow an institutionally-structured prescription for the way of doing things right and meeting their goals of proficiency. Just because you complete Paramedic school doesn't automatically mean you're going to be a good Paramedic, as I'm sure anyone who is a trainer or has more than three years in EMS can tell you. We also need to quit believing more bureaucracy can lead to better performance when what we need is spirit, motivation, recognition, and morale. Case in point: crime hasn't lessened. We now just have more laws to be broken. Society, as a whole, has legislated more law than can possibly be followed, but it has failed to change heart of its members. Hence we have more sexual perpetrators than ever thought possible, and more illegal immigration, and more uninsured drivers, and more drug addicts, and more homeless, and more disruption of the family unit... and... and... and... Seek out someone with a true vision for Medstar and what it can become, and actually listen and act on what is discovered. Lord knows many of us have tried to step up to the plate and offer workable solutions to the problems and have been met with closed minds and closed doors. You cannot do this by working federal business hours. You have to be seen and hear for yourself at all hours on all days and nights. You can't be burned out from the streets expecting that because you put in your time, you're entitled to a cushy leather seat and a set schedule. You have to represent the agency to the media and the public and SHOW that you care, versus regurgitating what you think we expect to hear! 86 87 No 88 89 1. Do I believe in the direstion this company is going? No 2. DO I believe my managers are doing what they can to improve this company? No 90 why is it we are doing so many surveys? it just falls on deaf ear! 91 92 Good. 93 ON THE PREVIOUS QUESTION (E) Not all supervisors perform the same expectations that are required....My question is does the upper management do the same? We dont know! Why is this situation such a constant problem? If upper mangement does not know what does this answer to you? Changes make a difference...... 94 -- 95 96 I THINK MOST OF EVERY THING WAS COVERED BUT LETS WAIT AND SEE IF WE GET ANY CHANGES OUT OF THS BEFORE WE ADD ON MORE 97 none 98 I do not have any further questions. I am only one person, I will continue to do my best and pray that things can only get better. 99 100 101 102 the format of the survey is a complete and total waste of everyone's time. No one in upper management wants to lose their job, so in order to facilitate their job retention - every employee at medstar is pretty much forced to put their thoughts down in an online format such as this and several other surveys in recent months. Upper management and even supervisors have received complaints and comments about how to improve the daily business at medstar,

Appendix B – MedStar Employee Survey Results Question 19

19. What question(s) have we not asked you in this survey that you wish we had? What would you have shared in response? and they are either tired of listening to the same old complaints or simply aren't interested in what the field employees have to say, so they've come up with this survey "tool" (quotation marks denote sarcasm in this case) so that they can cover their own collective ass. They can now claim that they've acted in the appropriate manner. woohoo. In all reality, they've only delayed the inevitable. So what they've actually done is collected a group of employees in the field that can't do any better or have just been here so long that they are used to dealing with all the bs and don't care anymore. Because anyone with half a brain in their head would leave and go to work somewhere else that pays better and doesn't ask them to work as hard. So how would you feel if you came to work every day with a group of people in which the majority has to be there, instead of wanting to be there? I don't think you'd stay very long at all. I think you'd use Medstar as a stepping stone instead of a career and get out as soon as you possibly could. 103 104 None that I can think of. 105 are we being paid fairly 106 107 More questions about experience. Experience goes a long way and is often over looked in many companies. The "old guys" often are not asked their opinion or advice, and these people have usually been around long enough to know, do not speak unles spoken to. If the old guys have something to offer, management should listen. The have a knowledge base and experience to educate people on the things that are not in books or management courses. 108 109 Nothing that I can think of at the moment 110 111 What should be done with current management? Fire the lot and restructure the company into a progressive department dedicated to not only patient care but employee mental, physical and financial welfare 112 113 On a personal level what could medstar offer to keep good employees? The ability to futher your education. Medstar will not work with you so that you are able to futher your education. Medstar does offer a paramedic class that is in house, but for people who cannot take advantage of that is left to suffer. Their are people who have familys to provide for and due to the fact that the cost of living has increased and medstar does not pay enough people make their money on their OT. For a lot of people if they do not work OT on a weekly basis they cannot put food on the table and a roof over their familys heads. Also with the same situation they will not work with your schedules. From personal expirence I work at night get off go straight to class and come straight back to work. Then their are rotations to fit some where in all that. People who are futhering their education and in the end is helping to company advance by placing more paramedics and will help with the compliance. The one thing that should be asked is why do we stay at medstar? The people who are "in it for the long hall" love their jobs. The benefit from the job that we have is more rewarding than any one could imagine. 114 Do I feel that there is anything to be gained in filling out this survey? Absolutely not. I apologize if I seem bitter. I have not yet been at medstar for a year. I truly believe in the work that I do. I am at MedStar to do what we are tasked to do. I firmly and passionately desire to provide the very best compassionate and professional Emergency Medical Service to each and every patient. Unfortunately, I believe that inter-departmental politics and weak upper management have lost sight of our charter. There is so much fighting between departments, and so much "not my job" or "this is MY slice of the pie" going on that we do NOT work effectively as a team. MedStar could be THE premier EMS service in the world. That's not a boast. We're in a unique world here. Unfortunately the people who are out there watching patients bleed, or vomit... the people who are pushing those meds, defibrillating, and doing CPR are obviously NOT the cherished resource that they should be. If they were, their voices would be heard... and they wouldn't continue to LEAVE 115 116 Nothing about maintenance has been asked. We need better maintenance of vehicles and I

Appendix B – MedStar Employee Survey Results Question 19

19. What question(s) have we not asked you in this survey that you wish we had? What would you have shared in response? don't mean pretty outsides I mean they need to run smoothly, have adequate suspension when they go in for routine care they need to check things like alignment and ride in the patient compartment as well as changing the oil. Quit taking out the insulation when doing repairs the noise in some of these trucks is so loud you can't hear the radios and the older they get the worse it gets because maint. takes out insulation. Seatbelts need to adjust for height of the passenger or driver, arm rests need to work to reduce fatigue. the tablet chargers need to work or come out they are in the way and more so when they don't work. The lights radio and sirens need to be accessible by both people but are not. Radios don't work right. They don't repair things correctly just to get buy until the next crew complains. 117 118 Do you feel that you are compensated for doing your job? No Do you feel that you are compensated for doing well at your job? NO Should there be a cost of living increase given to employees at least every other year? Yes 119 120 n/a 121 I believe we're surveyed to death at this point. We're ready to learn the truth behind the organizational responses and what actions will come of all of this. Thank you for your hard work and time at MedStar. We look forward to your report. 122 What do you think is the most important trait for the success at the workplace. Trust. Both in each other to do what is right and in management to give us direction and ability to grow. 123 124 this was pretty thourough questioning,I cant think of anything at this time 125 NA 126 127 128 129 This is really not a question but it would be nice to have an HR dept that keeps us in the public eye in a positive way. This very important position has been vacant for several years. And exactly why does it take so many people to keep or clinical dept up to par - these experienced people could be better served in the field or comm ctr - our employee roster hasn't grown much more then in previous years but we have tripled this dept needlessly 130 131 I will have to think on this one... I can think of a lot..... but the question remains... what will be done about it? if i suggest something, will it actually be considered or will I know why it wasnt considered? 132 133 I have nothing else to share 134 none 135 How do you feel that the company morale is? What can be done to help raise morale? 136 I dont have an answer for this question 137 138 think you covered the important things, thanks for the opportunity to vent. i know without a doubt if this had not been anonymous that i would be standing in the unemployment line. and from the inside talk of the field crews, i know that at least i wouldnt have to stand in line alone! i can honestly say collectively we were all pleased to have such an open forum this time. to use our own words, and voice our opinions so openly. it is seriously time for some changes, please relay to our fearless leaders that talk is cheap, and if it werent for the love of our city, and the people in it, there would be NOBODY here to run calls. our current pay certainly is not enough to keep us here. for me, the constant reminder that people need me is what keeps me coming back to work. otherwise i would definately have left medstar long ago! 139 140 141 I wonder why we are going into yet another summer understaffed? We all know that it happens every summer. Why could the current management not prevent this? There are people here that are leaving simply because summer is almost here. Why can we not plan for that? It seems

Appendix B – MedStar Employee Survey Results Question 19

19. What question(s) have we not asked you in this survey that you wish we had? What would you have shared in response? that the time to plan for this was last summer. It seems that given MedStar history of the last 20 years that we would know to do something different. Insanity is doing the same thing over and over and expecting something different. We did the samething to prepare for this summer as we did the last, more or less, and we are suprisingly in the same situation. Some one will be on TV by the end of summer explaining why our responses are long. The job market is competitive, there is a paramedic shortage, we are studying it, and my favorite... we have hired consultants. Here is a novel idea... Hire more paramedics. If we are fully staffed with paramedics hire some more. Double up medics if you have to. Double medic trucks are not unheard of. When the summer exedous begis we can hire some EMT's that take 2 weeks to train instead of paramedics that take a minimum of 3 months and usually take closer to 6 to 9 months to train. Decide what you want as a community. Do you want paramedics at your side as fast as the fire department gets there all the time? Or, are you ok with a slower response and sometime a really slow response? What are we willing to pay for as a community. This decision needs to be made before we can really know where to take this operation. Making posiive changes will take money. 142 Do I have confidence that current management staff is capable of making the changes neccesary for us to succeed and accomplish the goals discussed in both survey's? I feel that certain members of management would be able to grow and adapt while others would be unable or unwilling. 143 144 None 145 146 n/a 147 148 I do not think you can sum it up into one question, but something has to change here. There needs to be a change upstairs. We need new people with a fresh look at this system and we need someone who has not worked here to bring new ideas and a fresh outlook to this system. If we were the titanic we still have time to miss the iceburg but it is running short. 149 150 151 #NAME? 152

Appendix B MedStar Employee Survey Results 1. Generational View: Please select the range that includes the year you were born.

2. Gender View: Are you male or female?

Appendix B MedStar Employee Survey Results 3. Diversity View: The best description of your race/ethnicity is:

4. Education Level View: The highest level of non-EMS certification education earned is:

Appendix B MedStar Employee Survey Results 5. Certification: The highest level of EMS certification earned is:

6. Tenure View: I have worked at this organization for:

Appendix B MedStar Employee Survey Results 7. Organizational View: I would classify my position as being...

Appendix B MedStar Employee Survey Results 18.a. Do I know what is expected of me at work?

100% 91.50% 90%

80%

70%

60%

50%

40%

30%

20%

6.54% 10% 1.96% 0% Yes No Did not answer

18.b. Do I have the materials and equipment I need to do my work right?

100%

90%

80%

70.59% 70%

60%

50%

40%

27.45% 30%

20%

10% 1.96% 0% Yes No Did not answer

Appendix B MedStar Employee Survey Results 18.c. At work, do I have the opportunity to do what I do best every day?

100%

90%

80%

66.67% 70%

60%

50%

40% 31.37%

30%

20%

10% 1.96% 0% Yes No Did not answer

18.d. In the last seven days, have I received recognition or praise for doing good work?

100%

90%

80% 72.55%

70%

60%

50%

40%

30% 25.49%

20%

10% 1.96% 0% Yes No Did not answer

Appendix B MedStar Employee Survey Results 18.e. Does my supervisor, or someone at work, seem to care about me as a person?

100%

90%

80%

70% 65.36%

60%

50%

40% 32.68%

30%

20%

10% 1.96% 0% Yes No Did not answer

18.f. Is there someone at work who encourages my development?

100%

90%

80%

70%

60% 49.02% 49.02% 50%

40%

30%

20%

10% 1.96% 0% Yes No Did not answer

Appendix B MedStar Employee Survey Results 18.g. At work, do my opinions seem to count?

100%

90%

80% 73.20%

70%

60%

50%

40%

30% 24.18%

20%

10% 2.61% 0% Yes No Did not answer

18.h. Does the mission/purpose of my company make me feel my job is important?

100%

90%

80%

70%

60% 53.59%

50% 44.44%

40%

30%

20%

10% 1.96% 0% Yes No Did not answer

Appendix B MedStar Employee Survey Results 18.i. Are my co-workers committed to doing quality work?

100%

90%

80%

70%

58.82% 60%

50% 39.22% 40%

30%

20%

10% 1.96% 0% Yes No Did not answer

18.j. Do I have a best friend at work?

100%

90%

80%

70%

60% 51.63% 46.41% 50%

40%

30%

20%

10% 1.96% 0% Yes No Did not answer

Appendix B MedStar Employee Survey Results 18.k. In the last six months, has someone at work talked to me about my progress?

100%

90%

80%

70%

58.17% 60%

50%

39.87% 40%

30%

20%

10% 1.96% 0% Yes No Did not answer

18.l. This last year, have I had opportunities at work to learn and grow?

100%

90%

80%

66.01% 70%

60%

50%

40% 32.03%

30%

20%

10% 1.96% 0% Yes No Did not answer