GLYNN COUNTY MANAGER’S OFFICE 1725 Reynolds Street, Third Floor, Brunswick, GA 31520 Phone: (912) 554-7401 Fax: (912) 554-7596 Email: [email protected]
MEMORANDUM
To: The Honorable Commissioners
From: Alan Ours, County Manager
Subject: Request for Proposals for the Provision of Emergency Medical Services
Date: November 3, 2015
Background: During the 2015/2016 budget work sessions, the Board of Commissioners directed county staff to research the possibility of contracting with a private company to provide emergency medical services to determine if a private company could provide the service at a lower cost. To that end, staff has researched how a private contract would work and the potential impact to county services. There are a few private companies that provide 911 EMS service on behalf of counties in Georgia. The companies that contract for EMS service claim that they can provide the service more efficiently and at a lower cost.
Many counties in Georgia have a stand-alone EMS Department and a stand-alone Fire Department. Glynn County has a combined Fire and EMS Department. The privatization of EMS is less complicated when a county has a stand-alone EMS System. Glynn County’s Paramedic’s and EMT’s are also certified firefighters and respond to all structure fires. Glynn County typically responds with a fire engine with two firefighters and an ambulance with a Paramedic and an EMT to all structure fires in order to meet the National Fire Protection Administrations (NFPA) recommendation of having four firefighters on the scene of a structure fire. This is referred to as the “two in and two out” rule. If the County contracted for EMS Services, a fire engine would need to wait for other engine companies to respond to a structure fire before it would be recommended that they enter into a building according to NFPA standards. Doing so would add to the overall response time and increase the amount of property damage. Adding two firefighters per station per shift in order to fill the gap would cost approximately $2.2 million and the special fire millage would need to be increased by .59 mils.
The FY 16 budget for EMS is $3,458,864 and the projected revenue is $1,900,000. The difference between revenue and expenses is $1,558,864. If an RFP was sent out, the responding companies could provide an amount for a subsidy from Glynn County. One company has told me that they believe they could save the County $500,000 to $800,000 in operating costs, and another interested company provides EMS service to Paulding County with no subsidy. In addition, the County would save approximately $450,000 per year in capital costs by not purchasing a new ambulance. Unless an RFP is issued, it would be difficult to determine the actual savings by contracting out the service. The Main Issues There are four main issues with contracting out EMS, which are as follows:
Personnel Currently, 52 positions are assigned to EMS. The EMS team consists of individuals that have different amounts of years of service with Glynn County and who are at different points within the pay scale. If EMS is contracted out, it will be important for the successful company to offer our current employees positions at a wage equal to or higher than their current pay. In addition, benefits that are offered will be an important consideration. The men and women who currently work for EMS have invested many years serving Glynn County and it is important that they are not hurt financially by contracting out the service.
ISO Rating A survey of local insurance companies was performed to analyze how an increased ISO rating would affect home owners. All insurance companies, except State Farm, still use ISO ratings to help determine insurance rates. Of the companies surveyed, they indicated that rates would increase if the ISO rating increased, but since rates are property specific we could not get actual numbers. If our response to a structure fire changed from four firefighters to two firefighters, the ISO rating would most likely increase from the current 3 rating to a higher rating.
Structure Fires In 2014, Glynn County responded to 1863 fire calls, of which 103 were actual structure fires. The majority of the calls that a fire engine responds to are medical related and vehicle accidents. In 2014, EMS responded to 11,798 calls for service, of which 7,136 resulted in transports to the hospital. If Glynn County responded to a structure fire with only one engine and two firefighters, it would be difficult to start an interior attack until another engine arrived on the scene. Studies have proven that it takes three to five minutes for a fire to go from ignition to fully involved. An interior attack that can be made quickly will reduce the amount of property damage.
Coordinated Effort Within the private EMS, the response, treatment, and transportation of the patient and patient care are not seamless. The continuity of patient care is decreased when that care is passed off at the treatment and transportation point to a private entity. Within the private EMS system there is lack of a multi- faceted, “all hazards” approach to the response. In a multi-agency response, there could be a conflict in the incident command structure.
Conclusion From my research, it appears that Glynn County could save a substantial amount of money by contracting out EMS. However, since the County offers a coordinated approach to emergency responses, contracting out EMS does not appear to be the best service delivery of emergency services. The County’s current “All Hazards Approach” has worked well and should continue to be utilized. By contracting out EMS, County taxpayers would be directly impacted by the lack of continuity of care in the EMS response, higher insurance rates due to the likely increase in the ISO rating, and possible increases to the special fire millage rate. If the Board of Commissioners chooses to not contract out EMS, efforts should be made to increase the collection rate and to make the service more efficient.
Alternatives:
1) Request proposals from interested companies to provide EMS 2) Do not send out requests for proposals to provide EMS
Recommendation:
Staff recommends alternative number 2
Recommended Motion for the Finance Committee: I make a motion to not send out a request for proposals for the provision of EMS by a private company
Recommended Motion for the Board of Commissioners: I make a motion to not send out a request for proposals for the provision of EMS by a private company
Alternative Motion for the Finance Committee: I make a motion to send out a request for proposals for the provision of EMS by a private company
Alternative Motion for the Board of Commissioners: I make a motion to send out a request for proposals for the provision of EMS by a private company
Attachments Draft RFP Results of ISO Survey Report entitled Prehospital 9-1-1 Emergency Medical Response Report entitled Privatization and Prehospital Emergency Medical Services Power Point entitled Fire Service Based EMS
GLYNN COUNTY GEORGIA
EMERGENCY MEDICAL SERVICES
REQUEST
FOR
PROPOSAL
RFP #00964
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REQUEST FOR PROPOSAL EMERGENCY MEDICAL SERVICES RFP #00964
TABLE OF CONTENTS
PROPOSAL DOCUMENTS
Invitation to Proposers………………………………………………………………………..…………….Page 3
Instructions to Proposers……….………………………………………………………………………….Page 5
Request for Local Preference……………………………………………………………………..……….Page 8
General Terms and Conditions……………………………………………………………………………Page 9
Introduction…………………………………………………………………………………………………..Page 16
Program Services……………………………………………………………………………………………Page 19
Cost Proposal…………………………………………………………………………………………………Page 22
Oath………………..……………………………………………………………………………………………Page 26
Proposal Requirements….………………………………………………………………………………....Page 27
Representation……………………………………………………………………………………………….Page 31
Georgia Security & Immigration Information…………………….……………………………………..Page 32
Equal Employment Opportunity…………………………………………………………………………..Page 36
Legal and Character Qualifications……………………………………………………………………....Page 37
Proposal Bond………………………………………………………………………………………………..Page 39
Contract Agreement…………………………………………………………………………...... Page 41
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Glynn County Board of Commissioners Purchasing Department 1725 Reynolds St., 3rd Floor Brunswick, GA 31520 Phone (912) 554- 7135; Fax: (888) 272-5563 E-mail: [email protected]
EMERGENCY MEDICAL SERVICES – RFP #00964
INVITATION
The Glynn County Board of Commissionsers is interested in seeking proposals from interested qualified entites to provide Emergency Medical Services for Glynn County, GA.
There will be a non-mandatory Pre-proposal Conference at 1:30 p.m. on, June 3, 2014 at the Public Works Training Room, 4145 Norwich Street Ext., Brunswick, Ga. 31520. Any questions and /or misunderstandings that may arise from this invitation shall be submitted, in writing and forwarded, to the Purchasing Agent at [email protected] no later than June 9, 2014. All Questions and Answers submitted will be posted to the website no later than June 12, 2014. Answers to questions submitted that materially change the conditions and specifications of this invitation for Proposal will be promulgated to all addressees as an addendum. Any discussions or documents will be considered non-binding unless incorporated and promulgated in an addendum. It shall be the Proposers responsibility to seek clarification as early as possible prior to the opening of proposals.
The County will receive sealed technical and cost proposals at the following address:
Glynn County Board of Commissioners Purchasing Department W. Harold Pate Building 1725 Reynolds St., 3rd Floor Brunswick, Georgia 31520
Proposals will be received until June 24 , 2014 at 2:00 p.m. Hand-delivered proposals will be received up to 1:55 p.m. on the day of the opening. Proposals will be publicly opened and only the name(s) of those Proposers responding will be mentioned. No proposal may be modified in any way after the deadline for proposal openings.
These instructions are an integral part of any proposal. The Proposers' response shall include the required number of technical proposals and one fee proposal with all other information requested in this Request for Proposal (RFP). Technical response must not have fees listed therein. If a fee is located in the technical response, the submission will be considered non-responsive and will not be evaluated. Technical and Fee Proposals must be sealed in separate envelopes with the solicitation name and number and type of Proposal listed on the outside.
Glynn County anticipates making a single award; however, it reserves the right to make multiple awards should it deem in the best interest of the County. It is anticipated that such an award, if any, will be accomplished within sixty (60) days (unless otherwise agreed upon by the Proposer and the County) from the proposal opening.
Glynn County provides equal opportunity for all businesses and does not discriminate against any person or business because of race, color, religion, sex, national origin, and handicap or veterans status. This policy ensures all segments of the business community have access to supplying the goods and services needed by Glynn County. The Board of Commissioners, Glynn County, Brunswick Georgia reserves the right to reject any or all
3 | Page proposal, waive technicalities and make the award in the best interest of the County.
ALL PROPOSERS MUST HOLD AN EMERGENCY MEDICAL SERVICES LICENSE THROUGH THE GEORGIA DEPARTMENT OF PUBLIC HEALTH. A COPY OF THE CURRENT LICENSE MUST BE SUBMITTED WITH THE TECHNICAL PROPOSAL.
Sincerely, Keri Moreland Keri Moreland Purchasing Agent Glynn County Board of Commissioners
-End of This Section-
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REQUEST FOR PROPOSAL EMERGENCY MEDICAL SERVICES RFP #00964 INSTRUCTION TO PROPOSERS
1. Intent: It is intended that the Instructions to Proposers, General Conditions, and Detailed Specifications shall define and describe the complete work to which they relate.
2. Work to Be Done: The work to be performed under this contract consists of providing 24 hour Emergency Medical Services to the residents and visitors within the boundaries of Glynn County, Georgia.
3. Site Examination: The Proposer is advised to examine the location of the work and to inform himself fully as to its conditions; the character, quality and quantity of the products needed preliminary to and during the prosecution of the work; the general and local conditions and all other matters which can in any way affect the work to be done under the Contract. Failure to examine the site will not relieve the successful Proposer of his obligation to furnish all products and labor necessary to carry out the provisions of his contract. The Proposer shall notify the Purchasing Agent of the company representative name(s) of those attending the non-mandatory Pre-proposal meeting via email at [email protected] .
4. Proposal and Contract Security: Each Proposal must be accompanied by a Proposal bond for an amount equal to at least five percent (5%) of the amount of the Proposal. If for any reason whatsoever the Proposer withdraws from the competition after opening the Proposals, or if he refuses to execute the Contract, the Owner will proceed on the Proposal Bond. The Surety of the Proposal Bond, Performance Bond, and Payment Bond shall be a surety company authorized to do business in the State of Georgia, shall be listed in the Department of the Treasury Circular 570, and shall have an underwriting limitation in excess of 100% of the Proposal amount. The Bonds and Surety shall be subject to approval by the Attorney for the Owner.
Attorneys-in-fact who sign Proposal bonds or contract bonds must file with each bond a certified and effectively dated copy of their power of attorney.
5. Determination of Successful Proposer: The Contract will be awarded to the Proposer with the highest score, if awarded.
(a) Responsibility: The determination of the Proposer’s responsibility will be made by the Owner based on whether the Proposer:
1. maintains a permanent place of business, 2. has the appropriate technical experience, 3. has adequate staff and equipment to do the work properly and expeditiously and 4. has suitable financial means to meet obligations incidental to the work.
The Proposer shall furnish to the Owner all such information and data for this purpose as the Owner may request. The Owner reserves the right to reject any Proposal if the evidence submitted by, or investigation of, the Proposer fails to satisfy the Owner that he is properly qualified to carry out the obligation of the Contract.
(b) Responsiveness: The determination of responsiveness will be made by the Owner based on a consideration of whether the Proposer has submitted a complete Proposal form without irreg- ularities, excisions, special conditions, or alternative Proposals for any item unless specifically requested in the Proposal form.
6. Proposal Alternates: This section does not apply to this RFP.
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7. Submission of Proposals: Proposals shall be submitted at the time and place indicated in the Invitation. Glynn County will not accept late Proposals.
On the outside of the envelope containing the Proposal shall be noted the following:
EMERGENCY MEDICAL SERVICES RFP #00964
**If sending Proposal via UPS, FedEX or USPS, please list the above information on the outside of the shipping package/envelope to ensure there is no error in opening.
8. Proposal Form: Cost Proposals shall be submitted on the Cost Proposal Form included.
9. Gratuities: Glynn County acknowledges that, particularly during the holiday season, it may be customary to provide gifts to employees or departments. However, the Glynn County Personnel Policy prevents the acceptance of such gifts. Your cooperation in respecting the policy is appreciated.
10.Georgia Open Records Act: Proposers are reminded that documents and information in the possession of Glynn County will be treated as confidential/proprietary information only to the extent permitted by the Georgia Open Records Act, and will be exempt from disclosure to a third party only to the extent permitted by the Georgia Open Records Act. Should you believe that your Proposal contains any trade secrets you must submit an affidavit, along with the Proposal, that states that specific portions of the Proposal contain trade secrets as defined by Georgia law (Article 27 of Chapter 1 of Title 10 of the Official Code of Georgia). Furthermore the affidavit must be detailed, citing specifically (citing paragraphs, articles, provisions, pages, etc.) the portions of the Proposal containing any trade secrets.
11. Glynn County Local Preference: This project/solicitation may qualify for local preference in Glynn County, Georgia.
Glynn County shall give Local Preference in the awarding of contracts for sealed solicitations and requests for proposal (hereinafter called “Proposals”) whenever the application of such a preference meets the criteria established in the County Ordinance. In order for Local Preference to be used in the evaluation, all documentation as required in the Local Preference Policy must be submitted with the Proposal. This Local Preference privilege shall not apply where prohibited by law.
Definitions: Local Vendor: shall mean that the vendor meets each of the following requirements.
The principal place of business must be with the geographical boundaries of Glynn County, Georgia.
“Principal Place of Business” means a physical structure, office, or suite, but does not include a post office box, a temporary job site, or project location. Further, “Principal Place of Business means that if a vendor is a corporation their corporate office must meet the criteria established above.
Must have a current occupational tax certificate from Glynn County or the City of Brunswick.
Must have paid all real and personal property taxes owed to Glynn County, Georgia.
Eligibility In order to be eligible for the Local Preference, the vendor must, if incorporated, provide proof from the Georgia Secretary of State that the corporate office is within Glynn County, Georgia. Vendors must provide a copy of their current Glynn County Occupation Tax Certificate, and shall state that all real and personal property taxes due and owing to Glynn County are paid. These items must accompany the Proposal or the vendor will not be subject to award based on Local Preference.
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Application of Local Preference for Sealed Proposals Local vendors complying with the above requirements shall be afforded the opportunity, within a time frame specified by the County, to match the Proposal amount of the lowest responsible, responsive Proposal if: (1) the lowest responsive and responsible Proposer is not a local vendor (2) the local vendor is the second lowest responsive and responsible Proposer; and (3) the local vendor’s Proposal is within two (2%) or $10,000.00 whichever is less, of the lowest Proposal. Local preference shall not apply to Public Works Construction projects of $100,000 or more nor to public road construction projects of $20,000.00 or more.
Application of Local Preference for Requests for Proposal Local vendors complying with the above requirements shall be given two percent (2%) of the total points available within the evaluation criteria.
-Application to Follow-
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REQUEST FOR LOCAL PREFERENCE CONSIDERATON
Please note that while it is your responsibility to provide all required documents, the check list below is to assist you with the inclusion of documents required for consideration of local preference.
We request local preference consideration for the following:
PROJECT TITLE:______
COMPANY NAME, ADDRESS, PHONE #, E-MAIL, CONTACT NAME:
______
______
Your Proposal must include the following documentation.
If incorporated, proof from the Georgia Secretary of State that the principal place of business is in Glynn County, Georgia.
If not incorporated, proof that the principal place of business is in Glynn County, Georgia. Usually the occupation tax certificate will serve this purpose.
A copy of current Glynn County or City of Brunswick Occupation Tax Certificate
You must have paid all real and personal property taxes owed to Glynn County for the current year. List your local business address below:
______
Failure to include this information with your Proposal will result in non-consideration for local preference.
By my signature I acknowledge that I have read and understand all documents included in the Proposal package and that this firm does qualify for local preference status.
Name (Please print)______
Signature:______
Date______
Subscribed and sworn to before me the day of ______, 20___. My commission expires on the day of ______, 20___.
______NOTARY PUBLIC (Notary Seal)
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REQUEST FOR PROPOSAL EMERGENCY MEDICAL SERVICES RFP #00964 SECTION A GENERAL TERMS AND CONDITIONS
1.0 NOTICE OF AWARD OF CONTRACT
As soon as possible, and within 60 days after receipt of Proposals, the County shall notify the successful Proposer of the award of the contract. Should the County require additional time to award a contract, the time may be extended by mutual agreement between the County and the successful Proposer. If an Award of Contract has not been made within 60 days from the Proposal date or within the extension mutually agreed upon, the Proposer may withdraw the Proposal without further liability on the part of either party.
2.0 EXECUTION OF CONTRACT DOCUMENTS:
a. Within fifteen (15) days of Notification of Award of Contract, the County shall furnish the Contractor the conformed copies of Contract Documents for execution by him and his Surety.
b. Within fifteen (15) days after receipt, the Contractor shall return all the documents properly executed by himself and his Surety. Certificates of insurance for the required limits will accompany the Contract documents.
c. Within thirty (30) days after receipt of the documents executed by the Contractor and certificates of insurance, the County shall complete the execution of the documents. Distribution of the completed documents will be made upon completion.
d. Should either party require an extension of any of the time limits stated above, this shall be done only by mutual agreement between both parties.
3.0 PERFORMANCE BOND
Theu s ccessful Contractor must supply a Performance Bond, or irrevocable letter of credit, in the amount of 100% of the yearly subsidy price or $100,000 (whichever is greater) for each year that the contract is in effect. The County reserves the right to reduce bonding requirements. Contractor shall provide and pay for all costs associated with this bond. Bond reduction will occur only at contract renewal time and is based upon satisfactory contract performance, as determined by the County in its sole discretion.
4.0 INSURANCE:
The Contractor shall not commence work under this contract until all insurance described below has been obtained and such insurance has been approved by the County, nor shall the Contractor allow any subcontractor to commence work on his subcontract until all similar insurance required of the subcontractor has been so obtained and approved by the Contractor. Emergency Medical Services (Ambulance Services) are considered to be a high risk service; thefore, requires higher insurance coverage.
A. Liability.
The Contractor shall maintain such insurance as will protect him from claims under workmen's compensation acts and from any other claims for damages to property, and for personal injury, including death, which may arise from operations under this contract, whether such operations be by himself or by any sub-contractor or anyone directly or indirectly employed by either of them. Certificates of such insurance shall be filed with the Owner. The Contractor shall be responsible for
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providing adequate limits of insurance when working within property owned by railroads, as established by such railroad company.
B. Indemnity.
To the fullest extent permitted by laws, statutes, rules and regulations, the Contractor shall indemnify and hold harmless the County, Engineer, Engineer’s Consultants and the Officers, Directors, Employees, Agents, and other Consultants of each and any of them from and against claims, costs, damages, losses, and expenses, including but not limited to all fees and charges of engineers, architects, attorneys and other professionals and all court costs, arising out of or resulting from performance of the work, but only to the extent caused in whole or in part by negligent, reckless, willful and wanton, or wrongful acts or omissions of the Contractor, its Officers, Directors, Employees, Agents, and anyone directly, or indirectly employed by them or anyone for whose acts they may be liable, regardless of whether or not such claim, cost, damage, loss, or expense is caused in part by a party indemnified hereunder, except that no party shall indemnify any other party or person for their own sole negligence.
Such obligation shall not be construed to negate, abridge or reduce other rights or obligations of indemnity which would otherwise exist as to a party or person described in this Paragraph.
Comprehensive General Liability -The successful Proposer shall exercise proper precaution at all times for the protection of persons and property. He shall carry approved insurance from insurance companies authorized to do business in Georgia and having an A.M. Best’s rating of B+ or better with the following minimums:
*The limits of insurance are as follows: • Commercial general liability insurance - $2,000,000 per occurrence and $3,000,000 annual aggregate.
• Professional medical malpractice insurance - $2,000,000 per occurrence and $3,000,000 annual aggregate.
• Worker’s compensation coverage to statutory limits as required by law; employers’ liability insurance of not less than $1,000,000 bodily injury by incident; $1,000,000 bodily injury by disease for each employee.
• Personal injury protection (PIP) or medical payment coverage as required by law.
• “Umbrella” coverage in the amount of at least $15,000,000 shall be provided as additional coverage to all underlying liability policies. This policy may be written as a “Form Following Excess” policy.
*Contractors Liability Insurance shall be effective for the duration of the work as described in the contract documents, including authorized change orders, plus any period of guarantee as required in, Paragraph 06 above. The policy must be on an “occurrence” basis.
Additional Insured: The Contractor shall cause Glynn County, Georgia, and its officers, officials, members, representatives, agents, and employees to be added as additional insureds to such commercial general, automobile, and professional liability policies. Glynn County, and its officers, officials, representatives, agents, members and employees (collectively, Glynn County Representatives”) shall be added as additional insureds to such policy. Company’s insurance shall be primary insurance as respects Glynn County Representatives and any insurance or self-insurance maintained by the Glynn County Representatives shall be in excess of Company’s insurance and shall not contribute with it. Company agrees to waive any rights to subrogation against Glynn County to the
10 | Page extent that any loss, injury, claim, liability and/or damage is covered by insurance provided under the insurance requirements of this Agreement. Company shall furnish Glynn County with certificates of insurance and endorsements to the policy evidencing the insurance coverage and requirements of this paragraph prior to Company’s first entry onto the Property.
5.0 INDEMNIFICATION:
The Contractor will indemnify and hold harmless the County and their agents and employees from and against all claims, damages, losses and expenses including attorneys' fees arising out of or resulting from the performance of the work, provided that any such claims, damage, loss or expense is attributable to bodily injury, sickness, disease or death, or to injury to or destruction of tangible property, including the loss of use resulting therefrom; and is caused in whole or in part by any negligent or willful act or omission of the Contractor, and subcontractor, anyone directly or indirectly employed by any of them or anyone for whose acts any of them may be liable. In any and all claims against the County or any of their agents or employees, by any employee of the Contractor, any subcontractor, anyone directly or indirectly employed by any of them, or anyone for whose acts any of them may be liable, the indemnification obligation shall not be limited in any way by any limitation on the amount or type of damages, compensation or benefits payable by or for the Contractor or any subcontractor under the Worker's Compensation Acts, Disability Benefits Acts or other employee benefits acts.
6.0 NOTICE TO PROCEED:
The Notice to Proceed should be issued within ten (10) days of the execution of the Contract Agreement by the County. If there are reasons why the Notice to Proceed should not be issued within this period, the time may be extended by mutual agreement between the County and Contractor. If the Notice to Proceed has not been issued within the ten (10) day period or within the period mutually agreed upon, the Contractor may terminate the Contract Agreement without further liability on the part of either party.
7.0 TERMINATION:
Termination for Convenience of Owner:
The Owner may, at will, upon written notice to the Contractor, terminate (without prejudice to any right or remedy of the Owner) the whole or any portion of the Work for the convenience of the Owner.
Termination for the Contractor:
The Contractor may terminate any contract arising out of this RFP for any reason upon one hundred eighty (180) days written notice to the County. The termination notice shall be deemed received three (3) days after placing the notice in the United States mail.
8.0 ASSIGNMENTS:
The Contractor shall not assign the whole or any part of this Contract or any monies due or to become due hereunder without written consent of the County. In case the Contractor assigns all or any part of any monies due or to become due under this Contract, the Instrument of assignment shall contain a clause substantially to the effect that is agreed that the right of the assignee in and to any monies due or to become due to the Contractor shall be subject to prior liens of all persons, firms, and corporations for services rendered or materials supplied for the performance of the work called for in this contract.
9.0 SUBCONTRACTING:
a. The Contractor shall not subcontract the complete work, or any major part thereof, and shall not award any work to any subcontractor without prior written approval of the County, which approval wil l 11 | Page
not be given except upon the basis of written statements containing such information as the County may require.
b. The Contractor shall utilize the services of specialty subcontractors on those parts of the work which, under normal contracting practices, are performed by specialty subcontractors. If the Contractor desires to perform specialty work he shall submit a request to the County accompanied by evidence that the Contractor's own organization has successfully performed the work in question, is presently competent to perform the work, and the performance of the work by specialty subcontractors will result in materially increased costs or inordinate delays.
c. The Contractor shall be as fully responsible to the County for the acts and omissions of his subcontractors, and of persons either directly or indirectly employed by them, as he is for the acts and omissions of persons directly employed by him. The Contractor must ensure payment is made in full to any and all sub-contractors.
d. The Contractor shall cause appropriate provisions to be inserted in all subcontracts relative to the work to bind subcontractors to the Contractor by the terms of the General Conditions and other Contract Documents insofar as applicable to the work of subcontractors and to give the Contractor the same power as regards to terminating any subcontractor that the County may exercise over the Contractor under any provision of the Contract Document.
e. Nothing contained in this Contract shall create any contractual relation between any subcontractor and the County.
10. AUTHORITY OF PROJECT MANAGER:
The Project Manager or his representative shall act as the County's Technical Representative during the execution of this contract. He shall decide questions which may arise as to quality and acceptability of services and products furnished and work performed. He shall interpret the technical intent of the Contract Documents in a fair and unbiased manner. He will make random inspections to determine if the services are proceeding in accordance with the Contracts Documents. He shall judge as to the accuracy of quantities submitted by the Contractor in payment requests and the acceptability of the work which these quantities represent. The decisions of the Project Manager or his representative shall be final and conclusive and binding upon all parties to the Contract.
11. SEPARATE CONTRACTS:
a. The County reserves the right to let other contracts in connection with this project. The Contractor shall afford other Contractors reasonable opportunity for the execution of their work, and the Contractor and other Contractors shall properly connect and coordinate their work with each other.
If the proper execution or results of any part of the Contractor's work depends upon the work of any other Contractor, the Contractor shall inspect and promptly report to the Engineer or his representative any defects in such work that render it unsuitable for such proper execution and results.
b. The County may perform additional work related to the project with his own forces. The Contractor will afford the County reasonable opportunity for the execution of work, and shall properly connect and coordinate his work with theirs.
12. LAWS AND REGULATIONS:
a. The Contractor's attention is directed to the fact that all applicable Federal, State and County laws, municipal ordinances, and the rules and regulations of all authorities having jurisdiction over the project shall apply to the contract throughout, and they will be deemed to be included in the contract as though written out in full herein. The Contractor shall keep himself fully informed of all laws, 12 | Page
ordinances and regulations of the Federal, State, County and municipal governments or authorities in any manner affecting those engaged or employed in the work or the materials used in the work or in any way affecting the conduct of the work and of all orders and decrees of bodies or tribunals having any jurisdiction or authority over same. If any discrepancy or inconsistency should be discovered in these Contract Documents or in the specifications herein referred to, in relation to any such law, ordinance, regulation, order or decree, he shall herewith report the same in writing to the County.
b. He shall at all times observe and comply with all such existing and future laws, ordinances and regulations, and shall protect and indemnify the County and its agents the violation of any such law, ordinance, regulation, order or decree, whether by himself or by his employees. Permits and licenses of a temporary nature, necessary for the prosecution of the work shall be secured and paid for by the Contractor.
13. NOTICE AND SERVICE THEREOF:
a. All Notices, demands, requests, instructions, approvals, and claims shall be in writing.
b. Any notice to or demand upon the Contractor shall be sufficiently given if delivered at the office of the Contractor specified in the Proposal (or at such other office as the Contractor may from time to time designate to the County in writing), or if deposited in the United States Mail in a sealed, postage-prepaid envelope, or delivered, with charges prepaid, to any telegraph company for transmission, in each case addressed to such office.
c. All papers required to be delivered to the County shall, unless otherwise specified in writing to the Contractor, be delivered to the County Purchasing Agent, Glynn County, Georgia. Any notice to or demand upon the County shall be sufficiently given if delivered to the Office of said Purchasing Agent or if deposited in the United States Mail in a sealed, postage-prepaid envelope, or delivered with charges prepaid to any telegraph company for transmission, in each case addressed to said Purchasing Agent or to such other representative of the County or to such other address as the County may subsequently specify in writing to the Contractor for such purposes.
d. Any such notice or demand shall be deemed to have been given or made as of the time of actual delivery or (in the case of mailing) when the same should have been received in due course of post or (in the case of telegrams) at the time of actual receipt, as the case may be.
14. SPECIFICATIONS:
The RFP document, Terms and Conditions, Technical Specifications, Contract Documents, and all supplemental documents, are considered essential parts of the Contract Agreement, and requirements occurring in one are as binding as though occurring in all. They are intended to define, describe and provide for all work necessary to provide the services in an acceptable manner.
15. CHANGES IN THE CONTRACT:
a. Changes in the Work. The County may at any time, as the need arises, order changes within the scope of the work without invalidating the Contract Agreement. If such changes increase or decrease the amount due under the Contract Documents, or in the time required for performance of the work, an equitable adjustment shall be negotiated culminate by the issuance of a Contract amendment. The Purchasing Agent, also, may at any time, by issuing a Contract amendment, make changes in the details of the work. The Contractor shall proceed with the performance of any changes in the work so ordered by the Purchasing Agent unless the Contractor believes that such order entitles him to a change in the fee or time or both, in which event he shall give the Purchasing Agent written notice thereof within fifteen (15) days after the receipt of the Contract amendment, and the Contractor shall not execute such amendments pending the receipt of an executed Notice to Proceed instruction from the County.
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The County may, when changes are minor or when changes would result in relatively small changes in the Fee or Contract Time, elect to postpone the issuance of a Contract amendment until such time that a single amendment of substantial importance can be issued incorporating several changes. In such cases, the County shall indicate this intent in a written notice to the Contractor.
b. Changes in Fee. The Fee shall be changed only by a mutual agreement by the Contractor and the County transmitted as a Contract amendment. The value of any work covered by an amendment or
of any claim for increase or decrease in the Fees shall be determined by one or more of the following methods in the order of precedence according to the following list:
l) By estimating the number of unit quantities of each part of the work which is changed and then multiplying the estimated number of such unit quantities by the fee Proposal for a unit quantity thereof.
2) The County shall fix the total lump sum value of the amendment in the work of the Contractor, and shall set out the price which shall be added to or deducted from the Fees.
The Contractor shall, when required by the County, furnish to the County an itemized breakdown of the quantities and prices used in computing the value of any change that might be ordered.
16. COST PROPOSAL:
Offeror’s cost proposal shall include the (1) cost to Glynn County (subsidy) if any; (2) charges for services to citizens for Base Transport; (3) mileage rate; (4) Billing Methodolgy (i.e. Soft vs. Hard Billing, Residents vs Non-residents, and Transports vs. Non-transports). Statement for charges that says “Medicare allowable” will be permitted. Cost proposal must be submitted on the form provided herein.
17. CONTRACTOR'S CLAIM:
No claim for additional or other compensation beyond the fees shall be allowable unless the Contractor makes and continuously maintains written demand therefor within thirty (30) days of the occurrence of any event which given rise to such claim.
18. CONTRABAND:
Employees of the successful Proposer shall not enter County Buildings with goods or products that shall be considered contraband, i.e. drugs, drug paraphernalia, tobacco products smokeless or otherwise, etc.
19. OFFICE HOURS:
Normal working hours for the County office buildings are Monday through Friday, 8:00 A.M. to 5:00 P.M.
20. WORK SCHEDULING:
The successful Proposer shall arrange his work schedule in order to provide services seven (7) days a week, twenty-four (24) hours a day, three hundred sixty five (365) days a year.
21. GEORGIA SECURITY AND IMMIGRATION COMPLIANCE ACT
Pursuant to O.C.G.A. § 13-10-91 (Georgia Security and Immigration Compliance Act), every public employer, every contractor of a public employer, and every subcontractor of a public employer’s contractor must register and participate in a federal work authorization program. No public employer shall enter into a contract for the physical performance of services within this state unless the contractor 14 | Page
registers and participates in a federal work authorization program to verify the work eligibility information of all new employees.
No contractor or subcontractor shall enter into a contract or subcontract with a public employer in connection with the physical performance of services within this state unless such contractor or subcontractor registers and participates in a federal work authorization program to verify the work eligibility information of all new employees.
• Contractor acknowledges that the awarding of this contract is conditioned upon initial and ongoing compliance by the contractor and any subcontractor with the requirements of O.C.G.A. § 13-10-91 and Rule 300-10-1-.02 of the Georgia Department of Labor;
• The requirements of O.C.G.A. § 13-10-91 pertaining to registering and participating in a federal work authorization program apply to public employers, their contractors, and subcontractors, as follows:
(a) On or after July 1, 2007, to contractors and subcontractors of 500 or more employees;
(b) On or after July 1, 2008, to contractors and subcontractors of 100 or more employees; and
(c) On or after July 1, 2009, to all other contractors or subcontractors.
• Contractor agrees that in the event it employs or contracts with any subcontractor(s) in connection with this contract, Contractor shall secure from the subcontractor(s) an indication of the employee-number category applicable to the subcontractor.
• Contractor agrees that its compliance with the requirements of O.C.G.A. § 13-10-91 and Rule 300-10- 1-.02 of the Georgia Department of Labor shall be attested by execution of the Contractor Affidavit which is attached hereto and which shall be a part of this contract.
• Contractor agrees that, in the event it employs or contracts with any subcontractor(s) in connection with this contract, Contractor shall secure from the subcontractor(s) an attestation of the subcontractor’s compliance with O.C.G.A. § 13-10-91 and Rule 300-10-1-.02 of the Georgia Department of Labor by the subcontractor’s execution of a Subcontractor Affidavit provided by Glynn County. Contractor shall maintain records of such attestation for inspection by Glynn County at any time. The Subcontractor Affidavit shall become a part of the contractor/subcontractor agreement.
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REQUEST FOR PROPOSAL EMERGENCY MEDICAL SERVICES RFP #00964 SECTION B INTRODUCTION
1.0 LOCATION
Glynn County is located in the Southeastern part of the State of Georgia. Its Northern boundary is formed by the Altamaha River, Wayne and Brantley Counties on the west, Camden County on the south, and the Atlantic Ocean on the east. As a favorable consequence of its geology, the County has the Port of Brunswick. The Port has been of immense economic benefit to Glynn County.
By roadway, Brunswick is located: 78 miles from Savannah, 315 miles from Atlanta, 225 miles from Macon, 262 miles from Columbus, and 180 miles from Albany. Jacksonville, Florida is located 79 miles from Brunswick.
2.0 SERVICE AREA SUMMARY
Glynn County lies within the Lower Coastal Plain Physiographic Province and has topography typical of this province of very gently rolling uplands interspersed with low lying swampy area. Elevations range from sea level along the coast to forty five feet in the western part of Glynn County. Glynn County covers a land area of approximately 420 square miles.
Southeast Georgia Hospital (a general medical and surgical hospital) is located at 2415 Parkwood Drive, Brunswick, GA.
There are eight, (8) Nursing Homes-Skilled Nursing Facilities and ten (10) Assisted Living Facilities located in Glynn County.
Trauma centers and major hospitals are located in Chatham County, GA and Duval County, Florida.
The County’s units responded to 11,798 requests via 911 for emergency service in calendar year 2014 resulting in approximately seven thousand one hundred eleven ( 7,111) emergency transports and twenty-five (25) non-emergency, inter-facility transports. The County makes no representations about other non-emergency incidental transport volumes.
The patient mix is reported by the current provider as: 48 percent Medicare, 10 percent Medicaid, 25 percent insurance,10 percent self-pay patients. The remainder is classified as indigent.
3.0 POPULATION
The most recent census established the population of Glynn County at just below 83,000 and can increase to 100,000+ due to tourism/visitors.
4.0 STRUCTURE INTENTION SUMMARY
The purpose of the procurement process is to provide a high performance EMS system. The County desires clinical excellence, superb response time performance, cost containment, and a professional and courteous image. Under the contract, the relationship between the County and the Contractor should always be one of cooperation and not conflict.
Essential elements of a high performance system commonly include:
• Prevention and early recognition • Medical Dispatch
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• Telephone protocols and pre-arrival instructions • First responder and ambulance dispatch • First responder services • Transport ambulance services • Direct (on-line) medical control • Receiving facility interface • Indirect (off-line) medical control • Independent monitoring
The County desires the provision of high quality EMS service within the Service Area of Glynn County, GA in order to provide for the public health and safety. Response times are one measure of a high performance system. A comprehensive systems approach requires clinically appropriate response times to medical emergencies. Both the response time and medical skill level of the fire department first response to medical calls varies widely across the County depending on the particular fire district, the priority level of the call, call location and time of day.
The structure’s predominant response goal is to place paramedic level care resources on the scene of emergency response requests within a defined system time period of eight (8) minutes: zero seconds /90 percent reliability in urban areas and twelve (12) minutes: zero seconds /90 percent reliability in less densely populated and rural areas.
The Contractor’s response time is currently measured from the point of its departure from a station or location to its arrival on scene. Under this procurement the structure’s total response time shall be measured.
For each response presumptively determined to be an emergency response (as categorized by National Academies of Emergency Dispatch standards as Echo, Delta, Charlie or Bravo level calls) the contractor shall:
Place transport capable paramedic unit on scene within eight (8) minutes zero seconds at 90 percent reliability for assignments in urban response areas and within twelve (12) minutes zero seconds at 90 percent reliability for assignments in non-urban response areas.
For each response presumptively determined to be a non-emergency response (as categorized by National Academies of Emergency Dispatch standards as Alpha level calls) the contractor shall:
Place transport capable paramedic unit on scene within ten (10) minutes zero seconds at 90 percent reliability for assignments in urban response areas and within eighteen (18) minutes zero seconds at 90 percent reliability for assignments in non-urban response areas. Responses to Alpha level calls are made without the use of lights or sirens as approved by the Medical Director.
The County desires response times to medical emergencies that are optimal for patient outcome. Fire Stations will continue to respond to emergency medical calls utilizing the highest level of medical skills which may vary from department to department. The transport ambulance will be staffed with at least one paramedic and one Emergency Medical Technician (EMT) and will be licensed as an ALS unit under the State of Georgia statutes/regulations.
The use of quick response vehicles staffed with one paramedic and equipped with advanced life support equipment is encouraged but not required as a means to facilitate response time compliance in outlying areas or at peak times.
The Contractor must strictly follow all laws listed under O.C.G.A. Title 31. Health, Chapter 11. Emergency Medical Services.
The time of the Contractor’s arrival on the scene must be transmitted to the County’s 911 dispatch system.
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The County’s 911 system will be the repository of County 911 call data from receipt of the call through delivery of the patient to a hospital. Official response time compliance reports will be derived from data stored in the County’s 911 computer aided dispatch (CAD) system.
It is the County’s desire to have an EMS system that ensures high quality clinical care, provides efficient and reliable EMS services at a reasonable cost to consumers, and provides the community with an operationally and financially stable system.
5.0 CONTRACTOR’S FUNCTIONAL RESPONSIBILITIES
The Contractor shall furnish and manage ALS ambulance operations, billing and collection services including but not limited to employing field, billing and office personnel; equipment and vehicle maintenance; in-service training; quality improvement monitoring; purchasing and inventory control, community education, mutual assistance, and support services. The Contractor must apply for, secure, and renew all licenses, permits, certificates or similar government approvals which are or may be required by applicable law and provide copies of all licenses to the County.
The requirements include responding to each and every request for emergency ambulance service within the Service Area. The requirements for operations are delineated throughout these specifications and will become the basis of the performance based Agreement between the County and the Contractor.
All equipment and supplies, (e.g. on-board durable and reusable medical equipment, billing computer system hardware and software, and other equipment and software employed by the Contractor in the delivery of these services) shall be furnished by the Contractor. All County-owned equipment and vehicles are available for purchase. Billing and collection services shall be a Contractor’s responsibility and shall be conducted according to the professional guidelines outlined in the Agreement.
The County requests Contractor consideration of hiring current, certified Glynn County EMS personnel to help implement the scope of services as Emergency Medical Technicians and Paramedics. This is not a requirement that must be met, nor will it be considered in the award of this proposal.
-End of This Section-
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REQUEST FOR PROPOSAL EMERGENCY MEDICAL SERVICES RFP #00964 SECTION C PROGRAM SERVICES
1.0 GENERAL
The Glynn County Board of Commissioners (“the Owner”) seeks proposals from interested qualified emergency medical services providers. Some of the services include, response to medical emergency calls, transport of emergency and non-emergency medical patients, billing and collection of said services. The specific services requested are outlined in the scope of services. A detailed description of each service is contained within this request for proposal.
2.0 BACKGROUND AND OVERVIEW
During the course of fiscal years past, the Board of Commissioners has discussed outsourcing some of the services provided the residents and visitors of Glynn County. The Emergency Medical Services is one such amenitity.
Eight (8) fire stations provide varying levels of first response to medical emergencies in Glynn County through both paid employees and volunteer services. Fire stations’ medical skills and salaries vary and include certified first responders, emergency medical technicians (EMT) and paramedics. The County currently provides paramedic ambulance response to all 911 (emergency and non-emergency) calls and, if medically necessary, patient transport. The County DOES NOT provide non-emergency (inter-facility) patient transfers.
3.0 SCOPE OF SERVICES OUTLINE
1. The Contractor will furnsh all Emergency Ambulance Services for the entire population and visitors of Glynn County, GA as described herein.
2. The Contractor will adhere as directed in the response time performance, realiability and measurement methods as outlined above on Page 16, Item 4.
3. The Contractor will provide and maintain all ambulances, support vehicles, on-board medical supplies and equipment as well as office facilities and equipment that will be utilized to perform the services within this RFP.
4. When an ambulance is taken out of service due to mechanical failure or accident, a replacement ambulance must be made available within fifteen (15) minutes.
5. The Contractor will utilize the County’s Brunswick-Glynn 911 Center dispatch services. Emergency responses originating at the 911 system will be provided at no cost to the Contractor.
6. The Contractor will provide to the County, at their request, financial and transport data reporting documents at no additional cost to the County. Contractor shall maintain all books, documents, accounting records (these shall include all Vehicle Maintenance Records, Employee training records and employee license records) and other evidence pertaining to the services provided under the contract and make such materials available at its offices at all reasonable times during the contract period and for three (3) years from the date of the final payment under the contract period for inspection by County or by any other governmental entity or agency participating in the funding of the contract, or any authorized agents thereof.
7. The Contractor will provide an adequate coverage and dedicated number of ambulances and staff to achieve the complete scope of services detailed in this RFP throughout the life of the contract.
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8. The Contractor will foster an integrated First Repsonse program with the Fire Department.
9. Upon request by law enforcement, Fire Departments, or Search and Rescue, Contractor shall furnish courtesy stand-by coverage at special events and emergency incidents involving a potential danger to the personnel of the requesting entity at no additional cost to the County.
10. The Contractor will follow steps to improve prevention and access of services through community education programs to be provided to the school system and community groups.
11. The Contractor will provide a staff member to be involved in planning for and responding to any declared disaster and mutual-aid response in the County.
12. The Contractor will work with the assigned County staff member to address all complaints and concerns.
13. The Contractor will maintain the required staff and accreditations as detailed within this RFP. The Contractor’s staff will remain ethical and professional at all times.
14. The Contractor will follow the medical protocols as established by the Glynn County Fire Department’s Captain of Rescue.
15. The Contractor shall utilize management practices that ensure that field personnel working extended shifts, part-time jobs, voluntary overtime, or mandatory overtime are not exhausted to an extent that might impair judgment or motor skills.
16. The Contractor must have in place a program for random drug screening of all personnel providing response under the contract. Further, the Contractor will transport to a facility for testing any employee suspected to be using or under the influence of drugs or alcohol or other intoxicant, or have an agent of a testing facility come to the location of the employee to obtain a necessary sample. Any employee suspected of being under the influence of any drug or intoxicating substance will be relieved of duty until there is clinical proof to the contrary.
17. Should complaints arise which are directed at level of care, response or employee action or inaction, such complaints from the EMS Coordinator must be answered within 48 hours to include actions taken, including disciplinary action and other corrective measures.
18. Contractor will have available to the public, staff or a toll free phone number, capable of discussing and resolving billing questions.
19. Contractor is specifically advised to use its own best expertise and professional judgment in deciding upon the methods to be employed to achieve and maintain the high performance required under the contract. By “methods”, the County means compensation programs, shift schedules, personnel policies, supervisory structures, fluid vehicle deployment techniques, and other internal matters which, taken together, comprise each Contractor’s own strategies and tactics for getti ng the job done.
4.0 PERFORMANCE BASED CONTRACT
The most important aspect of this procurement is the fact that this procurement will result in the award of a Performance-based contract. Penalties will be assessed for failures to achieve minimum standards set forth in the Contract. This procurement requires the highest levels of performance and reliability, and the mere demonstration of effort, even diligent and well intentioned effort, shall not substitute for performance results.
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Specifically: Ambulance response times must meet the response requirements set forth in the RFP.
Every primary and coverage ambulance unit must at all times be equipped and staffed to operate at the State of Georgia certified paramedic on all emergency and non-emergency calls received under the contract.
Clinical performance must be consistent with approved medical standards and protocols and guidelines set forth by the State of Georgia.
There must be an unrelenting effort to detect and correct performance deficiencies and to continuously upgrade the performance and reliability of the entire EMS system.
Clinical and response time performance must be extremely reliable, with equipment failure and human error held to an absolute minimum through constant attention to performance, protocol, procedure, performance auditing, and prompt and definitive corrective action.
This is not a level-of-effort contract. A contractor who fails to perform must and shall be promptly replaced, because human lives, and not merely inconvenience or money, are at stake. In accepting a Contractor’s offer, the County neither accepts nor rejects the Contractor’s level-of-effort estimates; rather, the County accepts the Contractor’s promise to employ whatever level- of-effort is necessary to achieve the clinical, response time, and other performance standards required by the terms of the Contract.
For purposes of determining the Contractor’s compliance with the response time standards as set forth in this RFP, and for calculating damages every emergency request for ambulance service shall be counted except as follows:
• Requests during a disaster, locally or in a neighboring jurisdiction that a Contractor’s ambulance is dispatched too.
• An inclement weather condition exists.
5.0 CONTRACT PERIODS
Base Year - The base year of this contract, if awarded, will commence July 1, 2016 and continue through June 30, 2017.
First Option Year - The fiscal year commencing on July 1, 2017 thru June 30, 2018.
Second Option Year - The fiscal year commencing on July 1, 2018 thru June 30, 2019.
Third Option Year - The fiscal year commencing on July 1, 2019 thru June 30, 2020.
6.0 AWARD OF CONTRACT
The contract will be awarded to that responsible bidder whose bid, conforming to the invitation for bid will be most advantageous to the County; price and other factors considered. Glynn County reserves the right to reject any or all bids and to accept any single item or combination of items in the bid, and to waive informalities and minor irregularities in all bids received. A written award, e-mailed (or otherwise furnished) to a successful bidder within sixty (60) days from date of bid opening shall be deemed to result in a binding contract without further action by either party.
Exercising of Option Periods - Thirty (30) days prior to the expiration a contract period, Glynn County will evaluate the County's future needs and determine the necessity for continuing these services. Glynn County's decision to exercise an option period will be provided to the successful bidder, in writing. 21 | Page
7.0 RESPONSE DAMAGES
As used herein, the term emergency request shall include any response by the Contractor under the contract on an emergency service request received by the contractor from 911 Dispatch or a call received directly from the public within the service area.
Response to emergency requests shall be determined the moment the Contractor’s ambulance is notified of the emergency service request. The Contractor has a duty to immediately notify 911 Dispatch that they are responding to an emergency service request. If, in each monthly period, the Contractor fails to respond to emergency requests in a timely manner, it shall pay response damages set forth in this RFP.
In each monthly period (beginning on the first day of each month), and commencing on the first day of operations, not less than one hundred percent (100%) of the Contractor’s response to emergency requests shall be performed as set forth in the RFP.
Failure of the Contractor to meet response time requirements may result in a deduction from the monthly operating subsidy or a charge of penalty fees based on not adhereing to the standards set in Section B, Item 4, Structure Intention Summary on page 16. The response for an emergency request may also be excluded when the EMS Coordinator and QRC determines there is other good cause for an exception.
Percentage of responses Damages per monthly period to emergency request which satisfy response requirements: (damages are cumulative)
90-100% ALS Responses = No penalty
80-90% ALS Responses = $1500.00 penalty
75-80% ALS Responses = $3000.00 penalty
<75% ALS Responses = $5000.00 penalty and immediate review for possible contract termination.
Ambulance availability: The Contractor’s failure to provide available ambulances as required in the RFP may result in a deduction from the monthly operating subsidy paid or a charge of penalty fees to the Contractor.
Ambulance availability level: Damages (cumulative)
Zero (0) ALS units in county $500.00/per hour (this will be broken in five minute increments)
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REQUEST FOR PROPOSAL EMERGENCY MEDICAL SERVICES RFP #00964 SECTION D COST PROPOSAL
PROPOSAL FROM: COMPANY NAME:
______
COMPANY ADDRESS:
______
______
1. The undersigned Proposer proposes and agrees, if this Proposal is accepted, to enter into an agreement with Owner in the form included in the Contract Documents to perform and furnish all Work as specified or indicated in the Contract Documents for the Proposal Price and within the Proposal Times indicated in this Proposal and in accordance with the other terms and conditions of the Contract Documents.
2. Proposer accepts all of the terms and conditions of the Invitation and Instructions to Proposers, including without limitation those dealing with the disposition of Proposal security. This Proposal will remain subject to acceptance for 60 days after the day of Proposal opening, or for such longer period of time that Proposer may agree to in writing upon request of Owner.
3. In submitting this Proposal, Proposer represents, as more fully set forth in the Agreement, that:
(a) Proposer has examined and carefully studied the Plans (if any) and Specifications for the work and contractual documents relative thereto, and has read all Technical Provisions, Supplementary Conditions, and General Conditions, furnished prior to the opening of Proposals; that Proposer has satisfied himself relative to the work to be performed.
(b) Proposer further acknowledges hereby receipt of the following Addenda:
ADDENDUM NO. DATE
Proposers are advised that it is their responsibility to verify that any and all addendums have been received prior to submission of the Proposal. In case any Proposer fails to acknowledge receipts of any such amendments in the space provided on the Proposal form, the Proposal will nevertheless be construed as though the amendment(s) have been received and acknowledged, and the submission of the Proposal will constitute acknowledgement of the receipt of amendments.
(c) Proposer has visited the area and become familiar with and is satisfied as to the general, local and site conditions that may affect cost, progress, performance and furnishing of the Work;
(d) Proposer is familiar with and is satisfied as to all federal, state and local Laws and Regulations that may affect cost, performance and furnishing of the Work.
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(e) Proposer has correlated the information known to Proposer, information and observations obtained from visits to the area identified in the Proposal Documents and all additional examinations, investigations, explorations, tests, studies and data with the Proposal Documents.
(g) This Proposal is genuine and not made in the interest of or on behalf of any undisclosed person, firm or corporation and is not submitted in conformity with any agreement or rules of any group, association, organization or corporation; Proposer has not directly or indirectly induced or solicited any other Proposer to submit a false or sham Proposal; Proposer has not solicited or induced any person, firm or corporation to refrain from Proposal; and Proposer has not sought by collusion to obtain for itself any advantage over any other Proposer or over Owner.
Note: While it is your responsibility to include all required documents you are reminded that, you must attach the following documents to this Proposal form and you must acknowledge the following:
Proposal Form Proposal Bond Representation Oath Acknowledge Addendum/Amendments Georgia Security and Immigration Compliance Act Requirements as required (Failure to return required documents with your Proposal will render your Proposal non-responsive.) Request for Local Preference Consideration (ensure all necessary documents are submitted with proposal).
Cost to the Entity (subsidy)
Charges for Base Transport
Mileage Rate
Please include summary of Billing Methodology: (Attach additional page if necessary)
5. Proposer accepts the provisions of the Agreement as to liquidated damages in the event of failure to complete the Work within the times specified in the Agreement.
6. The following documents are attached to and made a condition of this Proposal:
(a) Required Proposal Security in the form of 5% of the Proposal Total Price.
7. The undersigned further agrees that in case of failure on his part to execute the said contract and the Bond (if applicable) within fifteen (15) consecutive calendar days after written notice being given of the award of the contract, the check or Proposal bond accompanying this Proposal, and the monies 24 | Page
payable thereon shall be paid into the funds of the Owner as liquidated damages for such failure, otherwise, the check or Proposal bond accompanying this proposal shall be returned to the undersigned.
8. Communications concerning this Proposal shall be addressed to:
Glynn County, Georgia Purchasing Division Attn: Keri Moreland 1725 Reynolds St., Suite 300 Brunswick, Georgia 31520 Voice: 912 554-7135 Email: [email protected]
9. Terms used in this Proposal which are defined in the General Conditions or Instructions will have the meanings indicated in the General Conditions of Instructions.
SUBMITTED on , 20___.
______COMPANY REPRESENTATITIVE’S NAME
______TITLE
______SIGNATURE
Comments: ______
______
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OATH (To be submitted)
State of Georgia County of Glynn
I,______(name of individual), solemnly swear that in the procurement of the contract for EMERGENCY MEDICAL SERVICES, that neither I, nor any other person associated with me or my business, corporation or partnership, has prevented or attempted to prevent competition in the Proposalding or proposals of said project or from submitting a Proposal or proposal for this project by any means whatever.
Lastly, I swear that neither I, nor any other person associated with me or my business, Corporation or partnership has caused or induced any other PROPOSER or Proposer to withdraw his/her Proposal or proposal from consideration for this project. Said oath is filed in accordance with the requirements set forth in O.C.G.A. § 36-91-21 (e).
This day of , 20___.
Name of Party ______
Corporate or Partnership Name______
Sworn to and subscribed before me this ______day of, ______, 20___.
______NOTARY PUBLIC My Commission Expires:
(SEAL)
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REQUEST FOR PROPOSAL EMERGENCY MEDICAL SERVICES RFP #00964 SECTION E PROPOSAL REQUIREMENTS
1.0 INTRODUCTION
1.1 Overview:
The Proposers shall provide detailed information so as to demonstrate its understanding of the services requested. Work will consist of providing all labor and equipment necessary to offer Emergency Medical Services to the residents and visitors of Glynn County, GA. Submission is to be created as per the required scope of work within this Request for Proposal.
1.2 Documents:
Glynn County is not interested in elaborate brochures. All documents will be typewritten on standard 8-1/2” x 11” white paper bound in two volumes (Volume 1 – Technical Proposal and Volume II – Cost Proposal). Exception would be schematics, exhibits, photographs or other information necessary to facilitate the County’s ability to accurately evaluate the proposal. The Proposers are to submit one (1) original and four (4) copies of Volume 1 – Technical Proposal and one (1) original Fee Proposal.
1.3 Submission:
The Proposers shall package and seal its proposals so that they will not be damaged in mailing. Technical and Fee proposals are to be packaged and sealed separately. Proposers are reminded that under Georgia law, all opened documents fall under the open records act and are subject to inspection by the public. Proposers are reminded that documents and information in the possession of Glynn County, GA will be treated as confidential/proprietary information only to the extent permitted by the Georgia Open Records Act, and will be exempt from disclosure to a third party only to the extent permitted by the Georgia Open Records Act. Should you believe that your Proposal contains any trade secrets you must submit an affidavit, along with the Proposal/proposal, that states that specific portions of the Proposal/proposal contain trade secrets as defined by Georgia law (Article 27 of Chapter 1 of Title 10 of the Official Code of Georgia). Furthermore the affidavit must be detailed, citing specifically (citing paragraphs, articles, provisions, pages, etc) the portions of the Proposal/proposal containing any trade secrets. Accordingly, proprietary information and/or data can not be withheld from public inspection. All proposals and supporting documents will be submitted in accordance with the “Instructions to Proposers” Section.
A prospective service provider’s response shall include, at a minimum, the following information. Please note that the proposal should address the requirements in a clear and concise manner in the order stated herein.
Proposals must be tabbed as follows and must include, in the applicable tab, the information/documents specified. Proposals that do not adhere to the following format or include the required information/documents may be considered incomplete and therefore non-responsive.
TAB 1- EXECUTIVE SUMMARY
Present in brief, concise terms, a summary level description of the contents of the proposal and your company and its capabilities. Give the names of the person(s) who will be authorized to make representations for the Proposers, their title(s), address(es), telephone, and e-mail address. The summary must be limited to a maximum of two pages and the signer of the proposal must declare that the proposal is in all respects fair and in good faith without collusion or fraud and that the signer
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of the proposal has the authority to bind the principal proponent.
TAB 2— Experience and Ability and Additional Proposal Requirements
This RFP is for a EMERGENCY MEDICAL SERVICES provider. All work shall follow the Occupational Safety and Health Administration (OSHA) and Environmental Protective Agency(s) requirements to maintain a safe working environment. County has the right to increase or decrease the Contractor’s assignment and/or areas of operation within the scope of this contract.
The proposal should provide a detailed outline of how work will be accomplished.
At a minimum the proposal should include the following information:
• Organizational Chart • Information describing company’s technical and analytical capabilities • Training and experience (list all certifications) • Equipment resources (Year, Make and Model of Ambulances with Mileage, etc.)
For each of the above items the Proposers shall include details of the project such as: the public agency, their contact, all pertinent phone numbers and dollar amounts. The Proposers shall provide information necessary to investigate the work with the public or private agency. Include any pertinent information needed to determine the Proposer’s experience and ability to perform the anticipated work.
TAB 3— Past Performance
The proposal will address how the Proposers have previously managed tracking the information required in the scope of work.
The Proposers shall provide at least three (3) references for contracts of a similar size and scope, (if available) including at least two (2) references for current contracts or those awarded during the past five (5) years. Include the name of the organization, the length of the contract, a brief summary of the work, and the name and telephone number of a responsible contact person. Also provide a description of any conflicts occurring over the last five (5) years with these or any other contract for similar work.
TAB 4— Understanding of Project Requirements
The Proposers shall provide their interpretation of what is required to meet the needs of the County. The Proposer will use this document, their knowledge and experience to develop their understanding of this project. The Proposers are urged to develop scenarios or examples to fully explain their position.
2.0 PROPOSAL EVALUATION FACTORS
It is the County’s intent to evaluate the proposals based on technical merit and price. It is the intent of the County to choose the Proposer whose proposal provides the highest value to the County. The County reserves the right to waive any irregularities, reject any and/or all proposals, in whole or in part, when, in the County’s opinion, such rejection is in the best interests of the County. The County reserves the right to seek additional/supplemental representation on specific issues as needed.
2.1 Technical Evaluation Method
Each proposal will be reviewed by a team of qualified individuals. Their proposal review and evaluation will be subjective; however, the weighting values are established to minimize that 28 | Page
subjectivity. The following delineates the value attributed to each section.
SECTION WEIGHT
Company/Personnel Experience 25% Project Understanding/Approach 20% Past Performance 25% Local Preference 2%
Technical Total: 72%
Fee 28%
Total 100%
Note: While the evaluation team will review the proposal in its entirety and may consider anything that they find relevant, particular emphasis is placed on the following:
Current Project Knowledge- knowledge of current location/site analysis technology, practices and procedures.
Company Experience- detailed information relative to Proposer’s general qualifications as well as qualifications specific to this project; past performance record on similar work, corporate history and team organization.
Project Understanding-provision of adequate, specific, information regarding the Proposer’s technical approach to this project. Such information shall include, but not be limited to:
Specific technical approach information Personnel experience-general as well as specific qualifications and experience of individuals.
3.0 Cost Proposal
Each Proposer is required to submit a cost proposal as part of its response. The cost proposal will be evaluated and scored in accordance with scoring criteria. By submitting a response, the supplier agrees that it has read, understood, and will submit a Lump Sum Price Proposal by the following instructions/rules:
1. The submitted cost proposal must a lump sum price for all inclusive services. 2. Cost proposals containing a minimum order/ship quantity or dollar value, unless otherwise called for in the RFP, will be treated as non-responsive and may not be considered for award; and 3. The quoted cost as listed in the cost proposal shall be firm throughout the term of the resulting contract, unless otherwise noted in the RFP or contract.
Based on the total score of the Technical and Cost proposals, the Board of Commissioners may choose a Proposer with whom to negotiate the final project methodology / scope, fees, and schedules with a view toward entering into a contractual agreement. This RFP Technology/Cost split will be 72/28.
NOTE: The BOC reserves the right to accept a proposal, as submitted, and enter directly into a contractual agreement with that selected Proposers. Accordingly, it is imperative that all Proposers present their best technical and cost offers in their initial submission.
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4.0 ORAL PRESENTATION
Following the evaluation of the proposals, the Team, may request the top ranking firm(s) to make an oral presentation and/or be interviewed. If a determination is made that presentations are necessary, they will take place in Brunswick, Georgia at a mutually acceptable date and time that will be promulgated by the Contract Administrator.
5.0 NEGOTIATIONS
Following any presentations, the finalist(s) shall be re-evaluated. Should it become necessary, the Contract Administrator shall negotiate with the Proposer(s) whose proposal(s) is/are determined to be most advantageous to the County.
6.0 CONTRACT FORMATION
If the negotiation produces mutual agreement, the draft contract provided herein shall be constructed and forwarded to the successful Proposer for execution and then to the County’s Board of Commissioners for acceptance. The draft contract format will be the only acceptable document for execution. The Proposers are cautioned not to introduce its format or suggest an association’s format, e.g. “AIA”. Glynn County will not entertain or accept any exceptions or amendments to the contract format provided.
-End of This Section-
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REPRESENTATION AFFIDAVIT (TO BE SUBMITTED)
This proposal is submitted to Glynn County, Georgia Board of Commissioners (County) by the undersigned who is an authorized officer of the company and said company is licensed to do business in Georgia and Glynn County. Further, the undersigned is authorized to make these representations and certifies these representations are valid. The Proposer recognizes that all representations herein are binding on the Company and failure to adhere to any of these commitments, at the County's option, may result in a revocation of the granted contract.
Consent is hereby given to the County to contact any person or organization in order to make inquiries into legal, character, technical, financial, and other qualifications of the Proposer.
The Proposer understands that, at such time as the County decides to review this proposal, additional information may be requested. Failure to supply any requested for information within a reasonable time may result in the rejection of the Proposer's proposal with no re-submittal rights.
The successful Proposer understands that the County, after considering the legal, financial, technical, and character qualifications of the Proposer, as well as what in the County's judgment may best serve the public interest of its citizens and employees, may grant a contract.
The successful Proposer understands that this proposal is made without prior understanding, agreement, or connection with any corporation, firm or person submitting a proposal for the same, and is in all respects fair and without collusion or fraud. I understand that collusive Proposalding is a violation of state and federal law and can result in fines, prison sentences, and civil damage awards.
Company Name: ______
Authorized Person: ______Signature: ______(Print/Type)
Title: ______Date: ______
Address: ______
______
Telephone: ______Fax: ______
Email:
Name and telephone number of person to whom inquiries should be directed:
Name: ______
Address: ______
______
Title: ______Telephone: ______
Fax: ______E-mail: ______
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GEORGIA SECURITY AND IMMIGRATION CONTRACTOR AFFIDAVIT
Instructions:
Contractors must attest to compliance with the requirements of O.C.G.A. 13-10-91 and the Georgia Department of Labor Rule 300-01-02 by executing the Contractor Affidavit in accordance with the requirements of the Georgia Security & Immigration Compliance Act.
-Affidavit to Follow-
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CONTRACTOR AFFIDAVIT AND AGREEMENT (Failure to submit will render Proposal non-responsive You must use this form, you must be enrolled in this program, you must include your EEV Number)
By executing this affidavit, the undersigned contractor verifies its compliance with O.C.G.A. § 13-10- 91, stating affirmatively that the individual, firm, or corporation which is contracting with Glynn County has registered with and is participating in a federal work authorization program [Employment Eligibility Verification (EEV) / Basic Pilot Program, operated by the U.S. Citizens and Immigration Services Bureau of the U. S. Department of Homeland Security, in conjunction with the Social Security Administration (SSA)] in accordance with O.C.G.A. § 13-10-91. Further, the undersigned contractor states affirmatively that the individual, firm, or corporation contracting with Glynn County will continue to utilize and participate in the EEV federal work authorization program throughout the term of this contract.
The undersigned further agrees that, should it employ or contract with any subcontractor(s) in connection with the physical performance of services pursuant to this contract with Glynn County, contractor will secure from such subcontractor(s) similar verification of compliance with O.C.G.A. § 13-10-91 on the Subcontractor Affidavit provided in Rule 300-10-01-.08 or a substantially similar form provided by Glynn County. Contractor further agrees to maintain records of such compliance and provide a copy of each such verification to Glynn County at the time the subcontractor(s) is retained to perform such service.
EEV Number
BY: Authorized Officer or Agent Date (Contractor Name)
Title of Authorized Officer or Agent of Contractor
Printed Name of Authorized Officer or Agent
SUBSCRIBED AND SWORN BEFORE ME ON THIS THE DAY OF , 20 .
Notary Public My Commission Expires:
Note: As of the effective date of O.C.G.A. 13-10-91, the applicable federal work authorization program is the “EEV/Basic Pilot Program” operated by the U.S. Citizenship and Immigration Services Bureau of the U.S. Department of Homeland Security in conjunction with the Social Security Administration (SS)
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GEORGIA SECURITY AND IMMIGRATION SUBCONTRACTOR AFFIDAVIT
Instructions:
In the event that your company is awarded the contract for this project, and will be utilizing the services of any subcontractor(s) in connection with the physical performance of services pursuant to this contract, the following affidavit must be completed by such subcontractor(s). your company must provide a copy of each such affidavit to the Glynn County Board of Commissioners, Purchasing Division, with the executed contract documents.
All subcontractor affidavit(s) shall become a part of the contract and all subcontractor(s) affidavits shall be maintained by your company and available for inspection by the Glynn County Board of Commissioners at any time during the term of the contract. All subcontractor(s) affidavit(s) shall become a part of any contractor/subcontractor agreement(s) entered into by your company.
-Affidavit to Follow-
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SUBCONTRACTOR AFFIDAVIT
By executing this affidavit, the undersigned subcontractor verifies its compliance with O.C.G.A. § 13- 10-91, stating affirmatively that the individual, firm, or corporation which is engaged in the physical performance of services under a contract with (______) (name of contractor) on behalf of Glynn County has registered with and is participating in a federal work authorization program [Employment Eligibility Verification (EEV) / Basic Pilot Program, operated by the U.S. Citizens and Immigration Services Bureau of the U. S. Department of Homeland Security, in conjunction with the Social Security Administration (SSA)] in accordance with the applicability provisions and deadlines established in O.C.G.A. § 13-10-91.
EEV Number
BY: Authorized Officer or Agent Date (Contractor Name)
Title of Authorized Officer or Agent of Contractor
Printed Name of Authorized Officer or Agent
SUBSCRIBED AND SWORN BEFORE ME ON THIS THE DAY OF , 20 .
Notary Public My Commission Expires:
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EQUAL EMPLOYMENT OPPORTUNITY (EEO) PRACTICE
EEO Plan: The successful Proposer will develop and implement an EEO policy that, as a minimum, will recruit, hire, train, and promote, at all levels, without regard to race, color, religion, national origin, sex, or age, except where sex or age is a bona fide occupational qualification.
EEO For Veterans/Handicapped: The successful Proposer will also provide equal employment opportunities for qualified disabled veterans, handicapped persons and veterans of the Vietnam Era.
EEO For Successful Proposer Programs: The successful Proposer, will ensure equal employment opportunity applies to all terms and conditions of employment, personnel actions, and successful Proposer-sponsored programs. Every effort shall be made to ensure that employment decisions, programs and personnel actions are non-discriminatory. That these decisions are administered on the basis of an evaluation of an employee's eligibility, performance, ability, skill and experience.
EEO Acquisitions: The successful Proposer will develop and implement a policy that will give equal opportunity to the purchase of various goods and services from small businesses and minority-owned businesses.
Does the Proposer have the above EEO policy in place? Y N
If the answer to the above is no, will the Proposer have such a policy in place prior to Y N commencing work on this project:
Statement of Assurance: The Proposer herein assures the County that it is in compliance with Title VI & VII of the 1964 Civil Rights Act, as amended, in that it does not on the grounds of race, color, national origin, sex, age, handicap, or veteran status, discriminate in any form or manner against employees or employers or applicants for employment and is in full compliance A.D.A.
______(Firm's Name)
______(Authorized Signature)
______/______(Title) (Date)
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LEGAL AND CHARACTER QUALIFICATIONS
Convictions: Has the Proposer (including parent corporation, if applicable) or any principal ever been convicted in a criminal proceeding (felonies or misdemeanors) in which any of the following offenses were charged?
Y N a Fraud b Embezzlement c Tax Evasion d Bribery e Extortion f Jury Tampering g Anti-Trust Violations h Obstruction of justice (or any other misconduct affecting public or judicial officers’ performance of their official duties i False/misleading advertising j Perjury k Conspiracy to commit any of the foregoing offenses
Civil Proceedings: Has the Proposer or any principal ever been a party, or is now a party, to civil proceeding in which it was held liable for any of the following?
Y N a Unfair/anti-competitive business practices b Consumer fraud/misrepresentation c Violations of securities laws (state and federal) d False/misleading advertising e Violation of local government ordinance
License Revocation:
Y N Has the Proposer or any principal ever had a business license revoked, suspended, or the renewal thereof denied, or is a party to such a proceeding that may result in same?
Responses: If "yes" is the response to any of the foregoing, provide Information such as date, court, sentence, fine, location, and all other specifics for each "yes" response.
______
______
Principals: The full names and addresses of persons or parties interested in the foregoing Proposal, as principals, are as follows:
NAME ADDRESS
______
______
______
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______
______
References: The Proposer lists below work he has done of similar nature as this solicitation, as references that will afford the County opportunity to judge as to experience, skill, business standing, and financial ability.
CONTACT PHONE PERSON TITLE NUMBER/EMAIL ______
______
______
______
______
______
______
-End of This Section-
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PROPOSAL BOND (Turn this form in with the bond) STATE OF GEORGIA
COUNTY OF GLYNN
KNOW ALL MEN BY THESE PRESENT, that we, ______
______, as Principal, and
______, as Surety, are held and firmly bound unto Glynn County, Georgia in the sum of______
Dollars($______) lawful money of the United states, for the payment of which sum well and truly to be made, we bind ourselves, our heirs, personal representatives, successors and assign, jointly and severally, firmly by these presents.
WHEREAS, the Principal has submitted to the County a Proposal for:
EMERGENCY MEDICAL SERVICES #00964
NOW THEREFORE, the conditions of this obligation are such that if the Proposal be accepted, the Principal shall, within fifteen days (15) days after receipt of conformed contract documents, execute a contract in accordance with the Proposal upon the terms, conditions and prices set forth therein, and in the form and manner required by the County and executed a sufficient and satisfactory Performance Bond and Payment bond payable to the County, each in an amount of one hundred percent (100%) of the total contract price, in form and with security satisfactory to the County, then this obligation shall be void; otherwise, it shall be and remain in full force and virtue in law; and the Surety shall, upon failure of the Principal to comply with any or all to the foregoing requirements within the time specified above, immediately pay to the aforesaid County, upon demand, the amount hereof in good and lawful money of the United States of America, not as a penalty, but as liquidated damages.
This bond is given pursuant to and in accordance with the provisions of Section 23-1705 et seq of the Code of Georgia, as amended by the Act approved February 27, 1956, and all the provisions of the law referring to this character of bond as set forth in said sections or as may be hereinafter enacted and these are hereby made a part hereof to the same extent as if set out herein in full.
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IN WITNESS WHEREOF, the said Principal has hereunder affixed its signature and said Surety has hereunto caused to be affixed its corporate signature and seal, by its duly authorized officers, on this ______day of ______, 20___.
PRINCIPAL: ______
Signed and sealed in the By:______presence of: Title: ______1. ______(Seal)
2. ______
______
SURETY: ______
Signed and sealed in the By:______presence of: Title: ______(Seal)
1. ______
2. ______
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CONTRACT NUMBER C-15-XXXX-00964 SAMPLE CONTRACT FOR SERVICES BY AND BETWEEN GLYNN COUNTY BOARD OF COMMISSIONERS AND ______
This Agreement made and entered into by and between Glynn County, Georgia, party of the first part (hereinafter called the “County”) and ______party of the second part (hereinafter called the “Contractor”); and
WHEREAS, The Glynn County Board of Commissioners at their ______, 2015 meeting awarded the Proposal for the hereinafter referred to as the Project (Solicitation RFP #00964) and;
WHEREAS, the Contractor and the County for the consideration hereinafter named, agree and acknowledge that: Part A: Contract Form
ARTICLE 1. The Contractor agrees to provide all the staff, facilities, materials, equipment and labor necessary to carry out, in good faith, the complete requirements of the project specified as EMERGENCY MEDICAL SERVICES, in strict conformity with all sections of Solicitation RFP #00964, hereinafter set forth, whose program services together with the Contractor’s Proposal, the Advertisement for Proposals, Instructions to PROPOSERs, General Conditions, Representations, this Agreement, and all addenda hereto annexed, shall form essential parts of this Agreement as if fully contained herein.
ARTICLE 2. The Contractor agrees to commence the project included in this Contract on a date to be specified in a written Notice to Proceed, tentatively July 1, 2016.
ARTICLE 3. The County agrees to pay the Contractor, in current funds, for the performance of this Contract the sum of ______Dollars (______), which sum shall also pay for all loss or damage arising out of the nature of the project aforesaid, or from unforeseen obstructions or difficulties encountered in the performance of the project and for all expenses incurred by, or in consequence of the project, its suspension or discontinuance, and for well and faithful completion of the project and the whole thereof, as herein provided.
ARTICLE 4. The County and Contractor agree that the Specifications, and all Addenda thereto together with this Agreement, form the Contract and that such Specifications are as fully a part of the Contract as if attached or herein repeated. The Contractor, recognizing the particular requirements of the County budgetary process, agrees to waive the terms of O.C.G.A. Section 13-11-1 et seq., known as the “Georgia Prompt Pay Act”. Contractor agrees that the work and services required by this contract may require inspection and approval of the County’s engineers or consultants and that the time for payment shall be tolled for a reasonable time as required for said inspection and approval. Contractor further agrees to toll the time for payment hereinunder for an additional and reasonable period of time for the Contract Technical Representative overseeing the project or work contemplated by this agreement to approve the work and/or services performed. Once the necessary installation and approvals by the engineers or consultants and Contract Technical Representative have been made, the County shall have 30 working days from approval by the Contract Technical Representative in which to pay the Contractor; subject to any documentation requests by the County as necessary to allow the County to evaluate the completeness and accuracy of monies due. A ten (10%) percent retainage may be instituted by the County at any time in accordance with laws of the State of Georgia.
To the fullest extent permitted by laws, statutes, rules and regulations, the Contractor shall indemnify and hold harmless the County, Engineer, Engineer’s Consultants and the Officers, Directors, Employees, Agents, and
Project: EMERGENCY MEDICAL SERVICES (KM) 41 | Page other Consultants of each and any of them from and against claims, costs, damages, losses, and expenses, including but not limited to all fees and charges of engineers, architects, attorneys and other professionals and all court costs, arising out of or resulting from performance of the work, but only to the extent caused in whole or in part by negligent, reckless, willful and wanton, or wrongful acts or omissions of the Contractor, its Officers, Directors, Employees, Agents, and anyone directly, or indirectly employed by them or anyone for whose acts they may be liable, regardless of whether or not such claim, cost, damage, loss, or expense is caused in part by a party indemnified hereunder, except that no party shall indemnify any other party or person for their own sole negligence. Such obligation shall not be construed to negate, abridge or reduce other rights or obligations of indemnity which would otherwise exist as to a party or person described in this Paragraph.
This agreement consists of parts.
Part A: Contract Form Part B: Affidavit of Payment of Claims Part C: Certificate of Insurance Part D: Drug Free Workplace Part E: Special Conditions Part F: Scope of Work/Deliverables
Contractor agrees to perform the project as contemplated herein in a manner that does not jeopardize the safety of Contractor’s workers, County personnel or any other person. In addition, Contractor agrees to perform the project contemplated herein in a manner that poses no threat to the environment or violates any federal, state or local statute, ordinance, rule or regulation regarding environmental concerns.
Contractor agrees to comply with the laws of Georgia which require authorization or licensing to conduct business in the State. Notwithstanding statutory exemptions or exclusions, Contractor agrees to subject itself to the jurisdiction and process of the Courts of the State of Georgia as to all matters and disputes arising or to arise under this Agreement and the performance thereof, including all issues relating to liability for taxes, licenses or fees levied by the State. Contractor irrevocably consents that any legal action or proceeding against it under, arising out of or in any manner relating to this Contract shall be brought in any court in Glynn County, Georgia.
Contractor designates the Secretary of the State of Georgia as its agent for service of process, provided no such agent located in Georgia is on file with said Secretary. Contractor, by the execution and delivery of this Contract, expressly and irrevocably assents to and submits to the personal jurisdiction of any court in Glynn County, Georgia and in any said action or proceeding. Contractor hereby expressly and irrevocably waives any claim or defense in any said action or proceeding based on any alleged lack of jurisdiction, improper venue or forum non convenes or any similar basis.
Contractor shall take affirmative action in complying with all federal and State requirements concerning provision of services or fair employment and treatment of all applicants for employment without regard to or discrimination based on race, color, religion, sex, national origin or disabilities (particularly in regard to the Americans with Disabilities Act.)
Contractor assumes sole responsibility for completion of the work undertaken pursuant to this Agreement. The County shall consider Contractor the sole point of contact with regard to contractual matters. Sub- contracting of any part of the work or service contemplated by this Agreement may not be entered in by Contractor without prior written approval by the County.
Project: EMERGENCY MEDICAL SERVICES (KM)
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Contractors and all approved subcontractors shall compensate its employees, at a rate equal to or greater than the prevailing local wage rate in Glynn County as determined and announced by the Wage and Hour Division of the U.S. Department of Labor.
To the fullest extent permitted by law, contractors and subcontractors shall comply with the Official Code of Georgia, Section 34-9-410 et seq., as amended from time to time. Proof of Certification of Drug Free Workplace Programs under the named statute shall accompany each Proposal for public improvements projects submitted to the County for consideration.
No assignment or transfer of this Agreement or any right accruing here under shall be made in whole or in part by Contractor without the express written consent of the County.
A waiver by either party of any breach of the provisions hereof shall not be deemed a waiver of any succeeding breach of such provision or any other provision of this Agreement.
Should any term, provision or other part of this Agreement be declared illegal or unenforceable, it shall be excised or modified to conform to the appropriate laws or regulations, and the remainder of the Agreement shall not be affected but shall remain in full force and effect.
The provisions, covenants, and conditions in this Agreement apply to and bind the parties, their legal heirs, representatives, successors and assigns.
No modification or amendment of the terms hereof shall be effective unless written and signed by the authorized representatives of all parties hereto.
This Agreement constitutes the final and complete agreement and understanding between the parties regarding the subject matter hereof. All prior and contemporaneous Agreements and understandings, whether oral or written, are to be without effect in the construction of any provisions or term of this Agreement if they alter, vary or contradict this Agreement.
The Contractor and the County, their successors, executors, administrators and assigns hereby agree to the full performance of the covenants herein contained.
Continued on next page
Project: EMERGENCY MEDICAL SERVICES (KM)
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IN WITNESS WHEREOF:
The parties hereto have executed this Agreement under their respective seals as of the date last written below in three (3) counterparts, each of which shall without proof or accounting for the other counterparts, be deemed an original contract.
GLYNN COUNTY, GEORGIA
By: ______Dale Provenzano Title: Chairman, Board Of Commissioners Glynn County, Georgia (Seal)
Attest: ______Cindee Overstreet Title: County Clerk
Date: ______
======
CONTRACTOR: Company Name
Signed and sealed in By: ______the presence of: Title: ______(Seal)
1. ______
2. ______
Attest: ______(Corporate Secretary) Title: ______
Date: ______
Project: EMERGENCY MEDICAL SERVICES (KM)
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PART B AFFIDAVIT OF PAYMENT OF CLAIMS (Submitted with Final Invoice)
______this ______day of ______,
20_____appeared before me, ______, a Notary Public, in and for ______, and being by me first duly sworn states that all subcontractors and suppliers of labor and materials have been paid all sums due them to date for work performed or material furnished in the performance of the contract between:
Glynn County Board of Commissioners (County) and ______(Contractor), last signed______, 20____for the EMERGENCY MEDICAL SERVICES.
BY:______
TITLE:______
DATE:______(Seal)
Subscribed and sworn to before the day of , 20___.
My commission expires on the day of , 20___.
______NOTARY PUBLIC
(Notary Seal)
Project: EMERGENCY MEDICAL SERVICES (KM)
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PART C STATEMENT OF INSURANCE COVERAGE
This is to certify that (Insurance Company) of (Insurance Co. Address) has issued policies of insurance, as identified by a policy number to the insured name below, and that such policies are in full force and effect at this time. Furthermore, this is to certify that these policies meet the requirements described in the General Conditions of this project; and it is agreed that the insurer will endeavor, if allowed by the policy, to provide the Owner thirty (30) calendar days’ notice of nonrenewal, cancellation, or termination of the coverage. Such notice shall be delivered to:
Glynn County Georgia Board of Commissioners, Purchasing Agent, 1725 Reynolds St., Suite 300, Brunswick, Georgia 31520.
It is further agreed that Glynn County Board of Commissioners shall be named as an additional insured on the Contractors policy
1. Insured:
2. Project Name: EMERGENCY MEDICAL SERVICES
3. Project Number: RFP #00964
4. Policy Numbers(s):
DATE: (INSURANCE COMPANY)
ISSUED AT: (AUTHORIZED REPRESENTATIVE)
ADDRESS:
NOTE: Please attach Certificate of Insurance form to this page (Attach any endorsements)
Project: EMERGENCY MEDICAL SERVICES (KM) 46 | Page
PART D DRUG FREE WORK PLACE CERTIFICATION
In order to have a drug- free workplace, a business shall:
Publish a statement notifying employees that the unlawful, manufacture, distribution, dispensing, possession, or use of controlled substances is prohibited in the workplace and specifying the actions that shall be taken against employees for violation of such prohibition.
Inform employees about the dangers of drug abuse in the workplace, the business’s policy of maintaining a drug-free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations.
As a condition of working on the commodities or contractual services then under Proposal, the employee shall notify the employer of any conviction of, or plea of guilty or nolo contendere to, any violation of Chapter 893 or of any controlled substance law of the United States or any State, for a violation occurring in the workplace no later than five (5) days after such conviction.
Impose a sanction on, or require satisfactory participation in a drug abuse assistance or rehabilitation program if such in available in the employee’s community, by any employee who is so convicted.
Make a good faith effort to continue to maintain a drug-free workplace through implementation of this section.
As the person authorized to sign this statement, I certify that this firm complies fully with the above requirements.
______Company Name
______Authorized Signature
______Title
Date:______
Project: EMERGENCY MEDICAL SERVICES (KM)
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PART E SPECIAL CONDITIONS
01 - GENERAL CONDITIONS
The General Conditions of the Contract shall apply to all work in this Contract except as otherwise specified in these Special Conditions. Requirements of these Special Conditions supersede those of the General Conditions.
02 – PLANS
The attached plans, if any, form a part of this contract:
03 - TECHNICAL SPECIFICATIONS
The "Technical Specifications" (hereinafter referred to as "Specifications"), must be complied with during the execution of this project. In the event a conflict between the "Plans" and these "Specifications" is discovered, the Contractor shall obtain clarification as to how to proceed from the Contract Technical Representative listed below. If the conflict is minor, the project may proceed with verbal agreement from both parties. Should the conflict be considered major by either party, a written agreement in the form of a change order or amendment must be executed.
04 - NOTICE
Notice requirements as stated herein shall be satisfied by posting written notice to the following representatives:
A. Contract Administration
The Contract Administrator for this Request for Proposal (RFP) shall be Ms. Keri Moreland, (912) 554- 7135. The Contract Administrator shall act as the County's Representative during the execution of any subsequent contract and related amendments. She will evaluate any contract disputes in a fair and unbiased manner. The decisions of the Contract Administrator shall be final and conclusive and binding upon all parties to the Contract. Any contractual questions arising during the proposal period or during the contract period(s) are to be addressed to the Contract Administrator at the following address:
Glynn County Georgia Board of Commissioners Attn: Keri Moreland, Purchasing Agent 1725 Reynolds St., Suite 300 Brunswick, GA 31520 Phone (912) 554-7135 E-Mail: [email protected]
B. Contract Technical Representative
The Contract Technical Representative is the County's day-to-day manager of the services contracted for. He shall provide the successful Proposer direction and monitor the results within the limits of the contract's terms and conditions. He will decide questions which may arise as to quality and acceptability of services performed. He shall judge as to the accuracy of quantities submitted by the successful Proposer in payment requests and the acceptability of the services which these quantities represent. He will be the point-of-contact for developing contract changes and amendments to be approved by the County and
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executed by the Contract Administrator. Any technical questions arising, subsequent to contract award, are to be addressed to the Contract Technical Representative at the following address:
Glynn County Administration Attn: Alan Ours, County Manager 1725 Reynolds Street, 3rd Floor Brunswick, Ga. 31520 Phone: (912) 554-7402 Email: [email protected]
-End of this Section-
Project: EMERGENCY MEDICAL SERVICES (KM)
49 | Page
PART F STATEMENT OF WORK SPECIFICATIONS FOR EMERGENCY MEDICAL SERVICES RFP #00964
01-SCOPE OF SERVICES
1. The Contractor will furnsh all Emergency Ambulance Services for the entire population and visitors of Glynn County, GA as described herein.
2. The Contractor will adhere as directed in the response time performance, realiability and measurement methods as outlined above on Page 16, Item 4.
3. The Contractor will provide and maintain all ambulances, support vehicles, on-board medical supplies and equipment as well as office facilities and equipment that will be utilized to perform the services within this RFP.
4. When an ambulance is taken out of service due to mechanical failure or accident, a replacement ambulance must be made available within fifteen (15) minutes.
5. The Contractor will utilize the County’s Brunswick-Glynn 911 Center dispatch services. Emergency responses originating at the 911 system will be provided at no cost to the Contractor.
6. The Contractor will provide to the County, at their request, financial and transport data reporting documents at no additional cost to the County. Contractor shall maintain all books, documents, accounting records (these shall include all Vehicle Maintenance Records, Employee training records and employee license records) and other evidence pertaining to the services provided under the contract and make such materials available at its offices at all reasonable times during the contract period and for three (3) years from the date of the final payment under the contract period for inspection by County or by any other governmental entity or agency participating in the funding of the contract, or any authorized agents thereof.
7. The Contractor will provide an adequate coverage and dedicated number of ambulances and staff to achieve the complete scope of services detailed in this RFP throughout the life of the contract.
8. The Contractor will foster an integrated First Repsonse program with the Fire Department.
9. Upon request by law enforcement, Fire Departments, or Search and Rescue, Contractor shall furnish courtesy stand-by coverage at special events and emergency incidents involving a potential danger to the personnel of the requesting entity at no additional cost to the County.
10. The Contractor will follow steps to improve prevention and access of services through community education programs to be provided to the school system and community groups.
11. The Contractor will provide a staff member to be involved in planning for and responding to any declared disaster and mutual-aid response in the County.
12. The Contractor will work with the assigned County staff member to address all complaints and concerns.
13. The Contractor will maintain the required staff and accreditations as detailed within this RFP. The Contractor’s staff will remain ethical and professional at all times.
14. The Contractor will follow the medical protocols as established by the Glynn County Fire Department’s Captain of Rescue.
15. The Contractor shall utilize management practices that ensure that field personnel working extended 50 | Page
shifts, part-time jobs, voluntary overtime, or mandatory overtime are not exhausted to an extent that might impair judgment or motor skills.
16. The Contractor must have in place a program for random drug screening of all personnel providing response under the contract. Further, the Contractor will transport to a facility for testing any employee suspected to be using or under the influence of drugs or alcohol or other intoxicant, or have an agent of a testing facility come to the location of the employee to obtain a necessary sample. Any employee suspected of being under the influence of any drug or intoxicating substance will be relieved of duty until there is clinical proof to the contrary.
17. Should complaints arise which are directed at level of care, response or employee action or inaction, such complaints from the EMS Coordinator must be answered within 48 hours to include actions taken, including disciplinary action and other corrective measures.
18. Contractor will have staff available or a toll free phone number, capable of discussing and resolving billing questions.
19. Contractor is specifically advised to use its own best expertise and professional judgment in deciding upon the methods to be employed to achieve and maintain the high performance required under the contract. By “methods”, the County means compensation programs, shift schedules, personnel policies, supervisory structures, fluid vehicle deployment techniques, and other internal matters which, taken together, comprise each Contractor’s own strategies and tactics for getti ng the job done.
02-PERFORMANCE BASED CONTRACT
The most important aspect of this procurement is the fact that this procurement will result in the award of a Performance-based contract. Penalties will be assessed for failures to achieve minimum standards set forth in the Contract. This procurement requires the highest levels of performance and reliability, and the mere demonstration of effort, even diligent and well intentioned effort, shall not substitute for performance results.
Specifically:
Ambulance response times must meet the response requirements set forth in the RFP.
Every primary and coverage ambulance unit must at all times be equipped and staffed to operate at the State of Georgia certified paramedic on all emergency and non-emergency calls received under the contract.
Clinical performance must be consistent with approved medical standards and protocols and guidelines set forth by the State of Georgia.
There must be an unrelenting effort to detect and correct performance deficiencies and to continuously upgrade the performance and reliability of the entire EMS system.
Clinical and response time performance must be extremely reliable, with equipment failure and human error held to an absolute minimum through constant attention to performance, protocol, procedure, performance auditing, and prompt and definitive corrective action.
This is not a level-of-effort contract. A contractor who fails to perform must and shall be promptly replaced, because human lives, and not merely inconvenience or money, are at stake. In accepting a Contractor’s offer, the County neither accepts nor rejects the Contractor’s level-of-effort estimates; rather, the County accepts the Contractor’s promise to employ whatever level- of-effort is necessary to achieve the clinical, response time, and other performance standards required by the terms of the Contract. 51 | Page
For purposes of determining the Contractor’s compliance with the response time standards as set forth in this RFP, and for calculating damages every emergency request for ambulance service shall be counted except as follows:
• Requests during a disaster, locally or in a neighboring jurisdiction that a Contractor’s ambulance is dispatched too.
• An inclement weather condition exists.
03-CONTRACT PERIODS
Base Year - The base year of this contract, if awarded, will commence July 1, 2016 and continue through June 30, 3017.
First Option Year - The fiscal year commencing on July 1, 2017 thru June 30, 2018.
Second Option Year - The fiscal year commencing on July 1, 2018 thru June 30, 2019.
Third Option Year - The fiscal year commencing on July 1, 2019 thru June 30, 2020.
04-RESPONSE DAMAGES
As used herein, the term emergency request shall include any response by the Contractor under the contract on an emergency service request received by the contractor from 911 Dispatch or a call received directly from the public within the service area.
Response to emergency requests shall be determined the moment the Contractor’s ambulance is notified of the emergency service request. The Contractor has a duty to immediately notify 911 Dispatch that they are responding to an emergency service request. If, in each monthly period, the Contractor fails to respond to emergency requests in a timely manner, it shall pay response damages set forth in this RFP.
In each monthly period (beginning on the first day of each month), and commencing on the first day of operations, not less than one hundred percent (100%) of the Contractor’s response to emergency requests shall be performed as set forth in the RFP.
Failure of the Contractor to meet response time requirements may result in a deduction from the monthly operating subsidy or a charge of penalty fees based on not adhereing to the standards set in Section B, Item 4, Structure Intention Summary on page 16. The response for an emergency request may also be excluded when the EMS Coordinator and QRC determines there is other good cause for an exception.
Percentage of responses Damages per monthly period to emergency request which (damages are cumulative) satisfy response requirements:
90-100% ALS Responses = No penalty
80-90% ALS Responses = $1500.00 penalty
75-80% ALS Responses = $3000.00 penalty
<75% ALS Responses = $5000.00 penalty and immediate review for possible contract termination.
Ambulance availability: The Contractor’s failure to provide available ambulances as required in the RFP
Project: EMERGENCY MEDICAL SERVICES (KM)
52 | Page
may result in a deduction from the monthly operating subsidy paid or a charge of penalty fees to the Contractor.
Ambulance availability level: Damages (cumulative)
Zero (0) ALS units in county 500.00/per hour (this will be broken in five minute increments)
-End of this Section-
Project: EMERGENCY MEDICAL SERVICES (KM)
53 | Page
ISO Rating and Insurance Rates
In order to gain a better understanding of how insurance rates could be affected by a change in the ISO rating, a phone survey was conducted with State Farm, Allstate, Nationwide, McGinty-Gordon, and Turner & Associates.
• All but State Farm still use the ISO ratings to determine rates. • For those that use ISO ratings, they also noted that there are many factors that play a role in determining insurance rates. • All but State Farm agreed that if the ISO rating on a $250,000 home increased, there would be an increase in insurance rates but none would specify what that increase would be due to the various other factors that would affect the rate. • A representative from Turner & Associates stated that if an ISO rating went from a 4 to a 9 rates would almost double. I would assess that going from a 3 to a 6, would cause a substantial increase, but not double the rates. Fire Service- Based EMS
PtiPromoting the Benefits When you call 9‐1‐1…
• Who do you want to respond? – A‐Team – B‐ Team – C‐ Team Introduction • Why do fire departments provide EMS? Labor-Mana!lement Initiative The RlReal Reason
• Why do fire departments provide EMS? • Better service • Core government function • Greater good of the community • Quality of life • Value • Similarity of life saving goals The Real Reason Fire Departments RllReally PidProvide EMS
Every day someone who has had a bad day returns to their normal lflife because o f fire‐based EMS. U.S. Fire‐Based Facts
• 95% of career Fire Departments provide EMS at some level‐ ranging from first response‐ defibrillator to advance life support (ALS) with transport. • 80% of career firefighters are cross trained multi‐role firefighter‐EMTs (BLS) • 34% of career fire fig hters are fire fig hter paramedics. U.S. Fire‐Based Facts
• Prehospital 9‐1‐1 emergency response is one of the essential public safety functions provided by the United States fire service
• Career fire fig hters (EMTs and paramedics ) respond to 9‐1‐1 medical emergencies for more than 85% of th e populliation U.S. Fire‐Based Facts
• Fire service‐based emergency medical services (EMS) systems are strategically positioned to deliver time critical response and effective patient care. U.S. Fire‐Based Facts
• The fire department is geographically deppyloyed throughout the community to minimize response times. • When response time is the priority for medical emergencies. • Firefighters are in the best position to respond quickly and provide vital services. U.S. Fire‐Based Facts
• Of the 200 most populated communities, 97 percent have the fire service delivering pre‐ hospital emergency medical service response. • Additionally, the fire service provides critical advanced life support (ALS) response and care in 90 percent of the 30 most populated United States cities and counties. EMS Defined
• Much of the dialogue in the public arena today concerning prehospital 9‐1‐1 emergency medical care often focuses on ambulance services and, accordingly, may ignore the important distinction between prehospital 9‐ 1‐1 emergency medical response and the other key uses of the ambulance‐based, out‐of hospital providers for non‐emergency medical and transportation services. Non Emergent Service
• Sub‐specialties of ambulance service in the out‐of‐hospital arena must not be confused with 9‐1‐1 emergency response. • For example, ambulance services are often employed for; – interfacility transfers for specialty care – need to trans fer pat ients from one hilhospital to another EMS Defined
• For government decision makers who do not work in the public safety environment, it may be difficult to appreciate the differences between; – emergency response and – ambulance transport. • Like ly to dfidefine a call to 9‐1‐1 in a medica l emergency as ‘needing an ambulance.’ U.S. Fire‐Based Facts
• The ride for the sick or injured person in the ambulance is only part of the system. • A comprehensive EMS system includes rapid response, intervention, stabilization, and then transportation to a definitive care facility, if needed. EMS Response Defined
• Ambulances,,, of course, are necessary to transp ort patients to a hospital where more definitive care may be needed. • However, the most relia ble vehic le to ensure a rapid response generally is the neighborhood fire truck. • Recent advances in resuscitative medical care, particularly in cardiac emergencies, what occurs in the first few minutes after onset of the medical emergency will change the long term outcome. • In many of these critical circumstances, what happens on‐scene determines whether the patient lives or dies. EMS Defined
• Therefore, prehospital 9‐1‐1 emergency response, is not only a key function of each community; it has become, almost universally, a principal duty of the fire service as well. Benefits of EMS
The goal of this discussion is to resolve and demonstrate that the use of fire service eqqpuipment and personnel to provide 9‐1‐1 emergency response is the best approach for a community regardless of size.
If EMS is the intersection of public safety, public health, and medical care… The U.S. Fire Service is uniqqyuely qualified to be at that intersection. U.S. Fire‐Based Facts
• Fire service‐based EMS brings the treatment to the patient wherever they are. Treatment by firefighters beg ins immediately, even if the patient is trapped in a building that’s on fire, pinned in a car crash, or in a collapsed structure. • The provision of EMS response, treatment, and transportation by firefig hters is seamless. One agency is responsible for the continuity of patient care and provides EMS within an “all‐hazards” response model. EMS Response Defined
• Now equipped with automated defibrillators to reverse sudden cardiac arrest, the fire truck, coupled with bystander CPR, has become one of the greatest life‐ saving tools in medical history. • Time efficiency is a key component of the best designed EMS systems. – Stroke centers to treat stroke within the golden 3 hour window, – Cardiac catheterization centers to treat heart attack in the 90 minute door‐to‐balloon time, and – Trauma centers to treat hemorrhaging patients, • The service most capable of rapid muutlti‐faceted response, rapid identification and triage to the appropriate facility is a fire service‐based EMS system. Multi‐Role Responders “ll“All Hazard” • Fire service‐based prehospital 9‐1‐1 emergency medical care systems are more effective from the perspective of scene safety, – short response time, – integrated rescue and treatment, and – transport to a medical facility. • Firefighter response is a key element of patient safety, both medically and environmentally. Multi‐Role Responders “ll“All Hazard” • In ttehe eeara of hoeadomeland securi ty teatsthreats adand tethe spiraling growth of the commercial transport industry, the threat of hazardous materials (Haz‐ Mat) is center‐stage. • Fire service Haz‐Mat teams are the front‐line of prottitection. • Rapid delivery of medical care can be pre‐empted by such chem‐bio threats, but where rapid care can be given, it can be expedited directly by cross‐trained fire‐service Haz‐Mat care providers. Most Effective System
• The U.S. Fire Service‐based emerggyency response and medical care system is the most effective, coordinated system worldwide. • The National Incident Management System (NIMS) and other nationally‐defined coordination plans ensure that fire service‐based 9‐1‐1 emergency response and medical care provides skilled medical services to the patient regardless of; – the circumstances – the location or – condition of the patient. U.S. Fire‐Based Facts
• Firefighters are long‐term workers in their communities. • Most fire departments have very low turnover rates. • Fire fig hters know ab out th e need s i n thhieir communities…and firefighters are highly experidienced emergency medica l care providers. U.S. Fire‐Based Facts
• The fire service EMS deployment model is more robust than any private for‐profit ambulance‐ based EMS model. • Firefighters are deppyloyed and ready to res pond to any type of emergency. • Fire Service‐based EMS provides this pivotal public safety service while also emphasizing responder safety, competent and compassionate workers, and cost‐effective operations. History of Maltese Cross
• During the Middle Ages, the Knights of Malta, the forerunners of the fire service, took care of travelers and specifically burn victims from the Crusades and associated battles. • Eventually, the Knights of Malta adopted the Maltese Cross as their emblem and it has created a revered legacy for fire departments . History of Maltese Cross
• Known as the Hospitallers of Jerusalem • Hospitallers became firefighters out of necessity • weapons of war at that time was the glass fire bbbomb • After rescuing a fellow knight from the inferno and extinguishing the fire, a Hospitaller was awarded a medal, shaped like a Maltese Cross History of Maltese Cross
• Maltese Cross as their identifying mark on armor • More than 1200 years ago, some of the earliest ancestors of the fire service were “all‐ hazards responders • These are two of the concepts firefighters still believe in today and hold as their most sacred responsibilities—caring for the sick and caring for their own. Community‐Based
• Community‐based fire station, with its ready availability of personnel 24 hours a day • the unique nature of medicine outside of the hospital, • creates a symbiot ic bl en d of t he tradit iona l public concepts and duties of the fire service wihith rapid ddlielivery of adddvanced prehilhospital 9‐ 1‐1 emergency response and care. Community‐Based
• Fire stations are strategically placed across geographic regions, commensurate with; – population densities – workload needs • All‐hdhazard response ifinfras truc ture meeting the routine and catastrophic emergency needs of all communities… regardless of the nature of the emergency. Safety Net
• Prehospital 9‐1‐1 emergency patient medical care is a major part of the safety net for the American healthcare system. • Provider of last resort for the needy • Fire service‐bdbased, prehilhospital 9‐1‐1 emergency patient medical care provides uncondit iona l service to all members of th e population Labor-Management Initiative The Public’s Knowledge of EMS
• Limited • Everyone is a Paramedic • Don’ t know ALS from BLS • Someone always shows up
EMS System Models (l(Deployment Conff)iguration)
• Fire service‐based system using cross‐trained/multi‐ role firefighters. – Firefighters are all‐hazards responders • Fire service‐bdbased system using emp loyees w ho are not cross‐trained as fire suppression personnel. – Single role EMS‐trained responders accompanying firefighter first‐responders • Combined system using the fire department for emerggyency response and a private or “third service” provider for transportation support. – Single role emergency medical technicians and paramedics accompany firefighter first responders to emergency scenes to provide patient transport Study Objectives
• Determine how; – First responder crew size, – ALS provider placement and – NbNumber of ALS providers …is associated with the effectiveness of EMS providers. Results: ALS Arrival (Trauma)
First • Crews with 1 ALS on the engine Responder and 1 ALS on the ambulance Crew Size completed all task 2.3 minutes faster than crews with 2 ALS on the ambulance. ALS Tasks – Once again the ALS on the First responder crew makes a difference. – Analysis of start time and duration Total of ALS task are still ongoing Time Results: ALS Arrival (Trauma)
Immobilize 4 FR ABCs
Body Sweep Oxygen 3 FR Vitals
Expose
2 FR Bleeding
Splint
BackBoard
0 FR Airway
BVM
0 200 400 600 800 1000 1200 1400 1600 Results: ALS Arrival (Car diac )
First • The crews with 1 ALS on the Responder engine and 1 ALS on the Crew Size amblbulance perfdformed 2 minutes faster than the crews with no ALS on the ALS Tasks engine and one ALS on the amblbulance
Total Time Results: ALS Arrival (Cardiac)
• The crews with 1 ALS on the engine and 1 ALS on the First Responder ambulance were able to initiate Crew Size critical skills earlier and perform them in a shorter time duration. 12‐Lead applied sooner – ALS Tasks – Intubation – shorter duration to complete • 4‐person FR crews performed both tasks earlier and in less time than Total other crew sizes. Time First Responder Crew Size (Cardiac)
At Patient
ABCs
Interview
4 FR Oxygen Vitals
12‐Lead
Expose
3 FR Arrest
Move Patient ABCs
Defib Pads 2 FR Shock
ABCs
CPR
Airway 0 FR IV
Epi
0.00 200.00 400.00 600.00 800.00 1000.00 1200.00 1400.00 Shock ROSC
Lidocaine Labor-Management Initiative Many lives are lost across USA because entergency services fail Turf wars between ambulance, fire crews cause deadly delays
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HowS~atde .111dWashington, DC.,cn~SO
iir.1JtJr~tbr~forgytn:s:lws:r•.11llilf'cbtltttd,1Lor~\lfOCbtoww-•cardi.lLB- uvu:um.lnSe>.m:!ito.~rrwdJo..,1,tflrt"f1&l'fl"1"1-wn_1~_.._•_'_""_m._n_l>q:...... ;;:..chln.:ft __ -_at_...,,__ Ml______Pi._as_•_...,_C011ER___ Sl'_o_l!Y_a_n_6"_ •_ USA Today. May 20, 2005 Policy Maker’s Knowledge of EMS
• Not much different than the public • Often get information from private sector • Believe that the private sector is free • Get bonus points for privatizing Talking Points of Fire‐Based EMS
• Continually emphasize service • Control emotions Advantages of Fire‐Based EMS
• Response time • Station locations • Quicker start of treatment • Marginal costs • Human resources • Rescue capabilities Paramedic to Patient Side
• Best chance to save a life • Shorter hospital stays • Less time in rehab • Early pain management • Continuity of care • Faster return to pre‐injury/illness condition Items for Detailed Discussions
• Privates are not free • Subsidized through money & personnel • Fire departments “stop the clock” • Fire departments begin treatment • Exttara haadsnds aaere needed for services • Patient care • Patient movement Benefits in Addition to Improved Service
• Marginal Costs • Money stays in community • Personnel for fire response • Regardless of number of fires Challenges to Fire‐Based EMS
• Transport to limited facilities • Units out of service longer • Won’ t be available if fire strikes • Government should look to privatize • Perception that it is a union issue • Privates are doing just fine – no complaints Preparation
• Cre dibility • Trust • Credentials • Knowledge • Support of medical professionals • Marketing • Customer service • Professionalism & Appearance Things to Avoid in Discussions
• Saves firefighter jobs • Makes money • Not enough fire to support staffing • Criticism of privates • Anything that appears self‐serving Fire Service Based EMS Advocates Resources • National organizations like IAFC, IAFF, Metro Chiefs and CFSI • FB EMS Advocates – White Paper • FB EMS ToolKit • FB EMS Guidebook (IAFF) • Videos (()DVD) – Right response – National Medical Report • http:www.fireserviceems.com/ SUMMARY Questions? IAFF
EMERGENCY MEDICAL SERVICES Privatization and Prehospital Emergency Medical Services
Monograph 1
International Association of Fire Fighters® Emergency Medical Services Privatization and Prehospital Emergency Medical Services Monograph 1
Department of Emergency Medical Services International Association of Fire Fighters, AFL-CIO, CLC
® Copyright © 1997 by the International Association of Fire Fighters. This publication is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise without written permission from the International Association of Fire Fighters, Department of Emergency Medical Services.
International Standard Book Number: 0-942920-22-8
i Foreword
Today, more than 80% of fire departments perform some level of emergency medical services (EMS), making professional fire fighters the largest group of providers of prehospital emergency care in North America. No other organization – public or private – is capable of providing prehospital emergency response as efficiently and effectively as fire departments. Fire department operations are geared to rapid response, whether it is for EMS or fire suppression. Cross-trained/dual-role fire fighters are trained to aggressively attack their work whether it involves fire, rescue, or medical emergency. It is no surprise that study after study has shown that fire department-based prehospital emergency medical care systems are superior to other provider types.
As we look to the future of prehospital emergency medical care, however, we must re-evaluate our role in the context of a rapidly evolving medical care system. Drawing on what we have learned during the past century, we must create a vision for the future of fire-based EMS. This vision must include legislation for the protection of fire-based systems, public education, prevention, and the possibly expansion of the scope of practice for paramedics. This vision must consider the effects of managed care organizations on prehospital EMS, as well as revenue recovery for the services fire fighters perform. We should support legislation to protect fire-based systems from the threat of privatization and to protect the citizens we serve by preserving the nation's universal emergency access number, 9-1-1. The information in this series of monographs is designed to guide local fire department leaders through the process of developing a vision for the future of a fire-based EMS system. This monograph is the first in the series and addresses privatization of emergency medical services. This monograph should be useful for IAFF members and fire service leaders who are preparing to contend with private ambulance service providers.
The role of the professional fire fighter is constantly changing. We are multi- faceted first responders, answering not only fire calls but also rescue, hazardous materials, and emergency medical calls. By confronting the challenge of change, we can continue to meet the needs of the communities we serve and do what we do best –– protect property and save lives.
Harold A. Schaitberger General President Acknowledgments
The IAFF would like to acknowledge the Department of Emergency Medical Services staff, specifically Jonathan Moore and Sandy Miller, for their work in the development of this publication.
The IAFF also wishes to recognize the members of the IAFF EMS Committee for their editorial review and support:
James L. Hill, District 7 Vice President, Co-Chair Dominick F. Barbera, District 12 Vice President, Co-Chair Robert B. McCarthy, President, PFF of Massachusetts Patrick Cantelme, President, IAFF Local 493, Phoenix, AZ Dan Fabrizio, President, IAFF Local 2, Chicago, IL Mark A. Lloyd, President, IAFF Local 385, Omaha, NE Richard L. Mayberry, President, IAFF Local 522, Sacramento, CA Gary Rainey, Secretary, IAFF Local 1403, Metro-Dade Co., FL Ronald L. Saathoff, President, IAFF Local 145, San Diego, CA
IAFF DEPARTMENT OF E MERGENCY M EDICAL S ERVICES
Lori Moore, MPH, EMT-P, Director
® International Association of Fire Fighters AFL-CIO, CLC Department of Emergency Medical Services 1750 New York Avenue, NW Washington, DC 20006 (202) 737-8484 (202) 737-8418 (FAX) Privatization and Prehospital EMS Table of Contents
INTRODUCTION ...... 1 WHAT IS PRIVATIZATION? ...... 2 Contracting Out ...... 2 Public/Private Partnership ...... 2
THE CONCEPT OF PRIVATIZING ESSENTIAL PUBLIC SERVICES ...... 3 FIRE BASED VERSUS PRIVATE EMS - A DIFFERENCE OF PHILOSOPHIES AND SERVICE ...... 5 Fire-Based EMS ...... 5 Private EMS ...... 5 Response Time Interval ...... 6 Patient Transport ...... 7
PUBLIC SUBSIDIES TO PRIVATE CORPORATIONS ...... 8 DEVELOPING PUBLIC/PRIVATE PARTNERSHIPS ...... 10 PROBLEMS WITH PRIVATIZATION ...... 14 PRIVATE AMBULANCE PROVIDERS: THE CORPORATIONS 16 American Medical Response, Inc. (AMR)...... 16 Laidlaw/MedTrans ...... 18 Rural/Metro Corporation ...... 19
PRIVATIZATION TACTICS ...... 20
PROPONENTS OF PRIVATIZATION ...... 23 American Ambulance Association (AAA) ...... 23 Other Organizations ...... 24
CONCLUSION ...... 26
GLOSSARY ...... 28
Appendix 1. Privatization of Emergency Medical Services Case Studies.
i INTRODUCTION
Public officials and citizens may be faced with a decision regarding the most appropriate provider of prehospital emergency medical services in their community. The options for emergency medical service (EMS) providers may include the fire department, a private ambulance service, a combination of the two, or various other provider types. As communities evaluate their emergency medical care needs, they may focus exclusively on patient transportation since third party payers for emergency medical services reimburse only for transport. Research on patient survival, however, has demonstrated that rapid, on-scene medical intervention produces the best patient outcomes. Therefore, designing a community’s EMS system should be approached from a global perspective. Though each component (initial response, ALS, transport, etc.) must be considered individually, the system must function as a single entity with all the elements fully integrated.
It is no secret that in some cases, a private ambulance provider could provide the transport component of an EMS system more cheaply than a publically-provided system. It is also known, however, that a private provider cannot optimally provide an entire EMS system more efficiently nor more effecively than a fire department. The infrastructure of the local fire department can be exploited to provide optimal response for emergency medical calls. Community leaders should examine the resources available for EMS within their fire department. The community should then determine the role fire fighters will play in the overall EMS system. That role may include delivery of the entire system.
Decision makers must consider not only the cost associated with EMS provision, but also response time, quality of service, associated revenue, and patient outcome in selecting a provider and designing an effective, cost-efficient EMS system.
1 WHAT IS PRIVATIZATION? WHAT IS HAT IS
Privatization describes the process of shifting the provision of a public service from the government to a private sector enterprise. Private sector whatWHAT enterprises include nongovernmental firms, partnerships, joint ventures, corporations, or other legal entities engaged in commercial activity for profit.
There are two approaches of privatization that are likely to impact the delivery of public provided fire-based prehospital emergency medical services – contracting out and public/private partnership.
CONTRACTING O UT Contracting out may be defined as a governmental entity employing a private sector enterprise and its employees to perform a service, rather than directly performing the service. The government may still pay and assume responsibility for the service but hire a private company to provide the service. In the United States, contracting out is the most frequently used form of privatization. It may also be referred to as outsourcing. A recent variation to contracting out is “managed competition.” This contracting process permits a governmental agency to prepare a proposal and submit a bid to compete with private bidders for the right to provide a public-sector service. The process is usually defined in a “request for proposal” (RFP) released by the local government.
PUBLIC/PRIVATE A public/private partnership may be defined as a coordinated, collaborative PARTNERSHIP effort between a private company and a government agency for the provision of essential services to the public. This partnership should be mutually beneficial to all parties concerned, including the public.
2 THE CONCEPT OF PRIVATIZING ESSENTIAL PUBLIC SERVICES
The primary goal of a private corporation is return on investment. If it fails to thrive financially, the private corporation faces ruin. Only individuals who have an ownership interest in the corporation (a corporation’s shareholders) have a right to vote on corporate matters. The corporation is designed to regulate private interest and exists mainly for private gain.1-2
The nature of private industry must be recognized by community leaders considering contracting with a private ambulance provider for a critical municipal function, such as emergency medical services. Public officials should also recognize the effectiveness and the economic value of the fire department providing a “whole” EMS system compared to contracting “pieces” of a system to a private company. When comparing system cost, the marginal cost of the fire department providing emergency medical services should be compared to the total cost of a private company providing a complete EMS system without fire department involvement. This costing method provides a clear picture of the true cost of the entire EMS system.
Recently, the U.S. General Accounting Office (GAO) was asked to identify lessons learned by, and related experiences of, state and city governments in implementing privatization efforts. The document released following this study (GAO-GGD-97-48) provides a profile for privatization. That profile includes six components that should exist for privatization to occur. The components include the following.
• A political champion — Privatization can best be introduced and sustained when a political leader champions it. • Implementation structure — Goverment leaders must establish an
3 organizational and analytical structure to ensure effective implementation. Such a structure can include a government-wide commission to identify privatization opportunities and set privatization policy or a staff office that can support agencies in their privatization efforts and oversee implementation. • Legislative and resource changes — Governments may need to enact legislative changes and/or reduce governmental resources to encourage use of privatization. • Reliable cost data — Reliable cost data on governmental activities are needed to support informed privatization decisions and to access overall performance. • Strategies for work transition — Goverments will need strategies to manage workforce transition. • Monitoring and oversight — Sophisticated monitoring and oversight are needed to protect the government’s interest when its role in the delivery of services is reduced through privatization.
Fire department officials should recognize attempts to develop these components within their own local governments as threats of privatization and should take action to prevent or counter these attempts.
4 FIRE-BASED VERSUS PRIVATE EMS - A DIFFERENCE OF PHILOSOPHIES AND SERVICE
FIRE-BASED EMS Unlike private contractors and other single-role providers, fire departments have the flexibility to provide prehospital emergency medical care by utilizing fire apparatus staffed with cross-trained/dual-role fire fighter emergency medical technicians (EMTs) and paramedics. Fire-based systems can maintain the shortest possible response times while avoiding duplication of services by cross training employees to function effectively in fire suppression, rescue, and EMS. Fire departments can deploy emergency response units in superior numbers from strategic locations than single-role private providers can while maintaining their profits.
PRIVATE EMS Third party payers, such as private health insurers, Medicare, and Medicaid, only underwrite the portion of prehospital emergency medical care associated with transporting a patient to the hospital. Private contractors, therefore, attempt to maximize profit by transporting a maximum number of patients with as few ambulances as possible. Efforts by private EMS corporations to maximize productive time for ambulances could result in a decreased level of service to the community.
It may not be cost effective for a private ambulance company to maintain multiple ambulances available for timely response in a way that is acceptable to the community. Reliance on an ambulance/transport- based system to provide critical initial response to medical emergencies thus results in increased response times for service to any given call. This tradeoff between profit and response time interval is at the heart of the EMS privatization dilemma.
5 It is in the economic interest of a private ambulance company to have their response time benchmark of performance set as high as possible. If response time benchmarks are not established high enough, private providers may rely on fire departments to “frontload” the system. Frontloading advanced life support systems occur when a fire department provides paramedics on first responder vehicles and a private ambulance company provides transport, and therefore collects the revenue.
RESPONSE T IME Private-for-profit EMS contractors and other single-role providers maintain INTERVAL that their performance should be measured against a response time standard of 8 minutes and 59 seconds. Research in EMS indicates that if emergency medical intervention is delayed as long as 9 minutes, patient survival of cardiac arrests approaches zero.3 Even the private-for-profit ambulance contractors agree that, in the face of their 9 minute response time, the fire service is best positioned to provide the required time-critical medical interventions in less than 9 minutes to ensure optimal victim survivability.4
Response time intervals must weigh heavily in an assessment of a specific EMS system’s effectiveness. The National Institutes of Health suggest first responders should arrive on the scene in less than 5 minutes, 90% of the time.5 Fire departments, on average, deliver basic life support (BLS) and advanced life support (ALS) response times in 3-5 minutes.6
As response time requirements become more stringent, a private provider, without fire department involvement, is forced to maintain and support increasing levels of surplus production capacity (more staffed ambulances) to handle the demand pattern fluctuations that prevail throughout this industry. The effect of this excess production capacity means an increase to the provider’s cost per patient served.7
6 PATIENT T RANSPORT Public officials must realize that ambulance transportation alone does not represent patient care or an EMS system. There are two factors at the heart of prehospital emergency medical care: (1) the call for service is potentially life threatening and time critical; and (2) the time and location of any particular medical emergency cannot be predicted. Given these two factors, an EMS system that sacrifices response times in favor of patient transport or ambulance services is really rationing access to those resources that have the greatest impact on an individual patient’s chance of survival.
7 PUBLIC SUBSIDIES TO PRIVATE CORPORATIONS
An often overlooked aspect of EMS privatization is the profit enhancement or service subsidy that municipalities provide to private ambulance corporations in the absence of an official partnership agreement. These subsidies are in the form of system essentials provided to private companies by local fire departments. By using these “free” resources, the private providers claim they operate “high performance” EMS systems.
In these so called “high performance” systems, local fire departments provide initial response, assessment, and even treatment for emergency medical incidents while private companies provide patient transport. Certainly, fire service personnel and vehicles typically are deployed to achieve maximum response availability and optimal geographic coverage. Most fire departments arrive at the scene within 3 to 5 minutes of receiving the call. By relying on the municipality to provide first response, private providers can increase their response times to 10 or even 12 minutes (90% of the time), reduce the number of ambulances required on the street (reduce overhead), and reduce the cost of service(or enhance profit).
To increase profits, private providers may not only increase response time, but also reduce staffing. A reduction in staffing may take the form of changing from a paramedic staffed ambulance to an EMT or EMT-I staffed ambulance in communities where fire department paramedics can be used to ride with the patient to the hospital.
Another example of public departments subsidizing private providers is an agreement that permits private ambulances to be deployed from public fire stations. Private ambulance providers may request the use of stations rent free where they are the selected EMS transport provider. These facilities, paid for by the local taxpayers enhance private company’ profit
8 by reducing the cost to the private provider.
Local officials must be wary of private companies attempting to benefit from any resources funded by the municipality. Any time the term “high performance” is used to describe the EMS system where a private ambulance provider operates, it may indicate that there are enhancements contributed by the municipality. The marginal cost of these enhancements should be evaluated, and this amount should be charged back to the private corporation.
As mentioned, some community leaders may consider a combination of the fire department and a private ambulance company as the most effective system design based on the needs in their community. If this option is explored, fire department officials must become intimately involved in system planning and implementation and the development of a written contractual agreement. The agreement should include provisions that detail the public/private partnership recognizing that partnership means equal work, equal benefit.
9 DEVELOPING PUBLIC/PRIVATE PARTNERSHIPS
Public/private partnerships or cooperatives range from complex contracts awarded after bidding to verbal agreements, establishments, or mutual understandings between top executives of the municipality and the private company. Emergency medical services partnership agreements may include a single EMS system component or a combination of components, as in the following examples:
• Delegation of response roles or tiered response— Fire department responds as BLS first responder with private provider following for ALS response and transport. • Delegation of response and transport roles —Fire department responds as ALS first responder with private provider following for ALS transport. • Delegation of transport roles or tiered transport — Fire department provides all ALS response and transport while private company provides BLS transport and transport between patient care facilities. • Time of day or geographic coverage assistance — Private company provides ALS and transport but enlists fire department assistance during peak call times or in areas of the jurisdiction that are difficult to reach. • Unit hour purchases – During peak call times, disaster situations, or during work slow down or stoppage on the part of the private company employees, private company attempts to purchase labor from the fire department in an effort to maintain appropriate EMS coverage; private company may also subcontract with the fire department on an on-going basis for the purchase of labor or equipment hours. • Mass purchase of vehicles, equipment, or supplies – Fire departments and private ambulance companies may form purchase agreements in an effort to cut cost of buying EMS related items. • Sharing management resources – Fire departments form agreements with private companies to provide joint training or EMS billing services.
10 Before entering into any agreement with a private EMS provider, fire department officials must look critically at the proposal and demand the following:
• A mutually beneficial agreement – Any public/private agreement should yield a “win/win” situation for all parties involved. A partnership should not have the fire department providing resources without receiving something of equal value in return. • Ongoing contract with private company top management – Private EMS companies are notorious for high turn-over rates. Be sure the private representative is credible and enabled to speak on behalf of the company. • Full accounting of the company’s activities in other communities – Some private EMS companies may view a public/private agreement as a doorway to a greater role in the overall system. Fire department officials should be prepared to recognize such hidden agendas based on previous company activity. • A comprehensive and detailed proposal – Fire department officials should examine the details of any public/private partnership proposal, compare them to the private company’s available resources, and be sure the company can deliver what it has proposed. For example, the company should be able to provide an adequate number of personnel and vehicles to consistently meet specified response time requirements.
Fire department officials should consider how the fire department can recover costs that benefit the private provider when negotiating a public private agreement, including the following costs:
• Costs of medical equipment and supplies used on a patient prior to transport – All insurance billing for such items must be done in conjunction with transport. However, fire departments may bill private ambulance companies for such services. • Costs of initial training and continuing education for fire fighter/EMTs and paramedics – These personnel frontload an EMS system and provide rapid response and on-scene care that is not reimbursed while the private company bills and collects revenue from transport. Large private ambulance corporations have made agreements to pay for these services.
11 • Costs associated with providing emergency dispatch and communications —If such services are provided with municipal employees and resources.
An example of such an agreement exist in Rancho Cucamongo, California. The public private partnership is between the Rancho Cucamongo Fire District and MedTrans, a division of Laidlaw (now AMR). Relevant sections of that contract follow.
PUBLIC/PRIVATE FIRST-RESPONDER AGREEMENT
This agreement is made between the RANCHO CUCOMONGA FIRE PROTECTION DISTRICT, hereinafter referred to as “DISTRICT”, the CITY OF RANCHO CUCOMONGA, hereinafter referred to as “CITY”, and MEDTRANS, a subsidiary of Laidlaw Medical Transport, Inc., a Delaware corporation, d.b.a. MERCY, hereinafter referred to as “MERCY”, to assist in the financing and the provision of improved prehospital emergency medical services within the areas served by the DISTRICT.
3. Responsibilities of Parties. a. Responsibilities of MERCY (1)Upon the commencement of DISTRICT’S ALS service, MERCY shall pay to DISTRICT, on or before the fifth day of each month, the sum of $17,500 each month for the first twelve ( 2) months in return for receiving service support from DISTRICT’S ALS First Response System. The monthly payment amount shall be adjusted at the beginning of each subsequent year from the date of commencement of DISTRICT ALS services.
(2) Commencing with the second year of the term of this Agreement, and at the beginning of each subsequent year thereafter, MERCY’s monthly payment to DISTRICT shall be adjusted in accordance with the percentage change in the prior year’s total number of emergency ambulance responses. Calendar year 1994 shall be the base year for purposes of this adjustment. The total monthly payment shall be computed by dividing the prior year’s total number of emergency ambulance responses by the total number of emergency ambulance responses in the base year
12 (1994), then multiplying the resulting quotient by the initial monthly payment ($17,500). The adjusted monthly payment, established by use of the formula set forth above, shall be subject to a further adjustment, commencing with the second year of the term of this Agreement and annually thereafter, based upon the percentage change in the Consumer Price Index, published by the U.S. Department of Labor Bureau of Labor Statistics, for the Los Angeles-Anaheim-Riverside statistical area (1982-84=00) for all urban consumers. The formula for adjusting the monthly payment to be made to DISTRICT, in mathematical terms, shall be as follows:
prior year’s responses Adjusted monthly payment = 1994 responses X $17,500 X % change in CPI
(4) MERCY shall comply with all applicable city, county, state and federal statutes, ordinances, regulations, policies and procedures related to the provision of emergency ambulance service. Billing, collection and reimbursement for services shall be subject to the limits imposed under San Bernardino County rate setting procedures.
(5) Following MERCY’s provision of EMS at the scene of any incident, MERCY shall promptly return DISTRICT personnel to DISTRICT fire stations, by MERCY’s vehicles, taxicab, or otherwise, when DISTRICT personnel have, in the opinion of MERCY’s personnel, been required to accompany MERCY personnel during patient transport. Further, MERCY shall replace any and all disposable medical supplies, including drugs and other medications normally supplied by receiving emergency care facilities, as may be utilized by DISTRICT’s personnel as part of their provision of emergency medical services.
13 PROBLEMS WITH PRIVATIZATION
Local government officials may view privatization of emergency medical services as an easy answer to problems of trimming municipal budgets. The EMS Case Studies in Appendix 1 show that privatization has resulted in decreased levels of service and that public departments typically are more cost effective. In addition to costs and levels of service, local decision makers exploring the option of privatization must consider the following.
• Private companies are able to provide cheaper services only through lower wages and fewer benefits for their employees, a reduction in the services provided, or both lower compensation and decreased service. Private providers must make a minimum profit, while fire departments can return surplus resulting from operations to the system or further reduce the price of services offered to the citizens. • Private companies may seek to develop monopolies or facilitate sole provider areas in certain geographic locations, forcing local governments to rely on a specific contractor even if costs rise or quality of service declines. • Calculations of the initial cost savings to the government typically do not include the costs of agencies that monitor and administer the contracts, nor does it include the costs of those governmental agencies that may provide service subsidies to the private company (as with municipal fire departments providing initial response for private ambulance companies). Private contractors typically bid on pieces of the system focusing only on that cost rather than the cost of the entire system.
• Corporate providers may attempt to influence the mission of government by allowing the profit motive to affect decisions. Therefore, it is profit, not public welfare or need, that receives first priority. If a municipality becomes dependent on a private company to provide EMS, the welfare of the community may be compromised whenever it conflicts with the company’s financial goals. For example, decreases in the number of ambulances provided or a decrease in levels of response personnel training may result. • Local jurisdictions may not be able to rely on private EMS providers on an ongoing basis. The jurisdiction may face continual battles over increasing subsidy requirements. In addition, private labor forces,
14 unlike fire departments, have the legal right to strike, leaving the jurisdiction without EMS services. • A contract with a private EMS provider does not ensure that the provider is solvent, and a firm’s economic hardship could result in temporary or permanent disruption of service.
15 PRIVATE AMBULANCE PROVIDERS: THE CORPORATIONS
In addition to general considerations about privatization, it is useful for fire department officials to know about the various private providers that may be competing against them to provide EMS service. Fire department leaders must be prepared to present comprehensive information to municipal officials who may not realize the full ramifications of privatizing their EMS service. The following information should provide a foundation for more detailed research about specific private EMS companies.
AMERICAN MEDICAL AMR was formed in February 1992 with the objective of becoming the RESPONSE, INC. (AMR) leading national provider of ambulance services. The company went (NYSE: EMT)8-9 public and concurrently merged four regional ambulance providers (two in California, one in Connecticut, and one in Delaware). In 1994, the company signed a $55 million deal with Computer Science Corporation to set up an electronic network for its billing and collection activities.
AMR’s strategy includes:
• Acquire companies to form “beachheads” for future growth • Expand these markets by acquiring smaller “lock-on” providers in areas contiguous to their beachheads and bid on contracts to serve surrounding areas • Eliminate redundancies and unnecessary costs through consolidation and regional integration
• Add ancillary services to extend their involvement in the prehospital market
As of September 1996, AMR had operations in 28 states and responded to 2.6 million calls annually. The company operates a fleet of 2,455
16 vehicles including 1,775 ambulances, 23 critical care units, 436 wheelchair vans, and 221 support vehicles. AMR employs 3,400 paramedics; 3,600 EMTs, 450 van drivers; and 2,850 other employees, including dispatchers and administrators. AMR’s annual revenue is $750 million.
AMR’s Prospectus
AMR’s future growth strategies are to offer managed care organizations and other payers a range of new services which collectively can be described as “medical pathway management.” AMR plans to use technologically advanced call dispatch centers to triage patients to the most appropriate medical pathway, which will reduce costs for the payers. These new services will be offered in three main phases which began in 1996.
Phase I: • Triage patients to all forms of medical transportation • Check insurance eligibility and ensure that patients remain in the health plan networks
Phase II: • Offer health advice by phone, using protocols designated by the payer • Offer recorded health education messages
Phase III: • Use mobile resources to offer urgent medical care in the home • Triage to all forms of medical treatment and schedule appointments
AMR also plans to expand into the management of physician groups and hospital emergency rooms. AMR hopes to be able to thus contract patient care from the prehospital scene through the emergency room up until admission to the hospital. Additionally, AMR plans to pursue large contracts with managed care organizations and various industries to offer on-site services including assessment, treatment of minor injuries, and employee health surveillance.
17 LAIDLAW/MEDTRANS In June 1993, Laidlaw, the Canadian waste and transportation giant, (NYSE: LDW.B)10 made its first acquisition of an ambulance company, MedTrans, in San Diego, California. From that beginning, Laidlaw has acquired more than 40 ambulance companies across the U.S. including CareLine, Inc., the third largest ambulance corporation in the U.S (as of October 1995) with an anticipated net revenue of more than $600 million. The ambulance transportation division of the Laidlaw corporation continues to be called MedTrans.
MedTrans operates in 23 states. The three largest markets are in California, Texas, and Florida. Other markets include Georgia, Alabama, Massachusetts, and Pennsylvania. MedTrans employs more than 10,000 employees, deploys 2,200 ambulances, and provides 2.6 million transports per year. Laidlaw states that continued growth will come from business expansion and further strategic acquisitions. The company plans to aggressively pursue privatization efforts of public EMS systems and expects to continue to win market share through successful competitive bids.
Laidlaw/MedTrans’ Prospectus
MedTrans’ future growth strategies include building alliances with international EMS organizations, and continuing to acquire companies in the U.S. Laidlaw/MedTrans is also pursuing broad coverage contracts with managed care organizations.
SPECIAL NOTE: 11 On Monday, January 6, 1997, Laidlaw announced that it will purchase American Medical Response (AMR) in a $1.12 billion transaction. The new company will have operations in 37 states, keep the American Medical Response name, and will be run by the top three AMR executives. The new AMR will be restructured into 4 geographically based groups - southern, eastern, central, and western. The restructuring will also create two separate operating units - health care transportation and health care services. Annualized revenue is projected in excess of $1.3 billion. 18 RURAL/METRO The Rural/Metro Corporation was founded in 1948 as a subscription fire CORPORATION suppression service. In 1978, the company sold stock to employees who (NASDAQ: now own more than 50% of the company. Rural/Metro promotes the RURL)12 company as the leading provider of ambulance, fire protection, and other safety services to municipal, residential, hospital, commercial, and industrial customers in the United States. Ambulance services account for 78% of the company’s revenue.13-14 Rural/Metro provides ambulance services in Arkansas, Alabama, Arizona, Florida, Georgia, Indiana, Iowa, Kentucky, Louisiana, Nebraska, New York, Ohio, Pennsylvania, South Carolina, Tennessee, and Texas. On February 11, 1997, Rural Metro announced the purchase of 7 ambulance services in Ontario, Canada. This will be the company’s first ambulance service outside the United States and will be known as Rural Metro Ontario.
Rural/Metro’s Prospectus
Rural/Metro’s strategy is to build market strength and create local and regional operations. The company also expects to expand into managed care contracting and assume the role of gatekeeper of 9-1-1. This effort will be facilitated by a recent agreement with National Health Enhancement Systems, Inc. The companies will contract to provide intake and telephone triage as well as transportation.
Rural/Metro was the first private ambulance corporation to gain a statewide non-emergency transport contract with a managed care organization.
19 PRIVATIZATION TACTICS
Private providers aggressively pursue opportunities presented through municipal requests for bids. The following are examples of privatization tactics observed throughout the United States and Canada.
• Private providers tout the attributes of being a large multi-jurisdictional operation. • Private providers promote the use of global positioning satellite (GPS) systems that pinpoint and monitor each ambulance’s location to facilitate the use of system status management. Company executives claim that this system improves vehicle utilization and decreases capital and human resource expenditures. Public officials should recognize that technology is not necessarily an adequate substitute for an effective communications system already in place. • Private company officials claim that the most efficient and least expensive EMS system uses a fire department to provide initial response to all medical emergencies for patient stabilization and initial treatment (since these are public safety issues). Only then does the private ambulance company respond to provide additional patient care transport (providing public health services). • Private company representatives claim the company has significant purchasing power to buy ambulances, defibrillators, and other expensive technological equipment at the lowest possible prices. • Private providers claim that community members are protected by the company’s risk management systems and ability to obtain insurance and bonding.
In addition to those listed above, private EMS corporations may engage in more aggressive efforts to privatize fire-based EMS systems, including the following.
• Bringing lawsuits to challenge the fire department’s right to provide EMS services alleging antitrust violations • Managers or other staff from the company seeking election to city
20 councils or county commissions or otherwise becoming active in local decision making • Forming local Political Action Committees (PAC) funds to support local candidates • Aggressively lobbying municipal leaders, including city council or county commission members • Mounting a public relations campaign that is extremely critical of fire unions (IAFF and its locals) • Making presentations regarding the instability of the revenue derived from EMS transport that instills fear and doubt in community leaders • Issuing unsolicited proposals to local governments for the purpose of obtaining a contract • Bringing in “EMS experts,” including attorneys and accountants to speak before municipal decision makers • Promoting the use of 3-digit numbers other than 9-1-1 for accessing emergency and non-emergency ambulance services • Marketing with state-of-the-art customized video and written materials • Implementing public relations/media campaigns, including newspaper ads, direct mail and billboards, promoting no tax-base funded services, or downgrading the fire department • Proposing public/private cooperation using the fire department to perform first responder ALS services while the private company provides backup ALS and transport services (Companies may offer a sum of money to the municipality to offset the cost of training fire fighters as paramedics, as in San Jose, California) • Filing formal rebuttals to fire department proposals
• Seeking to contract to provide non-emergency or inter-facility transport to gain entry into a community • Providing various community services including CPR classes, standby service at sports events and concerts, and public education for fire and injury prevention to gain name recognition
21 Points that won’t be discussed by a private EMS provider include:
• Specifics regarding response times
• Specifics regarding availability
• Specifics regarding multi-discipline responses (for example, mass casualty)
Regardless of the tactics used, fire service leaders should maintain that decision makers must look at what their community is getting for the price, particularly in equal access to all citizens regardless of ability to pay, response time performance, personnel capabilities, and overall system efficiency. Fire service leaders must help local officials recognize
22 PROPONENTS OF PRIVATIZATION
that no other organization can perform as effectively or efficiently as the fire service. In addition to private EMS companies, several organizations or their representatives may try to become involved in the public debate over privatizing EMS services. Private EMS providers have a trade organization representing their interests – The American Ambulance Association. In addition, there are several private organizations that support efforts to privatize government functions through training and by generating policy statements, position statements, and other materials quoted by privatization advocates. Fire department leaders should review carefully any information from these sources.
THEAMERICAN The American Ambulance Association is the national trade association AMBULANCE A SSOCIATION that represents providers of fee-for-service ground ambulance 15 (AAA) transportation. The association’s membership encompasses all categories of private ambulance providers, including volunteer ambulance corporations, hospital-based ambulance providers, and government- owned and operated services.
The AAA was formed in 1979. Its stated mission is to develop programs that advance the delivery of quality prehospital care services through education, information, and legislative advocacy. Its goals are to promote private ambulance companies and assist in the development of public/ private partnerships to provide medical transportation services.
The American Ambulance Association actively promotes privatization throughout the United States. Specific efforts include the following:
23 • Distributing and promoting the AAA’s manual “Contracting For Emergency Ambulance Services: A Guide to Effective System Design” to municipal leaders throughout the United States • Lobbying state elected officials to pass legislation that would prevent the fire service from providing EMS transport services (Tucker Bill AB 3156, CA) • Maintaining and distributing political action funds to candidates and elected officials sympathetic to their agenda • Pushing federal agencies to ensure ambulance reimbursement protection • Lobbying individual members of Congress and sponsoring programs in which Congressional leaders ride along with on-duty private ambulance providers (Stars-of-Life Program)
OTHER O RGANIZATIONS There are various policy oriented organizations (think tanks) throughout the United States that are avid proponents of the privatization of public Services. Fire service leaders should be aware of local involvement by any of the following.
The Reason Foundation (founded in l978)
The Reason Foundation is the leading national advocate of privatization. The Foundation conducts training, including how-to guides, case studies, and competitive government workshops. The Foundation also conducts policy research and publishes various papers and newsletters. The most recent publication regarding prehospital emergency medical services is titled “Privatizing Emergency Medical Service: How Cities Can Cut Costs and Save Lives” (December l995).
The Goldwater Institute (founded 1988)
The Goldwater Institute was established as an independent, non partisan
24 research and educational organization dedicated to the study of public policy. Through its research papers, editorials and policy briefings, the Institute promotes public policy founded upon the principles of limited government, economic freedom and individual responsibility.
To promote these principles and assist leaders in developing policies based on limited government and a free market approach, the Goldwater Institute conducts research on timely issues, as well as organizes briefings, policy conferences, and workshops. The Institute relies on contributions from the private sector, including individuals, corporations, and foundations. The Goldwater Institute neither seeks nor accepts public funding.
Heading the Institute’s research agenda are several studies: privatizing welfare, indigent healthcare options for states, issues of urban and suburban development, and emergency medical services operations.
American Enterprise Institute (founded 1943)
The American Enterprise Institute promotes free-enterprise. The Institute has several publications that advocate privatization including “Competition and Monopoly in Medical Care.”
The Heritage Foundation (founded l973)
The Heritage Foundation is considered the most powerful conservative think tank in the country. The Foundation concentrates on economic issues and provides information on virtually all areas of privatization.
And other organizations:
– The National Center for Policy Alternatives – The National Council for Public/Private Partnerships – International Privatization Group
25 CONCLUSION
Fire Fighters are the nation’s emergency medical services first responders. Over the last several years, large corporations have moved aggressively into the emergency medical field, drawn by the potential to make large profits from patient transportation. However, the fact remains that no other organization – public or private – is capable of providing prehospital emergency response as efficiently and effectively as fire departments. Considering cost,universal access, response time, survival rates, and quality of patient care, the fire service is the optimal choice for prehospital emergency care services.
IAFF local affiliate leaders that sense a threat of privatization, real or potential, are encouraged to contact their District Vice President, state or provincial presidents, and IAFF headquarters for assistance. Other materials available include:
• Effectiveness of Fire-Based EMS • Emergency Medical Services - A Guide Book For Fire-Based Systems • EMS, The Right Response (Video) • The Myth of Privatization Manual (for community leaders) • EMS Privatization Deterrent Kit for Fire-Based Systems
26 ENDNOTES 1 REVISED M ODEL B USINESS C ORPORATION A CT (1995) 2 M AYS, S., “PRIVATIZATION OF M UNICIPAL S ERVICES: A CONTAGION IN THE B ODY POLITIC,” 1995 DUQUESNE U NIVERSITY, DUQUESNE L AW R EVIEW 3 EISENBERG, M.S., ET AL., “PREDICTING S URVIVAL F ROM O UT-OF-HOSPITAL CARDIAC A RREST: A GRAPHIC M ODEL,” ANNALS OF E MERGENCY M EDICINE; NOVEMBER 1993; PP. 1652-1658. 4 “CONTRACTING FOR E MERGENCY A MBULANCE S ERVICE, A GUIDE TO E FFECTIVE SYSTEM D ESIGN”; AMERICAN A MBULANCE A SSOCIATION. 5 “STAFFING AND E QUIPPING E MERGENCY M EDICAL S ERVICES S YSTEMS: RAPID IDENTIFICATION OF T REATMENT OF A CUTE M YOCARDIAL I NFARCTION,” NATIONAL INSTITUTES OF H EALTH P UBLICATION N O. 93-3304, SEPTEMBER 1993; P. 10. 6 “NATIONAL S URVEY, FIRE D EPARTMENT O PERATIONS IN THE U NITED S TATES AND CANADA”; PHOENIX F IRE D EPARTMENT, 1995. 7 “CONTRACTING FOR E MERGENCY A MBULANCE S ERVICE, A GUIDE TO E FFECTIVE SYSTEM D ESIGN,” AMERICAN A MBULANCE A SSOCIATION. 8 HOOVER’S H ANDBOOK OF E MERGING C OMPANIES, THE R EFERENCE P RESS, INC., 1995; AMERICAN M EDICAL R ESPONSE C OMPANY P ROFILE, SHIRLEY, PAUL T., PRESIDENT & CHIEF E XECUTIVE O FFICER, SEPTEMBER 1996; AMERICAN M EDICAL RESPONSE, 1995 ANNUAL R EPORT. 9 A MERICAN M EDICAL R ESPONSE, FIRST Q UARTER 1996, REPORT TO SHAREHOLDERS. 10 L AIDLAW P RESIDENT’S A DDRESS TO THE G ENERAL M EETING OF S HAREHOLDERS, JANUARY 1996; LAIDLAW’S 1995 ANNUAL R EPORT. 11 “LAIDLAW P URCHASING A MERICAN M EDICAL R ESPONSE,” EMS INSIDER, FEBRUARY 1997. 12 R URAL M ETRO F INANCIAL R EPORT 1995. 13 R URAL M ETRO C ORPORATION, PAINE W EBBER, INC., ET AL., PROSPECTUS, APRIL 15, 1996. 14 R URAL M ETRO A MBULANCE, “EXTRAORDINARY P EOPLE, EXTRAORDINARY C ARE,” SCOTTSDALE, AZ. 15 A MERICAN A MBULANCE A SSOCIATION LETTER TO 1992 CONFERENCE PARTICIPANTS; AMERICAN A MBULANCE A SSOCIATION 1996 STRATEGIC P LAN D RAFT; AMERICAN A MBULANCE A SSOCIATION, “CONTRACTING FOR E MERGENCY A MBULANCE SERVICES: A GUIDE TO E FFECTIVE S YSTEM D ESIGN.”
27 GLOSSARY
Advanced Life Support (ALS) – All basic life support measures, plus invasive medical procedures including intravenous therapy, cardiac defibrillation, administration of medications and solutions, use of adjunctive ventilation devices, and other procedures which may be authorized by state law and performed under medical control. Ambulance – A vehicle designed and operated for transportation off ill and injured persons, equipped and staffed to provide for first aid or life support measures to be applied during transportation. Basic Life Support (BLS) – Generally limited to airway maintenance, ventilation (breathing) support, CPR, hemorrhage control, splinting of fractures, management of spinal injury, protection and transportation of the patient with accepted procedures. Cross-Trained/Dual-Role (CT/DR) – An emergency service that allows personnel trained in emergency situations to perform to the full extent of their training, whether the situation should call for firefighting or medical intervention for a victim. This system type offers a greater level of efficiency than its single-role counterparts. Emergency Medical Services – The provision of services to patients with medical emergencies. Emergency medical services has emerged as a field whose purpose is to reduce the incidence of preventable life- threatening and disabling injuries and acute illness whenever possible, and to minimize the physical and emotional impact of injuries and illnesses which do occur. The EMS field derives its origins and body of scientific knowledge from the related fields of medicine, public health, health care systems administration, and public safety.
EMS System – A comprehensive, coordinated arrangement of resources and functions which are organized to respond in a timely, staged manner to targeted medical emergencies, regardless of their cause and the patient’s ability to pay, and to minimize their physical and emotional impact.
28 APPENDIX 1.
PRIVATIZATION OF EMERGENCY MEDICAL SERVICES: CASE STUDIES
There are a number of communities that have moved from privatized EMS systems to a public sector system. Reasons for changing from private providers have included poor service from the private provider and desire to retain revenue associated with EMS transport for the municipality. Specific examples are given below.
Case 1: San Jose, CA (Public/Private Partnership)
Emergency medical services in San Jose, California are provided through a public/private EMS partnership. Prior to 1995, the EMS system in San Jose consisted of the San Jose Fire Department providing first responder services, including defibrillation, while advanced life support (ALS) and ambulance transportation was provided by a private ambulance service. The private contractor maintained 11 ambulances staffed with 2 paramedics for ALS response. These units typically responded within 10 minutes. For this level of response and patient transportation, the private contractor charged an average of $627 per transport, for a total gross revenue of approximately $8.8 million. Because the private ambulance provider's response times were greater than the medically accepted standard of 8 minutes, the likelihood that a patient would survive an out-of-hospital cardiac arrest was only 7.2%.
The San Jose Fire Department, in an effort to improve the overall EMS system and enhance patient survival following cardiac arrest, submitted a proposal for a fire-based EMS system, inclusive of transport. The fire department's proposal included the deployment of 30 ALS engine companies and 14 ambulances. Fire fighters would respond in 7 minutes or less, 90% of the time. The reduction in the response time interval for ALS alone would increase the predicted cardiac arrest survival rate to 17.7%.
Recognizing that the Fire Department had presented a viable system design, the private contractor became concerned. This concern led to the development of a plan for a public/private partnership. The cooperative plan required the fire department to deploy the 30 ALS engine companies and provide first response in 7 minutes or less, 90% of the time. For this system enhancement (called "front loading the ALS"), the private corporation was willing to pay $1.1 million to the City to cover the cost of sending fire fighters through paramedic training. Since the City of San Jose had not, until that time, received any revenue associated with EMS provision, the offer appeared lucrative and was accepted.
— 1 — The public/private partnership in San Jose now deploys 30 ALS engines staffed with 3 fire fighters and 1 fire fighter/paramedic, and 11 private ALS transports staffed with 1 EMT and 1 paramedic. Since the fire department provides the initial response with a paramedic, the predicted cardiac arrest survival rate is equivalent to that of a full fire-based system including transport.
On the surface, it appears that through this public/private partnership the private provider is making a payment to the City for the first responder service subsidy and recording this as a cost on their balance sheet. However, a closer analysis reveals that the cost of this payment to the City was offset through other service reductions. The net economic impact to the City is zero, while this arrangement enhances the private corporation's profits. The City provides additional personnel; and the private provider negotiated an increase in the response time interval required for ambulances to arrive on scene and a decrease in ambulance staffing. Response time requirements were increased from 10 to 12 minutes, 90% of the time. The staffing on the ambulances was reduced from 2 paramedics to 1 EMT and 1 paramedic. As part of the package, the private provider was granted a four year extension of the contract with Santa Clara County (including San Jose), California. The contract, including a public/private alliance with the San Jose Fire Department, should provide approximately $25 million annually to the private corporation.1
Case 2: Big Spring, Texas
The emergency medical services system in Big Spring, Texas began to evolve in July 1989. The City's Ambulance Advisory Committee held a meeting at which Rural/Metro Corporation, the provider of EMS at the time, claimed an anticipated loss of revenue for 1990. Rural/Metro executives requested an additional $57,000 from the City to cover this anticipated loss. In the same meeting Rural/Metro executives also requested a 25% increase in the City's cash subsidy and indicated that the fee for service would increase $30-$40 per patient transported. During this committee meeting, Rural/Metro reported their average response time for EMS calls was 6.2 minutes.
Following this meeting, Rural/Metro was granted a contract extension of 5 years (1990 - 1995) to continue to provide EMS and ambulance transport in Big Spring. Contract requirements included the number of ambulances to be operated in the City, staffing levels, guarantee of response times, monthly operations reports, and the providing EMS continuing education for the Big Spring Fire Department personnel.
1 American Medical Response, 1995 Annual Report, p. 2.
— 2 — In 1994, members of the Big Spring Fire Department assessed Rural/Metro's compliance with the contract requirements. Preliminary research showed several areas of non-compliance:
• Rural/Metro was not regularly providing monthly operations reports
• Rural/Metro was not making EMS continuing education available to the Big Spring Fire Department
• Rural/Metro was not staffing two ALS and two BLS vehicles in Big Spring; Only one ALS truck was staffed full-time; and the others were operated as needed by on call personnel
• Rural/Metro did not provide an ambulance vehicle housed within the Big Spring Fire Department facilities as a BLS back-up
• Rural/Metro frequently reported average response times of 6.0 minutes – well above the standard established in the contract
The City of Big Spring then released a request for proposal (RFP) for emergency medical services. Motivated by a desire to improve the prehospital EMS system for Big Spring residents, the local fire department submitted a proposal. The RFP required: four vehicles available in the City (two ALS/two BLS) 24 hours a day; on-call personnel could be used for non-emergency transfers only; and response times between 3.5 and 5 minutes.
The fire department proposed to more than double the number of ambulances provided at the time. Ambulances would be stationed and deployed from Big Spring fire stations. The proposal also included the cross training of fire fighters as paramedics for more efficient use of personnel. The fire department's proposal offered increased service, a reduction in response times, and a lower cost than the City paid to Rural/Metro as a subsidy.
Rural/Metro responded to the fire department's bid by portraying the proposal and the fire fighter's ability to provide EMS as inadequate. Corporate representatives distributed fliers to City Council members falsely charging that fire-based EMS would drive up costs, reduce service, and expose the City to great financial risks. The Fire Department and IAFF Local 2922 prepared and presented a formal rebuttal to these claims.
— 3 — On March 28, 1995, the City Council voted 6 to 1 to accept the fire fighters' bid and awarded them the EMS contract for the City of Big Spring. In June 1995, the Big Spring Fire Department was approached by Howard County to provide EMS in the balance of the county. Shortly thereafter, the Big Spring Fire Department was awarded the Howard County contract.
The first monthly report was released by the Big Spring Fire Department in November 1995 showing improvement in response times compared to the private provider's times. The Fire Department's response time in the City was 4.01 minutes, less than the State's 4.24 minute average. On-scene times were 14.57 minutes, also less than the State's average, 18.1 minutes.
On the first anniversary of the fire-based system, City officials stated they were pleased with the performance of the Fire Department, reporting that response times were on target with the American Heart Association (AHA) guidelines for prehospital cardiac care. The Fire Department has made several improvements following the first year of operation. For example, the fee structure was amended to make the service more affordable. The City also established an enterprise account for the fire department ambulance service, allowing the service to act as an independent revenue generating entity. This means that the service will be able to pay for needed equipment without drawing from the City's general fund. In fact, the total operating revenue reported at the end of September 1996 was more than $730,000.
Through careful planning and implementation of the Big Spring Fire Department's EMS plan, the citizens now enjoy improved response times, increased efficiency, and better continuity of care, provided by a cost-effective municipal transport system.
Case 3: Deerfield Beach, Florida 2
In 1992, the City Manager of Deerfield Beach, Florida was faced with the prospect of cutting essential services or increasing taxes and he invited the department heads to submit methods of increasing revenue. The Fire Chief then met with his administrative staff. This group reaffirmed that the department had a long history of revenue generation, yet there was one area that had not been explored as a significant source of revenue — ambulance transport.
At the time, the Deerfield Beach Fire Rescue (DBFR) Department was one component of a two-tiered EMS system. Two Fire Department paramedics would respond in a transport capable ambulance and
2 Stravino, A., "The Hostile Takeover of Transport Territory," Fire Chief, May 1994, pp. 70-77.
— 4 — initiate patient care. Then, a private ambulance would arrive to provide patient transport. The Fire Department's average response time was 3 to 4 minutes. The response times for the private ambulance averaged 9 to 11 minutes. If advanced life support (ALS) was necessary, ALS would start upon the arrival of fire department paramedics, and continue throughout transport with a fire department paramedic and fire department equipment remaining with the patient in the private provider's vehicle. The Fire Department ambulance would follow the private ambulance to the hospital to pick up the fire fighter/paramedic and fire department equipment. The Fire Department provided all medical supplies and equipment and administered all patient care, while the private ambulance company transported and billed the patient and collected the revenue for the service.
The Fire Chief began to explore revenue sources for Deerfield Beach from ambulance transport. He planned a study to determine the feasibility of converting the private ambulance system to a fire-based EMS system that included transport. There was strong labor/management support for the initiative and all Fire Department staff participated in the study. After a three month in-depth study, the Fire Chief recommended a one-tier fire-based system to the City Manager. The study revealed that patient care and the level of service would both improve if Fire Department paramedics were able to provide continuity of care throughout transport. Cost recovery issues were also considered. Revenue projections showed that DBFR could expect to collect 60% of the total amount billed. The Fire Chief recommended a six-month trial implementation of the one-tiered patient transport system to show that the fire department's predictions were accurate.
During the trial period, a large scale public education program was implemented to help the citizens of Deerfield Beach understand the proposed change in the operation of the EMS system. As a result, there was widespread community support for the fire department. The final decision, at this point, was to come from the City Commissioners.
Just prior to the City Commissioners' final vote, the private ambulance company launched an aggressive effort to defeat the proposed system change. The company offered to provide EMS transport service at no cost to the City (a zero subsidy agreement). The offer had little effect on the commissioners. Recognizing this, the private company then offered to pay the City $500,000 to retain the full EMS contract, adding that the City could save another $500,000 by laying off the fire fighters who work as paramedics. The commissioners were offended by these maneuvers. In fact, one commissioner, who had not been a strong supporter of DBFR, asked the private company representative if the company really suggested a layoff of 24 fire fighters. The answer was yes. The Commissioner then asked if the private provider employees could strike. Again, the answer was yes. The Commissioner then advised the private company representative that public employees could not strike nor had there ever been a
— 5 — service delivery problem or complaint concerning city employees. The commissioners dismissed the private provider's proposals.
The DBFR trial period was set to begin in October 1992; however, Hurricane Andrew hastened the trial's start. On August 23, 1992 Andrew hit South Florida. At 4 a.m., the private provider notified the fire department communication center that it would no longer accept ambulance calls because the storm's winds were so strong. Shortly thereafter, the communication center received a call for a patient with difficulty breathing. The Fire Department responded, provided care, and transported the patient who had severe pulmonary edema, saving the patient's life. By the next day, the DBFR Department had transported four patients to the hospital and continues to provide transport to this day.
— 6 —
Fire Service-Based EMS 2007
Authors and Contributors
Franklin D. Pratt, M.D., FACEP
Medical Director Los Angeles County Fire Department
Medical Director Emergency Department Torrance Memorial Medical Center Torrance, CA 90505
Assistant Clinical Professor Geffen School of Medicine UCLA
Steven Katz, M.D., FACEP, EMT-P
Associate Medical Director Palm Beach County Fire Rescue West Palm Beach, FL
President National Paramedic Institute Boynton Beach, FL
Chairman Department of Emergency Medicine Memorial Hospital West Pembroke Pines, FL
Paul E. Pepe, MD, MPH
Professor of Medicine, Surgery, Public Health and Chair, Emergency Medicine University of Texas Southwestern Medical Center and the Parkland Health and Hospital System
Director, City of Dallas Medical Emergency Services for Public Health, Public Safety and Homeland Security
2 Fire Service-Based EMS 2007
PREHOSPITAL 9-1-1 EMERGENCY MEDICAL RESPONSE:
THE ROLE OF THE UNITED STATES FIRE SERVICE IN
DELIVERY AND COORDINATION
ABSTRACT Prehospital 9-1-1 emergency response is one of the essential public safety functions provided by the United States fire service in support of community health, security and prosperity. Fire service-based emergency medical services (EMS) systems are strategically positioned to deliver time critical response and effective patient care. Fire service-based EMS provides this pivotal public safety service while also emphasizing responder safety, competent and compassionate workers, and cost-effective operations. As the federal, state, and local governments consider their strategic plans for an ‘all hazards’ emergency response system, EMS should be included in those considerations and decision makers should recognize that the U.S. fire service is the most ideal prehospital 9-1-1 emergency response agency.
INTRODUCTION TO FIRE SERVICE-BASED EMS
EMS is an essential component of the public services provided in the United States. The Federal EMS Act of 1973 defined an EMS system as “an entity that provides for the arrangement of personnel, facilities, and equipment for the effective and coordinated delivery of health care services under emergency conditions in an appropriate geographic area” (EMS Act 1973, (P.L. 93-154)). Much of the dialogue in the public arena today concerning prehospital 9-1-1 emergency medical care often focuses on ambulance services and, accordingly, may ignore the important distinction between prehospital 9-1- 1 emergency medical response and the other key uses of the ambulance-based, out-of- hospital providers for non-emergency medical and transportation services.
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The primary purpose of this discussion is to underscore the reality today that the fire service has become the first-line medical responder for critical illness and injury in virtually every community in America. Regardless of whatever agency provides medical transportation services, the fire service is the agency that first delivers on-scene health care services under most true emergency conditions. Therefore, prehospital 9-1-1 emergency response, in support of community health, security and prosperity, is not only a key function of each community; it has become, almost universally, a principal duty of the fire service as well. In addition, fire service-based EMS systems are strategically positioned to deliver time critical response and effective patient care rapidly. Furthermore, the fire service-based EMS accomplishes this rapid first response while emphasizing responder safety, sending competent and compassionate workers, and delivering cost-effective operations.
Although the role of the fire service is central in 9-1-1 emergency medical response, financial, political, cultural and organizational factors often can make the conversation about prehospital care providers confusing and complex for many decision makers in local communities. The goal of this discussion is to resolve and demonstrate that the use of fire service equipment and personnel to provide 9-1-1 emergency response is the best approach for a community regardless of size. This basic premise is consistent with recent Institute of Medicine publications that have placed EMS at the intersection of public safety, public health, and medical care. The U.S. Fire Service is uniquely qualified to be at that intersection and in the following pages, the history, evolution, and current medical capabilities of the fire service will be reviewed.
The Maltese Cross and Its Legacy for Fire-Service Based EMS During the Middle Ages, the Knights of Malta, the forerunners of the fire service, took care of travelers and specifically burn victims from the Crusades and associated battles. Eventually, the Knights of Malta adopted the Maltese Cross as their emblem and it has created a revered legacy for fire departments.
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The Knights originally began their work as the creators, administrators and care givers in a hospital in Jerusalem. As such, they were known as the Hospitallers of Jerusalem, starting their work before the year 1000 AD. For the next two hundred years, they helped the sick and poor and they set up hospitals and hospices across Europe.
Eventually, the Hospitallers became firefighters out of necessity. The conflict of the Crusades often threatened the hospitals that they had founded. So, they adapted and even engaged in battle to protect their hospitals. As a result, they also became firefighters because one of the weapons of war at that time was the glass fire bomb. The fire bomb, thrown by the enemy, created a horrendous inferno. After rescuing a fellow knight from the inferno and extinguishing the fire, a Hospitaller was awarded a medal, shaped like a Maltese Cross to honor those actions.
As conflict continued, the Hospitallers needed an identifying mark for their armor. This was necessary because without identifying markings, it was difficult to tell who was who because everyone was wearing similar armor in battle. They adopted the Maltese Cross as their identifying mark. (Maltese Cross, 2007, Foster, 2007)
In essence, more than 1200 years ago, some of the earliest ancestors of the fire service were “all-hazards responders.” They initially started as caregivers for the sick and then became firefighters to protect their own. These are two of the concepts firefighters still believe in today and hold as their most sacred responsibilities—caring for the sick and caring for their own.
Longstanding History of Fire Service-Based Medical Care in the U.S. The fire service has formally been part of the 9-1-1 emergency care delivery system since EMS began in the late 1960’s. Many of the original prehospital EMS providers were firefighters, who had “special” additional training in providing medical services during emergencies that occurred outside the hospital. Today, essentially every firefighter receives emergency medical training and the fire service provides the majority of medical services during emergencies that occur out of the hospital, just as it has done for the past
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four decades. Of the 200 largest cities in the United States, 97% have fire service-based prehospital 9-1-1 emergency medical response (JEMS 200-City Survey, 2006) and the fire service provides advanced life support (ALS) response and care in 90% of the 30 most populated U.S. jurisdictions (cities and counties) (IAFF/IAFC Fire Operations Survey, 2005).
Although the origin of the modern relationship between emergency medicine and fire departments is cited as the 1960’s, the involvement of the fire service in patient care began much earlier. For example, in 1937 a fire department ambulance in New York transported famous song writer Cole Porter to the hospital after a horseback riding accident.
While the fire service was involved in many famous anecdotal events, other accounts demonstrate its profound effect on public safety and patient care procedures. In 1921 Claude Beck, M.D., a surgeon at Western Reserve University in Cleveland, called the fire department so he could apply a “pulmotor,” an artificial breathing apparatus, to attempt resuscitation in a patient who died unexpectedly during surgery (Beck, 1941). Dr. Beck continued to be involved in resuscitation and today is recognized as one of the founders of the science of resuscitation.
The following quote from the Journal of the American Medical Association in 1928 summarized the evolving relationship between fire department-based out-of-hospital emergency care and subsequent resuscitation in the hospital. “…inhalators are introduced: Cases of gas asphyxiation occur; the rescue crew of the fire department is called and resuscitates the patient. A physician sees the resuscitation and is impressed by the effectiveness of the treatment. Some time thereafter he finds himself confronted with a child which he has delivered, and which has come through a prolonged labor. It refuses to breath effectively, in spite of the application of all the ancient practices. The respiratory center has been depressed by the diminished blood supply to the brain resulting from compression of the head, and needs more than the
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normal amount of carbon dioxide to stimulate breathing. So the physician calls in the fire department. If, as is often the case, the fire department succeeds where his medical skill and knowledge have failed, he calls for it again the next time. Now the hospitals in some cities are adopting the practice of calling for the inhalator whenever they have a baby who breathes poorly. In effect, they add the rescue crew of the fire department to their board of consultants, and these new consultants thus contribute another service to the community over and above that for which the fire department is primarily organized. Obviously, it is the hospitals that should be equipped to treat asphyxia -- asphyxia of every form -- and thus to help firemen overcome by smoke and gas, instead of relying on the fire department to help the hospital in such a matter as asphyxia of the newborn.” (Henderson, JAMA 1928. note: italics added).
According to a historical account on the City’s website, in 1947 in the city of Virginia, Minnesota, “the Fire Department took full possession of the ambulance along with a Pulmotor Resuscitator … This would be the first time that ambulance personnel would be properly trained in first aid, and resuscitation procedures of that time” (City of Virginia, MN, 2007).
Such widespread anecdotes not only indicate longstanding involvement of the fire service in medical care, but it demonstrates the often-quoted mission of the fire service established in the 19th Century, “To Protect and Save Lives and Property.” Clearly, protecting and saving lives is the first and foremost mission for these dedicated first responders.
Growth and Specialization of Fire Service-Based EMS As illustrated by its history, the fire service has continuously adapted and changed to meet the current needs of a community. As EMS developed, the fire service was integrally involved. In the early stages, firefighters were chosen by expert physicians to take on the role of paramedic. This era of EMS in the fire service is represented well by
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looking at the City of Miami Fire Rescue Department nearly half a century ago. The age- old firefighter mantra to “protect and save lives and property” is well-illustrated within the history books of the City of Miami Fire Rescue and serves as an important example of Fire Rescue today in the United States. Miami was the first city to call itself a “Fire Rescue” department. Miami Fire Rescue was also revolutionary in using the advancements of technology in 2-way radios to bridge physicians in the hospital with firefighter-paramedics in the prehospital setting.
In fact, the Rescue Division of Miami Fire Rescue was established in 1939 in order to give first aid to firefighters. Rescue One, the department’s first rescue truck used to treat citizens, came on-line in 1941. In these early days, “Rescue” services were limited to basic first aid with transportation usually performed by funeral homes.
In 1964, Dr. Eugene Nagel, started to teach first aid and basic cardiopulmonary resuscitation (CPR) to the firefighters of Miami Fire Rescue. Dr. Nagel’s goal was to improve out-of-hospital cardiac arrest survival in the community by using lessons learned from the “quick response” system in the hospitals and apply it to the prehospital setting. Dr. Nagel still reflects, “We chose firefighters because they were there, they were available, they were willing, and they were motivated. It was really quite simple” (Nagel interview, February 2007). According to Dr. Nagel, “The fire service is dispersed throughout America and is everywhere in our country. It is an efficient method for offering emergency care rather than creating a completely separate service with separate communications, vehicles, housing, and personnel. It worked well in Miami in the 1960’s and continues to work well when integrated into the fire service. It is a natural fit” (Nagel interview, February 2007). Firefighters in Miami clearly demonstrated in the pioneer days of EMS that firefighters are ideal candidates and willing dispensers of high-quality EMS. In Miami, this started with basic first aid, and progressed to CPR, intravenous therapy, electrocardiographs, telemetry, and advanced airway intervention. During this same time period, similar efforts were underway using firefighters in the cities such as Baltimore, Columbus, Seattle, and Los Angeles. Providing firefighters training in lifesaving techniques and procedures has allowed them to deliver advances in medicine to
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the prehospital 9-1-1 emergency care patient in a cost-effective and time-sensitive manner. Just as fire departments have evolved since the 1960’s to provide prehospital emergency medical care, government oversight must evolve to cohesively organize, coordinate, and supervise the integrated delivery of emergency medical care from the scene to the hospital and even the rehabilitation and recovery phase. A critical link in that chain of survival and recovery is the rapid on-scene response of the Fire service, a service that cannot be underestimated and truly emphasized in planning, funding, support, research, and quality assurance.
The protection of life and property has been the mission of the fire service for over 200 years, but the fire department of the 21st century is evolving into a multidisciplinary public safety department. It not only handles most aspects of public safety (beyond law enforcement security issues), but it also will continue to provide advances in emergency medical care and many developing public health needs such as preparations for pandemics, disasters, and weapons of mass effect.
Today, the community-based fire station, with its ready availability of personnel 24 hours a day, coupled with the unique nature of medicine outside of the hospital, creates a symbiotic blend of the traditional public concepts and duties of the fire service with the potential for the most rapid delivery of advanced prehospital 9-1-1 emergency response and care. Traditionally, fire stations are strategically placed across geographic regions, typically commensurate with population densities and workload needs. This creates an all-hazard response infrastructure meeting the routine and catastrophic emergency needs of all communities regardless of the nature of the emergency. Accordingly, the fire service helps ensure the prosperity and security of all communities and providing prehospital 9-1-1 emergency medical care is consistent with its legacy going back 1200 years.
Types of Fire Service-Based EMS Systems The fire service can be configured many ways to deliver prehospital 9-1-1 emergency medical care such as the following general configurations:
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Fire service-based system using cross-trained/multi-role
firefighters. Firefighters are all-hazards responders, prepared to handle any situation that may arise at a scene including patient care and transport.
Fire service-based system using employees who are not cross- trained as fire suppression personnel. Single role EMS-trained responders accompanying firefighter first-responders on 9-1-1 emergency medical calls.
Combined system using the fire department for emergency response and a private or “third service” (police, fire, EMS) provider for transportation support. Single role emergency medical technicians and paramedics accompany firefighter first responders to emergency scenes to provide patient transport in a private or third service ambulance.
While there are pros and cons to the various system approaches, the emergency medicine (EM) literature indicates that the most likely time to create error in medical care is when care is transferred from one provider to another in a relatively short encounter time. Such circumstances require that the fire service regularly exercise the leadership needed to ensure that integration of the parts of the prehospital emergency care system are coordinated well, with maximum benefit to the patient and minimum risk to the community. For example, in the fire service-based EMS model in which the fire department provides extrication, triage and treatment services, and a separate private provider transports the patients, appropriate quality assurance measures must be in place. This quality assurance is most effective when the fire department, as the public agency, administers and monitors the performance requirements on-scene and within the transportation agreement.
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National Incident Management System The U.S. Fire Service-based emergency response and medical care system is the most effective, coordinated system worldwide. The National Incident Management System (NIMS) and other nationally-defined coordination plans ensure that fire service-based 9- 1-1 emergency response and medical care always provides skilled medical services to the patient regardless of the circumstances surrounding the location and condition of the patient. In addition, the fire service has the day-to-day experience and ability to work smoothly with other participants in the prehospital 9-1-1 emergency medical care arena: private ambulance companies, law enforcement agencies, health departments, public works departments, the American Red Cross and other government and non-government agencies involved in medical care, disaster response and patient services. This type of universal coordination takes leadership, work, and the willingness to subordinate fire service prerogatives to those of the greater public need. The fire service is the creator of the unified command concept that brings everyone to the table, at the same time. Using the National Incident Management System, the fire service has superior ability to coordinate incidents of any size. As a result, it provides the best return on investment of public dollars to provide the delivery of prehospital 9-1-1 emergency medical service.
Emergency 9-1-1 Response is Different from Non-emergency and In- hospital Care For government decision makers who do not work in the public safety environment on a day-to-day basis, it may be difficult to appreciate the differences between emergency response and ambulance transport. Unless one actually has used the EMS system in a medical emergency, he or she might be likely to define a call to 9-1-1 in a medical emergency as ‘needing an ambulance.’ However, with the recent advances in resuscitative medical care, particularly in cardiac emergencies, we now know that what occurs in the first few minutes after onset of the medical emergency will change the long term outcome. In many of these critical circumstances, what happens on-scene determines whether the patient lives or dies. Therefore, rapid, efficient and effective delivery of emergency response and care is dependent on immediately sending nearby
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trained personnel to the scene of an emergency regardless of the vehicle or mode of transportation.
Ambulances, of course, are necessary to transport patients to a hospital where more definitive care may be needed. However, because ambulances are often busy evacuating, transporting and turning over patients at the hospital, the most reliable vehicle to ensure a rapid response generally is the neighborhood fire truck. It should be realized that the first emergency care provider who is responsible for competent care may arrive on a fire truck separate from an ambulance. This is the case in most communities in America.
There are sub-specialties of ambulance service in the out-of-hospital arena that must not be confused with 9-1-1 emergency response. For example, ambulance services are often employed for interfacility transfers for specialty care or the need to transfer patients from one hospital to another can provide a higher level of required care. These transfers may include critical care transfers between hospitals, but more often they may also be non- emergent interfacility transports or day transport for persons with home-delivered chronic care services. Such services typically are not performed by fire departments as a fundamental public policy device to better ensure dedicated 9-1-1 emergency services and thus provide security and prosperity for the community served.
Multi-Role Firefighters: Patient Safety from Multiple Perspectives To further emphasize that the prehospital 9-1-1 emergency care patient should be considered a separate and distinct type of patient in the continuum of health care, consider the setting and the circumstances of emergency medical care delivery. These patients not only have medical needs, but they also need simultaneous physical rescue, protection from the elements and the creation of a safe physical environment as well as management of non-medical surrounding sociologic concerns. The fire service is uniquely equipped to simultaneously address all of these needs.
The mission of the fire service is to protect and save lives and property. There are no other conflicting agendas. The fire service-based prehospital, 9-1-1 emergency response
12 Fire Service-Based EMS 2007 medical care system is designed to be part of society’s safety net. Fire and prehospital 9- 1-1 emergency response medical care are intimately intertwined. Separating them from the EMS focus only serves to polarize our country’s already fragmented emergency response system.
All out-of-hospital emergency care and ambulance transport professionals are taught that scene safety is the primary objective at every emergency scene. However, many of today’s non-fire service-based EMS professionals do not have the additional resources and often do not have the training to effectively secure a scene. When there is a strict medical orientation in their professional training and practice, adequate preparation to appropriately and safely provide emergency medical care to an emergency patient may be compromised. Scene safety issues are often not apparent until a crew is on-scene to assess the incident.
Decision makers should consider, ‘What does a non-fire based EMS crew do on the scene of a motor vehicle accident when the car is engulfed in flames and occupants are trapped inside, and fire crews were not dispatched?’ In many cases, a non-fire service-based EMS provider would need to request dispatch of a fire company after the initial scene size-up, further delaying care, and further increasing risk to rescuers and victims. Streamlining this approach into the fire service-based prehospital 9-1-1 emergency medical care system is quite arguably more effective from the perspective of scene safety, short response time, integrated rescue and treatment, and then transport to a medical facility. Regardless, the firefighter response is a key element of patient safety, both medically and environmentally.
In the era of homeland security threats and the spiraling growth of the commercial transport industry, the threat of hazardous materials (Haz-Mat) is center-stage. Again, fire service Haz-Mat teams are the front-line of protection and rapid delivery of medical care can be pre-empted by such chem-bio threats, but where rapid care can be given, it can be expedited directly by cross-trained fire-service Haz-Mat care providers.
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Fire Service-Based EMS as the Health Care System Safety Net Prehospital 9-1-1 emergency patient medical care is a major part of the safety net for the American healthcare system. They may be the provider of last resort for the needy, yet they can be one more mechanism for overloading the health care system. Nevertheless, to its credit, the fire service-based, prehospital 9-1-1 emergency patient medical care provides unconditional service to all members of our population. Therefore, the fire service must now become an integral part of the public health system and work closely with medical and public health experts to help alleviate unnecessary burdens on already overburdened hospital, medical and public health systems. Already part of local government, the fire service may be best positioned to sit at the table and help provide important data to facilitate creating solutions to pressing health care public policy issues.
Above all, rapid response times are a pivotal advantage of fire service-based, prehospital 9-1-1 emergency EMS systems. Now equipped with automated defibrillators to reverse sudden cardiac arrest, the fire truck, coupled with bystander CPR, has become one of the greatest life-saving tools in medical history. With stroke centers to treat stroke within the golden 3 hour window, cardiac catheterization centers to treat heart attack in the 90 minute door-to-balloon time, and trauma centers to treat hemorrhaging patients, time efficiency is a key component of the best designed EMS systems. The service most capable of rapid multi-faceted response, rapid identification and triage to the appropriate facility is a fire service-based EMS system.
EMS is Not an Ambulance Ride One of the central themes of this discussion is concern over the common misconception that EMS begins with the transport of a patient in an ambulance to a hospital. This misunderstanding resulted essentially in funding of transport service providers but not providers of emergency medical care rendered at the scene. This funding aberrancy occurred in the 1960s as Medicare provided reimbursement for transportation of trauma patients to the hospital, long before the contemporary EMS system developed. About the same time, fire service delivery of 9-1-1 emergency medical care was becoming part of the fabric of the fire service. It was managed and funded as an integral component of
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public safety service provided by a fire department. Thus, it was funded solely as part of the fire department budget.
Payment for transportation does not fairly portray the full picture of 9-1-1 emergency response and medical care. As the need to pay for EMS was realized, federal dollars for “emergency medical services” went to the perceived greatest area of need at that time, the need for transportation. These federal dollars even provided payment of non-emergency ambulance transport for the care of chronic medical problems. Even though much of the life-saving effect of EMS in today’s circumstances will play out routinely on the scene long before ambulance arrival, the focus on transport and not medical care delivery remains. This distinction has been lost and, to this date, never totally reconciled. Especially considering the resource impact, educating the public and government officials about this distinction within the EMS system in the U.S. is a critical and timely issue in the era of homeland security and Haz-Mat threats.
Funding for Prehospital EMS The fire service supports the recent Institute of Medicine recommendations for ensuring federal payment for emergency medical care not associated with transport. Although not labeled specifically for EMS activities, grant funds are received by fire departments and emergency management agencies to enhance EMS response capabilities throughout the United States. It is deceptive to imply that only funds awarded to single function EMS delivery agencies are the only dollars benefiting those receiving prehospital 9-1-1 emergency medical care services.
For example, Assistance to Firefighter Grants (AFG) are essential to ensuring that fire departments have the baseline response capability that prepares them to respond not only to local incidents but also to effectively participate in broader, national responses. Fire department ‘response’ is considered ‘all-hazards’, inclusive of emergency, prehospital 9- 1-1 medical care services. The program is extraordinarily cost-effective, with low administrative overhead and direct payments to local fire departments. As almost all fire departments provide EMS at some level, AFG dollars support equipment purchases,
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training efforts as well as public safety education and injury prevention efforts. In fiscal year 2006 (FY 2006), 4,726 grants were awarded to fire departments throughout the United States totaling $461,092,358.
Another example of federal funding of local emergency response systems is the Staffing for Adequate Fire and Emergency Response (SAFER) Grants. The single most important obligation the federal government should fulfill to enhance local preparedness and protect Americans against all-hazards—natural and man-made—is to assure that every fire department in the nation has sufficient numbers of adequately trained and equipped fire fighter/ EMS responders. In FY 2006, there were 242 SAFER awards totaling $96,151,433 provided to fire departments throughout the United States.
Both AFG and SAFER grants present the federal government with its best opportunity to assure a strong, emergency response component in every community in America.
Federal Oversight and Administration of EMS EMS has many voices at the federal level including the Department of Health and Human Services, Department of Transportation, Department of Justice, and Department of Homeland Security. Each voice advocates for specific entities that provide EMS as part of its services. Congress appropriately has empowered all EMS-related agencies under the Federal Interagency Committee on Emergency Medical Services (FICEMS). Recently, the FICEMS has been strengthened and provides the mechanism to accomplish this “coordination of the voices.” The leadership challenge is to bring all of the voices together. The FICEMS can do this, if given a chance and a mandate.
Conclusion In terms of the rapid delivery of emergency medical care in the out-of-hospital environment, fire departments have the advantage of having a free-standing army ready to respond anytime and anywhere. Prehospital, 9-1-1 emergency response in support of community prosperity and security is one of the essential public safety functions provided by the United States fire service. Fire service-based EMS systems are strategically
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positioned to deliver time critical response and effective patient care and scene safety. Fire service-based EMS accomplishes this while emphasizing responder and patient safety, providing competent and compassionate workers, and delivering cost-effective operations.
References Beck CS. Resuscitation for cardiac standstill and ventricular fibrillation occurring during operation. Am J Surg 53 (4):273-279, 1941.
City of Virginia, Minnesota, VFD History, Emergency Medical Services History, http://www.virginiamn.us/VFD%20History.htm , April 2007
Emergency Medical Services Systems Act of 1973. (P.L. 93-154). 93rd Congress S 2410.
Eugene Nagel, Personal Interview, February 2007
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