mandatory forms (2) to be submitted with proposals ...fire-based star cars 6 6 amr field supervisor...

REQUEST FOR PROPOSAL CONTRA COSTA COUNTY EMS AGENCY

Mandatory Forms (2) To Be Submitted with Proposals - Appendix 5

Face Sheet - FORM A

PROPOSAL TO PROVIDE EMERGENCY AMBULANCE SERVICES TO

CONTRA COSTA COUNTY 2004

***THIS FORM MUST APPEAR AS THE FIRST PAGE OF THE PROPOSAL*** This is a proposal to contract with Contra Costa County to provide primary emergency ambulance service to persons requesting said services through the County or a County-designated emergency dispatch center. NAME OF BIDDER: _____American Medical Response West___________________________ dba _____American Medical Response_______________________________ LEGAL ADDRESS: ___7575 Southfront Road____________________________________ ________Livermore, CA 94551____________________________________ ______________________________________________________________ PHONE: __(925) 454-6000____ FAX (required for notification) _(925)685-8804_____ CONTACT PERSON:____Leslie K. Mueller_________________________________ PHONE: ___(925) 602-1300____________ email: [email protected] ADDRESS FOR MAILINGS (if different): _____Leslie K. Mueller, Director of Operations__________________________ _____2350 Whitman Road, Suite F__________________________________ _____Concord, CA 94518_________________________________________ ____________________________________________________________________________

OFFICIAL USE ONLY: DO NOT FILL IN THIS SECTION PROPOSAL # _____________________ DATE RECEIVED:___________________TIME RECEIVED: ___________________ BY: ________________________________________________________________

TABLE OF CONTENTS

Executive Summary .......................................................................................................... 1

Section 1: Credentials and Qualifications ......................................................................... 7

Section 2: Commitment to Clinical Quality ..................................................................... 11

Section 3: Commitment to Employees ............................................................................ 31

Section 4: Operations Management ............................................................................... 48

Section 5: Commitment to EMS System and Community ................................................ 62

Section 6: Management and Administration................................................................... 79

Section 7: Organizational Requirements ........................................................................ 89

Section 8: Proposed Pricing ........................................................................................... 95

Proposal to Contra Costa County for Emergency Ambulance Services

1

Executive Summary

American Medical Response West, a California corporation doing business as American Medical

Response (AMR), views it as a privilege to submit our response to Contra Costa County’s Request

for Proposals for emergency ambulance services. We have proudly served Contra Costa County’s

communities over the past five decades, and we look forward to continuing the excellent working

relationship with our EMS system partners under the new contract.

AMR offers Contra Costa County a trusted partner in patient care, experienced local caregivers, a

knowledgeable leadership team, and a customer-focused organization. No other provider can

match our expertise creating innovative public-private partnerships in Bay Area counties, our

proven experience meeting response time standards in numerous high-performance EMS systems,

and our infrastructure of Bay Area resources to provide disaster support.

It is clear that Contra Costa County’s EMS system stakeholders wish to pursue a fully integrated

EMS system. AMR shares this vision, and our proposal outlines many ways that we can

contribute to achieving this goal. These characteristics, combined with the numerous service

enhancements outlined in our proposal, identify AMR as the organization best able to continue the

EMS joint venture that exists in Contra Costa County.

Commitment to C l in i ca l Ex ce l len ce

AMR has a long history of providing high quality Advanced Life Support (ALS) services in many

Northern California counties, including Contra Costa County, and we have an established track

record of proactively adopting clinical improvements. Together with our EMS system partners,

AMR will continue to work diligently to identify and implement those system changes that are in

the best interest of quality service delivery.

AMR proposes to enhance our Continuous Quality Improvement (CQI) process to include three

new leadership positions – an RN-level CQI Manager, as well as an

EMS Epidemiologist/Clinical Data Analyst and an Information Technologist, who will work

directly with County officials to analyze and report clinical performance data. Our entire clinical

team, including two existing full-time team members, as well as our Field Training Officers and

Peer Field Coaches, will work under the oversight of our in-house Medical Director.


2

We are also proposing the introduction of an Integrated Quality Leadership Council (IQLC),

comprised of personnel from AMR and our system partners, to identify, evaluate, and provide

solutions to EMS system operational issues. Additionally, we will establish an internal Quality

Leadership Council to monitor our CQI program, and a CQI hotline where system partners,

patients, and all system caregivers can request follow up by our team.

Key to our clinical program will be the system-wide approach to data collection and

management. We propose a full integration of electronic records and alignment of data sets

across the continuum of care, allowing for quantitative reporting of overall clinical performance

and meaningful data analysis, as well as data-driven training and community prevention programs

and greater collaborative research opportunities. AMR will continue to use our MEDS ePCR™

system, and we offer enhanced “real time” reporting capabilities under the new contract.

Presently, no other commercially developed ePCR system surpasses the number of implemented

sites as the AMR MEDS ePCR™ solution.

Commitment to ou r Work fo rce

By selecting AMR, the County will benefit from our company’s excellent working relationship

with our tenured, highly skilled, and locally experienced field providers – 63% of our Paramedics

have been with AMR for at least 5 years. We are committed to providing a work environment that

rewards their experience and dedication.

AMR will continue to offer competitive wages and

a wide range of benefits, including a 401(k) savings

and investment plan with a 100% employer match

(up to 5% of annual earnings). Through

empowered employee action teams, opportunities

for professional growth, job sharing, a

comprehensive safety program, and other retention

strategies, we work with our employees to create a

satisfying work environment.

Under the new contract, our commitment to our workforce will also include enhancements to our

recognition program, safety equipment, and Leadership Succession Planning Program. Expanded


3

support for our personnel will be provided by a team of nine Field Supervisors and a full-time

Employee Advocate.

Additionally, we are currently working with our labor union to introduce our new vision for

partnering with our employees and labor union, which embraces joint problem solving.

The innovative Labor-Management Partnership Program will fully integrate our union

leadership into our daily and strategic decision-making processes.

Commitment to Opera t ion a l Pe r f o rman ce

Under the new contract, AMR proposes the following enhanced Priority 1 response time

standards:

• Zones B, C, D, and E – 11:45 minutes (instead of 11:59 minutes) in urban/suburban areas

• Bethel Island and Discovery Bay – 16:45 minutes (instead of 20:00 minutes)

AMR also offers Contra Costa County a deployment option, with even lower response times for

Bethel Island and Discovery Bay. The following table compares our core proposal with this

deployment option.

Item AMR Core Proposal AMR Optional Proposal

Priority 1 Response Time Standards

Zone A Urban/Suburban Areas 10:00 minutes 10:00 minutes

Zones B-E Urban/Suburban Areas 11:45 minutes 11:45 minutes

Bethel Island and Discovery Bay 16:45 minutes 11:45 minutes

Zone E Rural Areas 20:00 minutes 20:00 minutes

Unit Hours

Weekly Transport Unit Hours 4,024 4,494

Weekly QRV Unit Hours 672 672


4

Item AMR Core Proposal AMR Optional Proposal

Deployed Resources

Peak AMR Transport Units 31 35

AMR QRVs 4 4

Fire-based STAR Cars 6 6

AMR Field Supervisor Units 3 3

To supplement our company’s ambulances and Quick Response Vehicles, we will subcontract

with fire agencies to deploy six Supplemental Transport Ambulance Resource (STAR) Cars –

transport-capable vehicles that will be staffed by fire agency personnel and will only be used in

pre-defined and urgent circumstances. Other local resources will include a bariatric ambulance

that can transport patients weighing more than 600 pounds, and AMR’s locally deployed

interfacility units that would be available to assist during times of unusually high demand –

Critical Care Transport (CCT) units, Basic Life Support (BLS) units, and five non-emergent units

staffed at the ALS level.

To ensure that our resources are always available to respond, we will continue to maintain our

vehicles at our fleet maintenance center in Concord. We propose new Type III modular

ambulances equipped with Opticom-compatible devices. As part of our disaster readiness

efforts, we will provide disaster vehicles, as well as disaster supply caches in strategic locations

around the county.

AMR proposes the following ambulance staffing model:

• One EMT and one Paramedic in Emergency Response Zones C and D

• A phased in approach to 1:1 staffing for Zone B, to accommodate the fire agency transition

• Dual Paramedic staffing as required by the RFP for Zone A

• Dual Paramedic staffing for Zone E – an enhancement to RFP requirements


5

Commitment to D i spatch Serv i ces

AMR proposes to partner with Contra Costa County Fire Protection District

Communications to become the primary dispatch center for all of AMR’s Advanced Life Support

(ALS) units serving the county. As part of an integrated response system, Consolidated Fire will

use System Status Management (SSM) technology to dispatch and re-position AMR resources as

system levels change. AMR will be responsible to develop, monitor, and maintain the System

Status Plan. Our vehicles will be equipped with Automatic Vehicle Locator (AVL) technology,

and we will work with Consolidated Fire to interface our AVL technology with its CAD. In the

event that Consolidated Fire needs assistance during a disaster, AMR’s Burlingame

Communications Center can provide backup services.

Commitment to the Communi t y

AMR commits to an exciting expansion of our community education and outreach efforts in

Contra Costa County, based on epidemiological research and identified community needs. A new

full-time Community Outreach Coordinator will manage the program, seek grant funding to

support initiatives, confer with the IQLG, and publish a quarterly community involvement

report. AMR also proposes to place 15 Automated External Defibrillators (AEDs) per year in

locations throughout the community as part of a Public Access Defibrillation program.

Commitment to F i r s t Responders

As a result of discussions with our system partners, AMR is proposing a number of commitments

to First Responders. In addition to the IQLC and STAR Cars, we will partner with

First Responders to develop an integrated logistics supply system, an integrated ePCR system with

alignment of data sets system-wide, and a program to rapidly return Paramedic firefighters to their

engine companies. Other proposed enhancements include establishing a local EMS training

program that will provide a full spectrum of continuing education opportunities to both AMR and

fire service ALS caregivers – at no cost. We will also implement Virtual Solutions Manager

software to assist in meeting continuing education requirements for our employees and First

Responders. AMR’s Operations Manager will function as our First Responder Liaison.


6

Commitment to Acc red i ta t ion

AMR is fully committed to attaining Commission on Accreditation of Ambulance Services

(CAAS) accreditation for our Contra Costa County operation within 14 months of renewal of our

contract. AMR has been working actively to put in place the necessary programming and policies

in line with CAAS requirements, and we believe we already meet many of the CAAS standards.

Imp lementa t ion P lan

As the incumbent emergency transport provider in Contra Costa County and a leader in EMS

system design and innovation, AMR, in partnership with key system stakeholders, will be able to

implement several enhancements following contract award, rather than waiting until July 1, 2005,

when the new contract goes into effect. In addition, we have worked during the recent contract

extension to implement a number of the system enhancements identified in the 2004 Fitch report.

With this extensive infrastructure already in place, we believe we are best prepared for rapid

implementation of contract enhancements upon contract award.

Commitment to a F i sca l l y Sound EMS Sys tem

Our proposed pricing will ensure the financial sustainability of the EMS system. In addition, we

offer the County a revenue sharing program, wherein AMR’s after-tax earnings would be

capped at a specified level, and any excess earnings would be shared between identified EMS

education, research, and prevention programs for Contra Costa County and AMR.

AMR is proud of the role we have played in the Contra Costa County EMS system through the

years. We wish to congratulate the County for pursuing a high performance EMS system with

clinical excellence and quality as the driving forces. AMR looks forward to continuing our long-

standing relationship in the years to come.


7

Section 1: Credentials and Qualifications

With decades of service to Contra Costa County, AMR has clearly demonstrated the experience,

resources, and financial structure required to provide clinically superior patient care and

exceptional performance for county residents. We have worked to support and partner with the

County and other EMS stakeholders, contributing to the continued evolution of the system into a

high-quality, high-performance, clinically-based model. We have focused our efforts on working

with our system partners to identify key issues and to provide ongoing solutions for the future. It

is our wish to build on these partnerships to continue developing an increasingly effective and

superior EMS system to serve residents in years to come.

1.1 ALS Experience

AMR has served Contra Costa County through our predecessor companies for more than 50 years.

AMR’s high-performance contract went into effect in 1991. Throughout our contract, AMR has

offered innovative system design solutions to the residents of Contra Costa County. These

innovations include placing ALS Quick Response Vehicles (QRVs) in remote areas of the county

to ensure adequate coverage and establishing public-private partnerships with fire agencies. Over

the past five years, we have worked side-by-side with the County and other system stakeholders to

develop a vision for the future of the EMS system and implement refinements and changes that

were necessary to ensure the continued evolution of the system as a high-performance, high-

quality patient care model.

AMR also provides contracted ALS services in many other Northern California communities, with

a variety of innovative public-private partnerships and other methods of service delivery to ensure

high quality patient care based on individual community needs. Details on these partnerships are

outlined in Section 5.1. A map of the Bay Area counties served by AMR, as well as a list of

similar contracts, is located in Section 7 attachments.

AMR’s resources have proven to be critically beneficial in many of the large-scale emergencies

and disasters affecting California communities, as well as in supplementing the state’s public

safety infrastructure. With our company’s operations in other Bay Area counties, we can rapidly

recall approximately 400 employees and 50 vehicles, as well as draw on our company’s additional

resources from operations in other areas in Northern California.


8

Only AMR has the regional bench strength to seamlessly move this large a number of additional

units to a scene when needed. With our linked communications centers in Burlingame, Modesto,

and Sacramento, and with AMR operations in Alameda, San Francisco, Marin, Sacramento,

San Mateo, Santa Clara, Stanislaus and San Joaquin Counties, we can assure Contra Costa County

that AMR will be there when needed.

Finally, the American Medical Response Group of companies (AMR Group) has significant

experience as a sole provider of ALS services throughout the nation, serving diverse communities

from rural to metropolitan regions. Nationally, the AMR Group contracts with more than

129 agencies to provide primary emergency medical services.

1.2. Ability to Meet Response Time Standards

As the incumbent emergency ambulance provider in Contra Costa County, AMR offers

unparalleled local experience and bench strength working with other stakeholders in this clinically

focused, high-performance EMS system to meet response time criteria. In the current contract, we

are proud to have met or exceeded response time standards countywide for the previous five years.

Current response time data for Contra Costa County is included in Section 1 attachments.

AMR has a proven track record of response-time compliance for several comparable counties in

the area as well. Response-time compliance history for the past 12 months for Alameda,

San Mateo, and Santa Clara Counties can also be found in Section 1 attachments.

1.3 Ability to Provide High Level of Clinical Performance

AMR has a long history of commitment to clinical quality in Contra Costa County, working with

the County and our system partners to continually improve our clinical performance and

accountability. Not only does AMR have the local community experience and EMS system

history in Contra Costa County, we are also deeply rooted in a customer-centered approach where

clinical quality is the core of our service delivery model. Our clinical focus is just one of the

reasons we have been able to continually attract the finest EMS professionals.

With the new contract, we are proposing to expand our current program and enhance integration

with our system partners to create a system wide CQI approach to clinical performance. Key to

our clinical performance is our commitment to the continuation of our sophisticated electronic


9

data management programs. Over the years in Contra Costa County, AMR has implemented

systems such as those listed below to address many of the best-practice recommendations

emanating from the field of EMS in regards to information systems.

• Adoption of uniform data elements and their incorporation into information systems

• Development of mechanisms to generate and wirelessly transmit data that are valid, reliable,

and accurate

• Development of information systems that are able to describe an entire EMS event

• Development of integrated information systems with other health care providers, public safety

agencies, and community resources, including data-sharing with hospitals and the

EMS Agency

• Developing feedback mechanisms, including the capability to develop ad hoc and specialized

reports to meet the needs of EMS system partners

More information regarding our clinical performance can be found in Section 2.

1.4. Financial Strength and Stability

AMR has the experience, stability, and financial depth to consistently provide superior patient care

to Contra Costa County. As indicated by our 2003 audited financial statements provided in

Section 7 attachments, AMR Inc.’s liquidity is strong, with $181.3 million of net working capital.

The company’s current ratio was 2.27 at August 31, 2003, with $323.7 million of current assets

versus $142.4 million of current liabilities. Additional indicators of a company’s health are its

operating cash flow and the percentage of that cash flow that is reinvested back into its systems

and equipment. For the 12 months ended August 31, 2003, AMR Inc. produced $61.6 million of

cash from its operating activities and $48.5 million was reinvested back into new equipment,

primarily new ambulances, medical, and communications equipment. At the local level,

AMR West carried $36.1 million of working capital at August 31, 2003 and realized $39.8 million

of cash from operating activities for the preceding 12 months.

These financial metrics are evidence of AMR’s ability to meet our commitments and ensure

stability in our role as a provider of high quality emergency medical systems.


10

1.5 EMS System Management Expertise

AMR is an active participant in the evolution of the Contra Costa County EMS system and has

been throughout our history of service to the community. We have worked with all the local

stakeholders to ensure their needs are met, including the EMS Agency, our local fire agency

partners, law enforcement, hospitals, and community groups. The result has built a great deal of

trust in AMR’s ability to serve the community, either through a system redesign, through

community outreach, or through our significant disaster resources. We believe AMR has

demonstrated a significant commitment to the community and to the County, which we further

believe has created an effective foundation for the future evolution of the EMS system.

The following is a brief overview of our management and leadership achievements; details can be

found in Section 5.1 of our proposal.

• CAAS Accreditation – There are 79 agencies in the United States that have received

accreditation by the Commission on the Accreditation of Ambulance Services (CAAS).

AMR has 14 CAAS accredited operations, representing 15% of total CAAS accredited

agencies. No other company in the nation surpasses AMR in CAAS accredited operations.

Our Contra Costa County operation is compliant with the majority of the CAAS standards and

is on track for accreditation in the next 14 months.

• Private-Public Partnerships – In three Bay Area counties, AMR subcontracts with our fire

agency partners to provide Paramedic First Responders on fire engines. In addition, we

subcontract with several agencies to provide supplemental transport resources. As part of

some of these agreements, we also provide a variety of support services for the fire agencies,

such as quality improvement activities, EMS education and training, medical equipment, and

tracking of fire personnel certifications.

• Disaster Preparedness – AMR understands the critical need to prepare for an effective,

coordinated response to disasters. AMR managers and employees serve on many local and

national disaster preparedness committees. In Contra Costa County, many of our efforts focus

on petrochemical disaster preparation, and we require all supervisors and managers to undergo

standardized joint emergency training, so all emergency personnel follow the same protocols

and know what procedures to follow in the event of an incident.


11

Section 2: Commitment to Clinical Quality

AMR has a long history of commitment to clinical quality in Contra Costa County, working with

the County and our system partners to continually improve our clinical performance and

accountability. Our clinical focus is just one of the reasons we have been able to attract the finest

EMS professionals to serve County residents.

We recognize that the new contract presents an exceptional opportunity to redesign and expand

our current clinical quality system. For many years, we have worked with the County and other

system stakeholders to identify clinical issues and to design and implement innovative solutions to

those issues. We know that there is still work that needs to be done to achieve the County’s vision

of a comprehensive and continuous quality improvement process that is organized, coordinated,

multidisciplinary, and integrated across the EMS system. We are proposing a number of

enhancements that will drive us to meet the County’s needs, transforming our current practices to

provide for continued clinical improvement as the system evolves to meet the direction provided

in “The EMS Agenda for the Future,” published by the US Department of Transportation,

National Highway Traffic Safety Administration (NHTSA).

Highlights of our current and proposed clinical programming include:

• Upgrading of our comprehensive internal Continuous Quality Improvement (CQI)

process to include three new leadership positions – an RN-level CQI Manager, an EMS

Epidemiologist/Clinical Data Analyst, and an Information Technology Specialist – to work

with the County on CQI issues, as well as the continued involvement of our in-house Medical

Director.

• Introduction of an Integrated Quality Leadership Council (IQLC) to identify, evaluate

and provide solutions to operational issues of the EMS system. The Council will be comprised

of personnel from the Contra Costa Consolidated Fire Protection District, the East County Fire

Protection District, Rodeo/Hercules Fire Department, Pinole Fire Department, Kensington/

El Cerrito Fire Department, and AMR.


12

• System wide approach to data collection and management in cooperation with the County

and other system partners to allow for quantitative reporting of overall clinical performance,

which can be tied to providing improved CQI, integrated EMS system patient care solutions,

training and community prevention

• A remedial approach to clinical CQI where best practices are taught and modeled, and where

positive participation by field personnel in the CQI process is supported and encouraged at all

levels in the organization.

• Enhanced data analysis systems and “real-time” reporting of pre-established sentinel

events, as defined by the National Highway Traffic Safety Administration (NHTSA), that

build on the existing electronic Patient Care Report (ePCR) system and support a truly

concurrent CQI monitoring of compliance to medical protocols and standing orders.

• Retrospective analysis of ePCR data to identify the training needs of field staff, both at an

individual (remedial) or group level (refresher courses). This analysis may also result in

recommended modifications to improve existing medical protocols or the acquisition of new

equipment, all focused on providing the highest quality care available in the EMS industry.

• Enhanced sharing of ePCR data with area hospitals–critical resources needed to support a

comprehensive and integrated system of prehospital care. In addition, hospitals can share

clinical outcomes with the EMS system that otherwise would go unreported, providing a rich

source of information for EMS system analysis and CQI.

• Proposed new onboard equipment to maintain the highest standard of clinical sophistication

available for the residents of Contra Costa County. This includes pilot-testing of new

equipment to determine the efficacy of implementation in the field, facilitating a cost-benefit

analysis.

• Data-driven injury and illness prevention programs that target the community and the

workforce, including retrospective evaluation measures to assess their effectiveness.

• Collaboration with the AMR Pacific Research Council and ongoing support of critical EMS

research topics important to both the County and AMR, not only resulting in information that

can be used locally for the benefit of county residents, but that can be shared in poster

presentations at conferences nationally to the benefit of prehospital care nationwide.


13

• Locally sponsored continuing education programs that work to reinforce and hone clinical

skills each month, providing for continued skills improvement. These will also be offered to

our fire agency partners at no cost.

2.1 Clinical Quality Improvement Program

AMR has worked closely with EMS Agency leaders to craft and deliver a comprehensive internal

clinical CQI program that focuses on providing accountability for the complete continuum of care

retrospectively, concurrently and prospectively. With the new contract, we are proposing to

expand our program and work with our system partners to create an integrated, system wide CQI

approach to clinical performance.

Internal Clinical CQI

AMR employs a highly-organized, multi-disciplinary CQI program, which is fully integrated

across the service delivery spectrum. Where typical health-care QA and QI programs touch on

the three core segments: “retrospective, concurrent, and prospective,” we have crafted methods

that drive these aspects to new levels and provide a self-directed work environment built on

trust, safety and competence. In the upcoming contract, our CQI efforts will be directed by

our newly expanded and locally accountable Clinical and Educational Services (CES)

Department. Details on our upgraded local CES Department may be found later in this section

in 2.1.2.

A summary of our CQI program follows. A more detailed description of AMR’s overall

philosophy and approach to CQI is provided in Section 2 attachments.

Retrospective or responsive component includes regularly scheduled and periodic

reviews and analyses of performance data, where areas for improvement can be identified

and solutions generated on a continual basis. For the new contract, we are proposing to

establish an internal Quality Leadership Council (QLC) – in addition to the proposed

system wide IQLC – to continuously review our performance, measure the results of our

CQI program, and make recommendations for improvement. We will also set up a variety

of methods to assess patient and stakeholder satisfaction, including a CQI hotline to allow

system partners and patients to leave commendations or suggestions for service


14

improvements on voice mail. AMR’s Paramedic CES Coordinator will be automatically

notified via pager or email of any incoming calls, and incidents that require feedback will

be attended to by the end of the next business day. Additional information on how we

monitor patient satisfaction can be found in Section 5.3.

Concurrent or on-line phase provides for monitoring of employees and operations to

ensure that established policies, procedures, and protocols are implemented in practice and

to identify areas where remediation is needed. One of the goals of our approach to

concurrent CQI is to provide this oversight in an educational, motivational fashion. We

are proposing to do this by deploying Peer Field Coaches on units to observe, correct and

reinforce skills in practice in the field. We will also establish electronic business rules on

our ePCR system to generate immediate, real-time electronic notification to individual

team members for immediate action on sentinel events. The specific events will be

determined cooperatively with the system’s Medical Director and could include items such

as compliance to protocol standards, significant clinical issues, and other measures such as

the identification of injury and illness “clusters” to help identify urgent or emerging

community health issues.

Prospective or predictive phase uses information and forecasting to predict potential

quality issues before they occur. It also includes providing the employee with performance

expectations and guidance before an incident occurs through careful screening of new

employees, providing effective new employee orientation and training, continuing

education, the purchase and use of new equipment, and new or revised policies,

procedures, or protocols. Details on our targeted recruitment, screening and orientation

processes may be found in Section 3.3. of this proposal.

System-wide Quality Improvement

Over the years, AMR has worked actively to develop an excellent, trust-based working

relationship with the County and our system partners. These efforts have created an

environment that has encouraged system innovation through special partnerships and

collaborations (details on these efforts and the results may be found in Section 5) and set the

stage for the County’s desired approach to overall system integration.


15

AMR has met with representatives from every Contra Costa County fire agency to discuss

opportunities for innovative partnerships that can meet the needs of the community as well as

overall system goals. As a result of these discussions, AMR is proposing the following

elements to meet the CQI component:

Integrated Quality Leadership Council (IQLC) – Central to our integration proposal is a

fully integrated leadership structure for the stakeholders of the EMS delivery system. We

are proposing that operational and equipment issues of the EMS system be identified and

evaluated, and solutions developed by the IQLC, providing for broad participation in the

improvement of the system at all levels. The Council will be comprised of personnel from

the Contra Costa Consolidated Fire Protection District, the East County Fire Protection

District, Rodeo/Hercules and Pinole Fire Departments, the Kensington/El Cerrito Fire

District, and AMR.

Coordination of Data Gathering and Quality Improvement Efforts – As more fire

agencies in the county implement SunPro-Ather software for electronic data collection,

AMR recognizes the importance of finding a technological solution that allows the SunPro

product and AMR’s MEDS ePCR™ system to interface. AMR is proposing a full

integration of electronic records and alignment of data sets system wide, in cooperation

with the County and our system partners. This will allow for quantitative reporting of

overall clinical performance, which can be tied to providing integrated EMS system patient

care solutions, training and community prevention, meaningful data comparison, and

greater collaborative research opportunities. In addition, we will provide system data to our

Fire Department partners so they can use real-time data to support their own CQI activities.

Sponsored Training – AMR will use its Northern California Training Institute (NCTI) to

establish a regional EMS training program within Contra Costa County. Through this

program, we will provide a full spectrum of continuing education opportunities to both

AMR and fire service personnel, including ACLS, PHTLS, and PEPP. The provision of

joint training classes give AMR and fire personnel increased opportunities to work

together and to develop relationships, continuing the vision of a truly integrated system.

Additionally, AMR will work with our fire service partners and NCTI staff to accredit fire

service personnel as instructors for the various class offerings at NCTI. We will


16

remunerate those instructors or their agencies depending on the exact nature of the agreed-

on relationship.

Six Sigma – AMR is in the process of adopting the Six Sigma approach to quality

management widely used throughout the health care industry, and we have incorporated

the model in our inventory and financial management processes. A number of our

leadership personnel have been trained in Six Sigma, and we are proposing to explore

through the IQLC the value of the Six Sigma process as it relates to the overall quality

management of the Contra Costa County EMS system.

2.1.1 Financial Commitment

AMR’s commitment to the quality improvement process is substantial as our proposal includes

annual expenditures of nearly $1 million to fund the following activities:

Five full-time positions in our local CES department, as well as 100 compensated hours

per month for designated field personnel to participate in CQI activities

New onboard medical equipment (see discussion under Section 2.5)

Monthly continuing education classes and expanded continuing education topics (see

discussion under Section 2.2) – including joint programs with fire agency ALS personnel

Increased information technology support to develop and implement ePCR business rules

necessary to achieve concurrent quality improvement, and on-scene hardware and software

support (see discussion under Section 2.6)

Annual AED procurement on behalf of the County's Public Access Defibrillation program

2.1.2 Staff Commitment

Under the new contract, AMR will expand our local clinical oversight and accountability

abilities. Our internal and system-integrated CQI activities will be directed by an RN-level

CQI Manager, located at our Contra Costa operation. While having the ability to draw on our

regional CES Director for support and expertise, the CQI Manager will report directly to our

Contra Costa Director of Operations and our Medical Director. We are also adding an EMS

Epidemiologist/Clinical Data Analyst and an Information Technologist, who will be available

to work directly with the County and the County Medical Director to gather, analyze, and


17

report system wide clinical performance data as specified by the County. More details on our

data management commitments may be found later in this section in 2.3.

The following is a list of our clinical personnel commitments. Job descriptions can be found

in Section 2 attachments.

RN-CQI Manager (new position)

CES Paramedic Coordinator

Paramedic Field Training Coordinator

EMS Epidemiologist/Clinical Data Analyst (new position)

Information Technologist (new position)

Regional CES Director

In addition, AMR is proposing to augment our clinical field oversight capabilities with the

following:

Field Training Officers (FTOs) – A minimum of 80 compensated hours per month will be

devoted by veteran field personnel to oversee the training and evaluation of new

employees and to provide critical CQI functions, such as peer chart review, remedial

performance training, evaluation of existing field staff, and active participation in internal

and external QI committees.

Peer Field Coaches – A minimum of 20 compensated hours per month will be devoted by

veteran field personnel to act as Peer Field Coaches, providing real-time input on the

quality of care. Peer Field Coaches will ride with personnel half time and work in a

clinical role the other half of their time.

Finally, AMR’s Medical Director, Dr. Gary Tamkin M.D., FACEP, is integral to AMR’s CQI

processes and is consistently used as a training resource for field personnel. Dr. Tamkin’s

curriculum vitae can be found in Section 2 attachments.

2.2 Continuing Education Program

AMR proposes an enhanced continuing education program that will include the use of

performance and outcome indicators directly correlating to the skills and scope of practice

demanded in the field. This Ongoing Training and Evaluation Program (OTEP) will be a


18

monthly, structured program for EMS personnel that allows them to meet the education

requirements and core topic content for recertification, and includes cognitive, affective, and

psychomotor evaluations following completion of each topic to determine student competence in

both content and skills. Designed in cooperation with -- and made available to our system

partners -- the OTEP curriculum will comply with state regulations and will be presented to the

County’s Medical Director for approval before implementation. OTEP will be open to all AMR

and system personnel at no cost.

Under our proposal, we will present the various continuing education courses both at our

operations in Contra Costa County and at various locations throughout the county. We will

coordinate the training and the location of this training with our system partners so that members

of local fire and law enforcement departments, as well as hospital staff, may participate in and

benefit from the training as easily as possible.

The courses will be taught by the local

CES Department in cooperation with AMR’s

Northern California Training Institute (NCTI),

and we are offering to train individuals from

the various system agencies as instructors,

paying instructor stipends under a contracted

basis. Details on NCTI and the value of the

extensive array of educational offerings we are proposing are included in Section 2 attachments.

Under the new contract, AMR will offer the following programs in addition to the core

educational programs outlined in the NCTI attachment. Details on these programs may also be

found in Section 2 attachments:

• Preparation for Multi-casualty Response – ICS 100 (all employees); ICS 200 and 300

(supervisors and operations manager)

• Ambulance Strike Team Leader – Field Supervisors

• Assaultive Behavior Management Training

• Infection Control


19

• Critical Incident Stress Management, including training for family members and an upgraded

Peer Counselor program for supervisors

• National Incident Management System (NIMS) – all state and local government agencies that

apply for federal funding must be NIMS compliant for fiscal year 2006

• Hazardous Materials (HazMat) Basic Awareness WMD program (required training for

Homeland Security funding)

Finally, we will continue to provide the following CQI and training programming:

• Monthly case reviews and periodic “Hot Topics”, which provide free Continuing Medical

Education units. Typically taught by emergency physicians followed by a case review

presented by field personnel, the Hot Topics series has been well received and continually well

attended, and – as a secondary and equally important benefit – supports building strong

collaborative relationships among EMS personnel, public safety, and hospital emergency

departments and staff. A Hot Topic brochure can be found in Section 2 attachments.

• Bay Area Paramedic Journal Club — AMR and County Medical Directors, together with

field Paramedics, conduct case studies and present their findings to other EMS professionals.

• Contra Costa County Trauma Symposium – We will continue our sponsorship and

involvement in this regional, collaborative conference now being offered annually (see Section

2 attachments for a brochure).

• “Shadowing” program arranged through Dr. Tamkin for field staff to spend the day with a

trauma surgeon or emergency department doctor to observe and/or practice clinical skills,

either as voluntary professional development or mandatory remedial training.

Virtual Solutions Manager

AMR will implement an internet-based service known as Virtual Solutions Manager (VSM)

to enhance our existing in-house continuing medical education program. This program will

allow us to place physician-approved, specific continuing medical education offerings on the

internet for access by AMR employees and Contra Costa County fire agency personnel. The

training placed on the VSM site will allow AMR employees to meet the ongoing education

requirements for Contra Costa County and the State of California certification. Additionally,


20

the program allows employees to monitor their own progress toward meeting state re-

certification requirements. The program also gives AMR an effective and efficient way to

monitor employee progress toward re-certification.

2.3 Clinical Benchmarking and Research Activities

AMR has long been committed to the practice of evidence-based medicine by demonstrating a

long-term investment in both the collection of clinical data as well as development of the next

generation of technology by which to capture the data. With the introduction of electronic data

collection through our company’s ePCR, key clinical and performance indicators are reported

monthly. The key performance and clinical indicators we currently collect include those required

by the County under the new contract:

• Cardiac arrest survival in accordance with Utstein protocols

• Fractal measurement of time to first defibrillation

• Successful intubation rates

• Successful IV application rates

• Field procedures authorized

• Pain reduction

• Fractal measurement of response time

• Presumptive impressions at dispatch compared to field intervention.

In addition, members of AMR’s CES Department have been active participants in our company’s

Regional Clinical Data Reporting Meetings. This is a taskforce designed by and conducted with

AMR Medical Directors from Contra Costa, San Mateo, and Santa Clara Counties in California, as

well as Medical Directors from our sister operations in Clark County, Washington, and

Multnomah County, Oregon, to incorporate the NHTSA data elements into our data gathering and

reporting processes. As a result of this project, AMR is proactively redesigning our data

management systems to be in line with NHTSA’s national data effort. The result will be consistent

reporting methodologies that will allow us to provide Contra Costa EMS with quantitative reports

that can easily be tied to public health goals and community education initiatives, as well as

participate in overall clinical studies.


21

Research is a necessary and mandatory part of the EMS profession. Through our company’s

Pacific Research Council, AMR has undertaken many research projects beneficial to both Contra

Costa County and the larger EMS system. For example, our internal data repository was the sole

source of information used by AMR clinicians and researchers for a study titled, The Changing

Pattern of Prehospital Morphine Administration, which won the prestigious “Best Research”

award presented at the 2001 annual EMS Today Conference in Baltimore, MD by the Prehospital

Care Research Forum sponsored by the University of California, Los Angeles (UCLA).

All throughout the Bay Area and beyond, AMR has more than a decade of experience collecting

and analyzing clinical data. As a result, we have created an impressive database containing

hundreds of data elements from nearly 3 million ambulance responses, a locally oriented database

no other provider can offer. Using this repository of data, the research potential in Contra Costa

County is almost unlimited, and AMR looks forward to working with Contra Costa County, the

County Medical Director, and the proposed IQLC to select projects that will mutually benefit the

local EMS system as well as the EMS industry nationally.

2.4 Personnel Certification and Training

All EMTs and Paramedics working in Contra Costa County meet the recertification requirements

for the State of California. To help ensure and always facilitate this, we will continue to offer all

necessary recertification training in-house, at no cost to the employee, as well as to our ALS

system partners. All AMR employees will continue to be paid for attending this required

training. Documentation of certifications, licenses, accreditation, and required training are kept at

AMR’s offices in Concord, and are available to County officials for review and inspection. We

also provide a monthly report to the County monitoring employee certifications. With the

implementation of our VSM program, described earlier, we will be able to monitor employee

certification levels on-line. Details on educational programming, training and VSM may be found

earlier in this section under 2.2.

Staffing Requirements

AMR will staff all ambulances serving Contra Costa County with a minimum of one

Paramedic and one EMT or two Paramedics, depending on the contracted Emergency

Response Zone (ERZ), in accordance with County requirements and as an enhancement as


22

described in section 4.2. All individuals will be fully credentialed by Contra Costa County and

will hold all necessary licenses, certifications, and/or accreditations.

AMR also deploys a number of non-emergency BLS transport units in the county in which we

can provide initial BLS training to new employees. Thus, we commit that all field personnel

serving the EMS system will have a minimum of 1,500 hours experience as BLS providers.

In addition, all employees will be fully oriented to the company and the EMS system before

being assigned to respond to emergency medical requests.

PARAMEDICS

Minimum qualifications for a Paramedic are:

State licensed and/or Nationally Registered EMT-Paramedic

Advanced Cardiac Life Support (ACLS) certification

Basic Trauma Life Support (BTLS) certification

Pediatric Education for Prehospital Personnel (PEPP) certification

CPR / AED certification

State of California driver’s license and an ambulance driver’s license, and a Medical

Examiner certificate

Emergency Vehicle Operator Course (EVOC) certification

AMR proposes to expand the scope of practice of Paramedics to better serve the

community, both in the field and when transferring high acuity patients between medical

facilities, by training selected Paramedics at the Critical Care Transport (CCT) level.

This will allow them to handle additional advanced-care responsibilities on authorization

by the County Medical Director.

EMERGENCY MEDICAL TECHNICIANS (EMTS)

Minimum qualifications for an EMT are:

County certified and/or Nationally Registered as an EMT-Basic

State of California driver’s license and an ambulance driver’s license, and a Medical

Examiner certificate


23

Emergency Vehicle Operator Course (EVOC) certification

CPR / AED certification

2.5 Medical Equipment and Supplies

AMR is fully committed to providing the equipment and supplies required by the County. A list

of onboard ambulance equipment is provided in Section 2 attachments. In addition, AMR affirms

the County’s right to inspect our equipment and supplies, and leverage penalties as described in

the RFP.

Currently, our employees participate in a local AMR committee to select the most appropriate

equipment, evaluating that equipment prior to full rollout, and updating the equipment to stay

current with trends in prehospital care. In addition, because we are a national company, we work

directly with manufacturers to determine if a piece of equipment can be modified to resolve

negative performance. AMR is proposing to enhance this committee by expanding system

participation. We will work with local fire agencies to jointly evaluate equipment for use system

wide and provide for joint purchasing opportunities whenever possible.

Exceeding Equipment Requirements

The County has expressed a desire to provide expanded cardiac assessment on scene. To

allow us to meet this vision, AMR will exceed the onboard equipment and supply

requirements of the County by upgrading to the following medical equipment:

Expansion of the LifePak 12 monitor/defibrillators to include 12-lead, capnography, and

non-invasive blood pressure capability – and which are compatible with fire agency

equipment

Flex Guide ET tube introducers to allow for successful orotracheal intubation under

emergency conditions when unfavorable anatomy or the need to limit neck motion is

present

We are also equipping all supervisor vehicles with the “WRAP” patient immobilization system

used by the majority of law enforcement agencies in the state. This device is designed to

effectively, yet gently restrain violent patients in the field, allowing for medical treatment.


24

Other upgraded equipment decisions will be made jointly with the County through a system

wide equipment committee or through the IQLC.

2.6 Collection and Use of Patient Care Data

Over the years in Contra Costa County, AMR has implemented systems to address many of the

best-practice recommendations emanating from the field of EMS in regards to information

systems. These include:

• Adoption of uniform data elements and definitions and their incorporation into information

systems

• Development of mechanisms to generate and wirelessly transmit data that are valid, reliable,

and accurate

• Development of information systems that are able to describe an entire EMS event

• Development of integrated information systems with other health care providers, public safety

agencies and community resources, including data-sharing with hospitals and the County’s

EMS Agency

• Developing feedback mechanisms, including the capability to develop ad hoc and specialized

reports to meet the needs of EMS system partners

Since 1997, AMR has worked in Contra Costa County

to test and implement an ePCR solution. While

conducting an exhaustive search for a commercial

solution, we found existing electronic patient care data

systems to be limited in “proof of concept”. They all

fell short of a comprehensive approach to data

integration from an EMS perspective.

In 2002, after a long search for an “off the shelf” ePCR product, AMR began implementation in

Contra Costa County of our MEDS ePCR™ system, which electronically captures clinical and

patient demographics. Only an organization with the resources of AMR could seriously entertain

such a substantial, “make or buy” decision. Thus, AMR demonstrated our industry leadership

through the development of an internal solution for data collection.


25

MEDS ePCR™ is designed to ensure compliance with all reporting standards and policies,

including the Health Insurance Portability and Accountability Act of 1996 (HIPAA.) The Patient

Care Report (PCR) component incorporates the prehospital data elements published by both the

California EMS Authority and NHTSA, as well as most elements identified in their current

National EMS Information System (NEMSIS) and California EMS Information System

(CEMSIS) research projects. Presently, no other commercially developed ePCR system surpasses

the number of implemented sites as the AMR MEDS ePCR™ solution.

By design, MEDS ePCR™ will provide a comprehensive approach to improving quality patient

care through integrated data sharing. The unique characteristics of MEDS ePCR™ include:

• Business rules designed to increase accuracy of PCR documentation

• Mapping of data points to the NHTSA data set (NEMSIS) and the California EMSA data set

(CEMSIS) for compliance with federal and state recommendations for clinical and

demographic reporting, allowing for data comparison with other EMS systems

• The ability to auto-populate fields by pulling data from our billing system when we have

previously transported a patient

• Ability to print legible PCRs at the receiving hospital in accordance with JCAHO standards

• Elimination of redundant entry of PCR data into a billing application

• Ability to perform quality improvement/assurance functions through immediate access to

PCRs

• Ability to immediately query the database to produce ad hoc reports specific to clinical

classifications

• Compilation of clinical data into a data warehouse that facilitates research and study of

millions of annual patient care encounters by our organization

• Utilization of a highly secure and encrypted connection that meets HIPAA compliance in all

electronic information exchanges

• Ability to download EKG strip from cardiac monitors and transmit data

• Ability to use the system as a communication conduit in the field (e.g., e-mail access)


26

Accurate and timely clinical data collection and analysis is an essential component of any EMS

quality improvement program. Our company currently warehouses more than 3 million

electronic patient care records, enabling us to conduct a number of research projects and system

analyses that would be extremely time-consuming, if not completely impractical, with paper

records. Multiple types of patient care summaries can be generated from our clinical data system,

including:

• Organizational performance summaries

• Individual performance summaries

• Ranked clinical performance

• Trauma/medical summaries

Customized reports are always available. AMR proposes that on contract award, a team of Contra

Costa County and AMR personnel meet and design a specific report that meets County needs.

However, at a minimum, AMR proposes to measure the following statistically documented

indicators of clinical quality:

• Compliance - Documentation that clinical procedures were followed (e.g., medical history,

physical examination, vital signs, current medications, allergies)

• Appropriateness - Whether the documented treatment was appropriate given the illness or

injury

• Skill Sets - The frequency of the use of Advanced Life Support skills (e.g., intravenous access,

use of defibrillators)

The last item (frequency of skills being used in the field) is important information for our local

CES Department and for the County. When audits indicate that various skills are not being used,

refresher courses can be provided to ensure field staff remain practiced in all necessary clinical

skills and procedures.

Advantages to Maintaining the MEDS ePCR™ Platform

Both AMR and the County have invested a great deal of resources to implement MEDS

ePCR™ as an ePCR solution. Much progress has been made to adequately train staff, refine

the data collection system, and generate timely and useful reports. Changing to another


27

platform is akin to “changing horses mid-race,” further delaying the process to move the

County to a paperless system that has enormous data analysis potential, both in “real-time” and

retrospectively. The technology also has the potential to integrate our information system with

First Responders’ and health care providers’ information systems, a prerequisite to achieving

an information system that is able to describe an entire EMS event (from dispatch to

discharge). This integration would serve as a powerful tool across the public safety and

healthcare system and would foster the incorporation of EMS within the health care networks’

structure to deliver quality care.

Proposed System Enhancements

AMR proposes several ePCR system enhancements, and we will devote the substantial

resources of additional CES staff to ensure they are implemented. First, we will develop new

business rules (parameters) for MEDS ePCR™ that will:

Send automatic e-mail notifications to the CES Department whenever there is a “real-time”

deviation of protocol in the field

Automatically create and electronically send daily “hot sheets” of patient vital sounds

outside the normal range, thereby realizing a virtual 100% chart audit rate

Send automatic notifications to the CISM team leader of critical incidents for his/or her

immediate response

Track and report pre-determined preventable injuries and illnesses community-wide in

order to target injury and illness prevention activities (e.g., elderly falls at particular

facility)

Automatically send out customer satisfaction surveys within two to three days after

service.

We will also re-tool the ePCR interface to ensure a “user-friendly” data collection system,

including reducing or eliminating redundancy, creating more auto-fill capabilities, creating

more drop-down menus, establishing auto-reminders when required data is missing from the

ePCR, and building an electronic “easy reference” for protocols and dosage calculations.

Finally, we will integrate the ePCR system across the continuum of care, from fire

agencies to hospitals. This will include re-aligning data sets to query and report like data


28

“Emergency Medical Services of the future is a community-based health management system that is fully integrated with the overall health care system. It has the ability to identify and modify high risk illness and injury indicators, provide injury prophylaxis, provide acute illness/injury follow-up, and contribute to treatment of chronic conditions and community health monitoring. This new entity is totally integrated with other health care providers and public safety and public health agencies, thereby decreasing utilization of acute health care resources. Emergency medical services serve as the public emergency medical safety net.” -- U.S. DOT/NHTSA, Washington, D.C., 1996.

currently collected by the County’s fire agencies to lay the foundation for joint research using

comparable data and to provide for monthly performance reports. AMR is currently achieving

this with Mt. Diablo and John Muir Medical Centers in Contra Costa County, allowing them to

receive paperless ePCRs to meet JCAHO patient record requirements, thus saving time and

money.

2.7 Community Injury and Illness Prevention Activities

As discussed in greater depth in Section 5.2, AMR proposes to hire a full-time Community

Outreach Coordinator whose primary responsibility will be to interpret local community health

data in partnership with EMS system stakeholders and:

• Collaborate with community agencies and health care providers with expertise and interest in

illness and injury prevention to focus prevention campaigns on local data and available

community resources

• Support a prevention-oriented atmosphere within the EMS system by involving system

stakeholders in community education programs and prevention initiatives

• Work with our CES Department to include the principles of prevention and its role in

improving community health in EMS education programs

• Work with our EMS Epidemiologist/Data Analyst and Information Technologist to improve

the ability of our ePCR system to capture and report on injury and illness data

• Seek external grant funding to support ongoing community health education programs and

annual health status improvement initiatives


29

Annual Health Status Improvement Program

AMR’s CES and Community Education personnel will take the following steps to annually

undertake projects that measurably improve the health status of the community:

Early Recognition and Project Identification. Potential health status improvement

programs will be identified and documented using the most recently available data on

community health indicators, including injury and illness data drawn from ePCRs.

Mutual Planning/Collaboration/Implementation. Having identified potential initiatives,

AMR personnel will work with the IQLC, public safety and public health stakeholders to

select a health status improvement project, generate successful strategies, suggest resources

to be marshaled or developed, and suggest realistic and measurable outcome indictors (e.g.,

fewer public safety citations for seat belt usage violations from previous years; fewer EMS

calls for falls at facilities serving seniors). When desired, AMR will take the lead in the

implementation of the projects, maximizing and focusing community resources to achieve

the desired and measurable health improvement outcome(s).

Evaluation and Dissemination. Using the results of outcome indicators, AMR will work

with the County to disseminate the successes and challenges of the project community-

wide through presentations, conferences and press releases highlighting the contributions

of community partners in the health improvement project.

2.8 Commitment to Improve Clinical Care

AMR understands that all we do affects clinical care, from who we hire to the equipment we use.

That’s why our commitment to improving clinical care includes:

• Recruiting and hiring the best staff possible.

• Providing the best training, in-service preparation, and ongoing education available in EMS

today, with a program that encompasses the three learning domains: affective, cognitive, and

psycho-motor.

• Equipping personnel with the right equipment to do the job. Due to our national presence and

purchasing power as a national company, many EMS equipment manufacturers use AMR’s

operations to field test new equipment. Through our CES and purchasing departments, we


30

have established procedures to assess new equipment and make recommendations for their

modifications to manufacturers.

• Incorporating a CQI process that touches on every aspect of the organization, which ultimately

results in improved patient care.

Under the new contract, AMR commits to:

• Comply with the System Standard of Care as established by the EMS Medical Director in

consultation with the Medical Advisory Committee.

• Statistically document compliance to system medical protocols and provide quantitative

reports as specified by the County.

• Participate in the review and update of medical protocols.

• Encourage and support personnel to interact directly with the system’s medical leadership on

all issues related to patient care (including CQI committees, reviews, audits, and remediation

programs) by dedicating 80 compensated hours per month for such activities.

• Participate in the medical audit process, and support and operationalize a positive process that

results in improvement in procedures, on-board equipment, and medical practice.


31

Section 3: Commitment to Employees

By selecting AMR as the continuing provider of emergency ambulance services, Contra Costa

County will retain a highly experienced and tenured workforce. AMR values our workforce and

the experience they bring to this EMS system, and we will continue to deploy a variety of

strategies to retain these skilled and motivated employees in the years ahead, including providing

increased opportunities for interaction, decision-making, and promotion. At the same time, we

will continue working to attract new employees who will mirror their commitment to the

community. AMR offers Contra Costa County:

• A stable full-time workforce with extensive EMS experience – 63% of our Paramedics have

been with AMR for at least 5 years –as well as a motivated part-time workforce, many of

whom are former full-time employees who now work for local fire and law enforcement

agencies

• A compensation package widely considered to the best in the industry, including a 401(k)

savings and investment plan with a 100% employer match (up to 5% of annual earnings)

• Successful recruitment and retention strategies that are reflected in our average annual

turnover rate of 7.65%, which is low by industry standard

• An excellent relationship with field personnel that results in open communication and

improvements to the EMS system

• A new Labor-Management Partnership Program that focuses on joint problem solving

• A new full-time Employee Advocate who addresses concerns and proactively plans to enhance

employee satisfaction

• A variety of recognition efforts through our Employee Action Committee, including our

Employee Anniversary Program

• An extensive array of career opportunities, including a commitment to implement our

“Passport to Success” leadership development program

• Our efforts to promote a workplace that is sensitive to diversity, with training based on

findings by the EMS Cultural Disparities Project

• A comprehensive safety program that includes employee participation, continually improved

safety equipment, a Field Safety Committee, and driver training


32

3.1 Compensation and Benefits

AMR currently operates under a Core Bargaining Agreement (CBA) with the local union that is

valid through June 30, 2006. The CBA outlines specific compensation and benefits for all non-

exempt field employees as documented in the completed Form B, which can be found in the

attachment binder behind the tab labeled “Required Documents”.

Wages and Benefits

AMR is committed to providing long-term career opportunities for employees. To do this, we

recognize that we must reward our experienced personnel by offering a comprehensive

compensation package that actively rewards tenure. Our benefits are described in Section 3

attachments.

AMR’s wages are some of the highest in the industry and include annual wage scale

adjustments. These adjustments – based on the Consumer Price Index in San Francisco – are

determined each July and range from 4% to 6%, plus step increases based on years of service.

An additional hourly premium is provided to personnel serving as Alternate Supervisors or

Field Training Officers (FTOs), ranging from fifty cents to one dollar per hour. Personnel who

are certified as Critical Care Transport-Paramedics earn an additional differential of 24%.

Retirement Planning

AMR participates in a tax-deferred 401(k) savings and investment plan administered by

Fidelity Investments, helping employees plan for their retirement years. Under the CBA,

AMR matches 100% of full and part-time union employees’ contributions, up to 5% of an

employee’s annual gross earnings.

Fidelity provides a high level of support to help employees plan their investment strategy, at

no charge. For example, employees can select to invest their money in “Freedom Funds”,

where investment professionals provide strategic asset allocation based on the employee’s

targeted retirement date, offering a simple approach to long-term retirement investing.


33

3.2 Commitment to Incumbent Workforce

AMR is privileged to have in place a team of 159 highly experienced, full-time EMS professionals

who will continue to provide services to Contra Costa County. These professionals bring a wealth

of knowledge regarding the EMS system’s unique needs. Our employees provide ongoing,

valuable feedback and are actively engaged in monthly Employee Action Teams and

labor/management forums.

To demonstrate AMR’s continued commitment to our workforce, we have proposed throughout

this response several significant enhancements that will benefit our personnel, such as:

• New Type III modular vehicles, with more space for patient care and a more comfortable cab

environment

• Additional Field Supervisors, increasing support for our field personnel

• Expanded training to earn Critical Care Transport-Paramedic certification

• Enhanced career paths for employees, such as formal succession planning programs

• In-vehicle mapping capabilities through our Automatic Vehicle Locator (AVL) system

• Improved safety equipment, such as helmets and brush jackets

• Enhanced training for identified personnel to work on Quick Response Vehicles (QRVs) in

outlying areas of the county

Employee Advocate

Under the new contract, we will create a new, full time Employee Advocate position. This

individual will focus on ensuring employee satisfaction and will be tasked with addressing

employee concerns, such as payroll or equipment issues, or assisting personnel who have been

injured on-the-job.

The Employee Advocate will also be responsible for proactively improving the work

environment through an enhanced employee recognition program, participation on Employee

Action Teams, and improved communication with field employees. A job description for this

position can be found in Section 6 attachments.


34

Labor-Management Partnership Program

AMR is also working with our labor union to implement a new vision for partnering with our

employees and labor union – a vision that embraces joint problem solving. This innovative

Labor-Management Partnership Program will fully integrate our union leadership into daily

and strategic decision-making processes. Union leaders and members will be fully

knowledgeable about our market environment, budget, and performance requirements.

Through this labor-management partnership, our employees will be able to understand what

contributes to AMR’s success and what they can do to make a real difference. Thus, we will

provide our employees with a secure but challenging work environment, where groups of

employees are largely managing their own work responsibilities as if it were their own

independent business.

Opportunities for Professional Growth

AMR believes in promoting from within, and 100% of Field Supervisors and our senior

management team in Contra Costa County were promoted from front-line roles. We provide

several programs that encourage employees to pursue career growth with our company,

including our succession planning courses outlined later in this section. In addition to more

common promotional opportunities, such as promotion to a Field Supervisor position, we offer

other career paths in areas like deployment strategy, safety and risk management, or quality

improvement. AMR employees also benefit from other options for expanding their knowledge

and skills, including:

Working on a Critical Care Transport (CCT) team

Serving on medical advisory committees and other county or state task forces

Serving as instructors in our continuing education courses and skills labs

Serving as a preceptor or Field Training Officer

In addition, and in response to employee feedback, AMR will launch a new and sustained

effort at defining and supporting a clear career path for EMS personnel under our new contract

with Contra Costa County. This program will consist of the following concurrent activities:


35

Identifying incentives for accepting a promotion from the field level to management

positions, such as training and higher education opportunities.

The creation of several new promotional opportunities by adding more Field Supervisor

and CCT-P positions.

Adopting a “Passport to Success” program, a tool that helps employees achieve their career

desires. (See Section 3.5, Leadership and Supervisory Training, for a more detailed

description of “Passport to Success”.)

Reward and Recognition

AMR takes every opportunity possible to recognize and reward our personnel. One key

enhancement is our Employee Anniversary Program, which recognizes personnel for their

years of service with AMR and acknowledges their contributions. This formal program

includes presenting pins for years of service, as well as gift certificates and other items for key

employment milestones. Other recognition programs include:

EMS Week celebrations

Employee Appreciation Committee

Recognition of significant clinical milestones, such as saves and births

Recognition of employee anniversaries and life events

Nominations and service awards for local, regional, and national programs

Seeking positive media coverage for individual and team successes

Posting customer commendations and filing them in personnel files

Seeking county and state EMS awards for outstanding personnel

Posting customer feedback cards and letters from patients and families

Publishing feature stories in AMR’s regional and national newsletters (see samples in

Section 3 attachments)

Participation in the “Stars of Life” employee recognition program sponsored by the

American Ambulance Association


36

Other Retention Strategies

Several other programs are targeted at providing a work environment that meets the needs of

our employees:

Shift Options – A variety of shift options, such as 24-hour Kelly schedules, 10-hour shifts,

and 12-hour shifts, giving employees the ability to meet personal needs and volunteer in

the community.

Workload Protection – If part-time personnel cannot fill overtime hours, assignments are

made according to our Core Bargaining Agreement. In addition, we build in protection

mechanisms to ensure that personnel have the opportunity to get adequate rest between

shifts.

Part-time Opportunities –While most of our employees work full time, AMR has a

variety of work schedules that allow employees who wish to work part-time the

opportunity to do so. More than 85% of our part-time Paramedics are former full-time

employees who now work simultaneously for local fire agencies.

Job Sharing – Two employees who wish to work part-time may share a full-time position

and retain some benefits – one person gets benefits and the other receives paid time off.

3.3 Recruitment, Selection, and Orientation

Contra Costa County residents currently benefit from AMR’s highly specialized employee

recruitment, screening, and orientation process, which was custom-designed to ensure that only

the most qualified, competent personnel serve our customers. Interwoven with our Continuous

Quality Improvement (CQI) program, the process focuses on proactively identifying superior

candidates and then providing the training needed to ensure their ability to achieve success.

Recruitment

Our extremely successful recruitment program is demonstrated by our full staffing status in

Contra Costa County, along with our waiting list of qualified candidates. Our field personnel

play a key role in screening new employees and identifying the best candidates. In addition,

our recruiting program is sensitive to achieving a diverse workforce, as discussed in Section

3.6.


37

Recruitment efforts start by publicizing openings in weekly employment bulletins, our

company’s Web site, and advertisements in trade journals. Our Human Resources Department

also stays in contact with a variety of Paramedic training programs nationwide and promotes

AMR at conferences and job fairs.

In addition, AMR’s Northern California Training Institute (NCTI) gives us an unprecedented

opportunity to recruit some of the finest new professionals in the field of EMS. Founded in

1988, NCTI maintains seven campuses stretching from Santa Barbara to Northern California’s

Siskiyou County, including a campus in Contra Costa County through Los Medanos College.

NCTI is the largest Paramedic training school in the United States, graduating more than 500

Paramedics annually. It is also the largest training school ever accredited by the Commission

on the Accreditation of Allied Health Education Programs.

Selection

AMR’s “Selection for Success” screening program uses a multiple-step approach to identify

those applicants most likely to succeed as field personnel. It includes:

A standardized application and written exercises

A standardized screening interview conducted jointly by our Human Resources department

and designated field personnel

A realistic job preview, using a video that correctly identifies the tasks related to fieldwork,

as well as our crews’ roles and responsibilities in the overall EMS system

Structured clinical and administrative oral interviews that assess not only a candidate’s

training and clinical skills, but also his or her motivational and interpersonal skills

Reference and background checks that include a seven-year criminal and DMV record

check, as well as a review of each applicant’s credentials and references

A pre-placement drug screen and physical examination

Orientation

Our orientation program is focused on incorporating new employees into our customer-

centered culture and providing a foundation for learning specific to community needs. It

includes the following components:


38

Component Total Hours

Initial classroom instruction, with company overview 32

Local and EMS Agency orientation 32

Field training, which includes evaluation of driving skills 72 for Paramedics

48 for EMTs

Emergency vehicle operations course 8

Total orientation program 144 for Paramedics

120 for EMTs

Topics covered during the initial classroom instruction can be found in Section 3 attachments,

including the table of contents from our Standard Operation Procedures manual. An

additional, mandatory four-day orientation to the local EMS system is also required.

Candidates who attend and successfully demonstrate competence in all areas then proceed to

the field orientation program.

Field Training and Evaluation Program

During the field training component of orientation, new employees work with assigned Field

Training Officers (FTOs), who oversee their training and provide evaluations. The FTO’s

goals are to ensure that the employee is a sound clinical practitioner, understands local policies

and procedures, and adheres to values related to customer service. During field training and

evaluation, the FTOs coach, team-build, evaluate, and prepare the new employee for the EMS

environment. They also use this time to identify clinical or operational problem areas that may

require remediation or additional off-line training time. The FTOs use direct observation, as

well as an analysis of the electronic Patient Care Report (ePCR) data to monitor performance.

As part of the evaluation, all new field personnel complete checklists of the skills and

knowledge needed to perform effectively in Contra Costa County, found in Section 3

attachments. In addition, they must complete daily quizzes covering area familiarization;

national, state, and local standards; and medical protocols.

AMR periodically recruits and carefully screens FTO candidates from the field, who are then

trained by our Clinical and Educational Services (CES) team. FTOs also provide critical CQI

functions, such as peer chart review, remedial performance training, and evaluation for


39

existing field staff. Our FTOs are tenured field practitioners with exceptional clinical skills, as

well as communication and teamwork skills.

Driver Safety and Emergency Vehicle Operations

All new employees must participate in and pass our intensive Emergency Vehicle Operator

Course (EVOC) training program. This program, which is one of the most comprehensive in

the industry, includes an 8-hour classroom component, as well as practical hands-on training,

with behind-the-wheel observed instruction by an FTO. Topics covered during our EVOC

program can be found in Section 3 attachments.

3.4 Field Supervision

Under the new contract, AMR proposes to assign one on-duty Field Supervisor in each of the areas

of the county (west, east, and central), for a total of nine Field Supervisors providing 24-hour

coverage, 7 days a week. By aligning our Field Supervisor assignments with fire agency battalion

shift schedules, we will create an environment for consistent work relationships and interactions.

In addition, this command structure increases the daily supervisor-to-field staff ratio from its

current 1:90 to 1:30, a 300% increase, enhancing accessibility to our employees and allied agency

partners.

AMR is committed to supporting and empowering Field Supervisors to effectively manage day-to-

day operations in Contra Costa County. Strategies and tools employed to provide the necessary

level of support for supervisory efficiency and effectiveness include:

• Technology –Tools that allow supervisors to continually monitor the system and complete

mandatory administrative tasks while remaining in the field, including wireless laptop

computers with access to CAD data and e-mail, as well as cellular phones, radios, and pagers.

• Training – Focused training on skills needed to effectively manage workforce issues, such as

communication, conflict resolution, decision-making, performance management, employment

law, and coaching and training field employees.

• Regional Support – Direct access to AMR’s regional support departments and leadership

team on a 24 hour basis, including Information Technology and Support, Safety and Risk

Management, CES, Fleet Maintenance, and Human Resources.


40

In addition, under the new contract, AMR proposes to require all our Field Supervisors to

complete Ambulance Strike Team Leader Training, enhancing their preparation for their critical

public safety leadership roles as part of the statewide disaster response system.

3.5 Leadership and Supervisory Training

Developing the next generation of leaders is critical for the long-term success of any organization,

especially one such as AMR, which is labor-intensive and promotes from within whenever

possible. This practice of promotion from within and developing our own leaders has many

benefits for Contra Costa residents, including eliminating the steep learning curve experienced by

outside hires, providing a career path for our employees, and improving employee morale.

Recognizing that leadership requires additional skills, AMR’s Leadership Succession Planning

Program helps eligible employees gain the skills they need to accept promotions and provides a

pool of qualified internal applicants for openings that occur in the leadership ranks. Everyone

currently in a leadership role is required to participate in this program, as are all employees who

have been selected or identified as potential leaders within the organization.

In addition, many of our leaders have also completed external leadership training, such as our

Operations Director, Leslie Mueller, who completed the EMS Management Training Institute

program in 1995 (completion certificate can be found in Section 3 attachments). We will continue

to explore program enhancements that incorporate industry best practices into our company’s

leadership training programs.

The design of AMR’s Leadership Succession Planning Program includes tiered learning specific

to each leadership level — Supervisor, Manager, Director, Vice President, and CEO. As leaders

reach another level, they are required to receive additional training based on their new role in the

organization. The educational elements for each tier of our leadership training are listed in Section

3 attachments. Our program includes:

• Leadership, Education and Development University (LEAD U) – an in-house course taught

by department leaders on critical industry topics such as employment law, compliance, and

finance. A detailed description of our LEAD U program can be found in Section 3

attachments.


41

• Development Dimensions International (DDI) – a program that helps develop leadership

skills such as conflict resolution and coaching for success. An outline of DDI training is

included in Section 3 attachments.

• Accelerated Development Program (ADP) – provides our leaders with mentors in higher-

level management positions who can provide coaching and serve as a resource for problem

solving.

Passport to Success

The “Passport to Success” program is a succession planning tool that is employee-directed and

individualized to the employee’s needs and career desires. Designed to assist employees as

they progress along the succession path, the program is based on the traditional concept of a

passport. In our program, the employee’s “passport” lists the different areas or subjects the

employee must navigate to successfully complete his or her succession preparation program.

The competencies and skills contained in the passport are unique for each position. Additional

items can be added to the passport as determined by the mentor and the employee, depending

on an individual’s specific developmental needs. For instance, if it is recognized that some

second-language skills would be helpful for the employee’s career growth, this may be added

to the passport for eventual completion. The time-frame for completion of each individual’s

“passport” varies depending on the individual, the desired target position within the company,

and the frequency of learning opportunities.

3.6 Diversity Awareness

AMR’s workforce in Contra Costa County reflects the success of our policies and practices

regarding equal employment opportunity. For example, our workforce is 32% female, a

significant accomplishment in the EMS industry.

In addition to maintaining a diverse workforce, AMR has worked collaboratively in Contra Costa

County to address the issue of cultural competency training for emergency responders through the

EMS Cultural Disparities Project. The interest in exploring this issue and developing an effective

training program for emergency responders is wide spread and includes county health workers,

county emergency services administrators, and community members.


42

The goal of the project is to develop a training guide for EMS personnel that will provide them

with culturally appropriate skills when interacting with the diverse population of Contra Costa

County. To most effectively achieve this goal, different cultural and linguistic communities

participated in focus groups to define the issues they would most like addressed by the training.

AMR is now working to implement the focus group findings throughout our Contra Costa

operation. For example, under the new contract, we will not only continue to offer diversity

awareness training for all new hires at orientation, but also during annual mandatory refresher

training for all employees. An outline for the diversity training can be found in Section 3

attachments.

In addition, AMR offers a salary differential to employees who speak a second language. We also

actively recruit in minority venues, including Spanish and Asian magazines, churches, and

schools. Sample advertisements are provided in Section 3 attachments. Contributing to a cultural

environment that encourages diversity at all levels, AMR also offers training in diversity topics

and cultural awareness to all company leadership personnel, in addition to the employee personnel

mentioned earlier.

3.7 Health and Safety Programs

A key area affecting our employees and our patients is safety. AMR views safety and risk

management as a cornerstone of a healthy, successful operation, and we manage this area with

unparalleled excellence. We aggressively address potential safety issues and manage the

associated risk using a team of full-time safety professionals, a Field Safety Committee, a local

Safety Coordinator, comprehensive training, and strict incident investigation policies.

All employees receive training on safety and risk management during their orientation to the

company, as well as mandatory refresher safety training annually. They also receive a copy of our

extensive Health and Safety Manual. A copy of the manual’s Table of Contents has been included


Safety Program Oversight

Our full-time Safety and Risk Management personnel at the regional and national level include

a regional Safety Director and Regional Safety Manager. Based in Livermore, our regional


43

Safety Manager, David Caraveo, has more than 18 years of experience, including work as an

Industrial Hygienist. His resume is included as part of Section 6 attachments. In addition to

his duties during business hours, he is available 24 hours a day for consultation with AMR or

County personnel. Mr. Caraveo is also responsible for gathering and compiling regional safety

information, implementing required training and corrective action, and monitoring the results

of employee compliance.

Safety Committee

AMR’s safety successes are only possible because of the commitment of our employees to

providing a safety culture within our operations. Key to this commitment is our local

employee-driven Safety Committee, which focuses on examining safety issues and

recommending behavioral, equipment, or workplace modifications. The committee addresses

safety issues specific to Contra Costa County. For example, recent agenda items have

included back injury prevention issues and posting the height of each ambulance on a sticker

above the rear view mirror to reduce the risk of overhead ambulance contacts.

Safety and Risk Management Data Analysis

With the goal of reaching and maintaining the highest possible safety performance at all levels

of the organization, AMR has established benchmarking methods based on safety-related Key

Performance Indicators (KPIs). These KPIs measure the incidence of injury and illness against

activities aimed at the control of losses. AMR has the unparalleled ability to benchmark safety

best practices for our operations in Northern California to more effectively track and evaluate

safety results over time. The ever-increasing amount of comprehensive quality data allows us

to develop safety and risk management programs that are best suited to the needs of our Contra

Costa County operation.

For example, during analysis of a KPI report in early 2004, we noticed an increase in lifting-

related injuries resulting in lost work days. We discovered the problem to be a training

deficiency in lifting and handling the gurneys. To reduce injuries all FTOs were re-trained in

instruction of lifting, patient handling, and gurney handling techniques.


44

Pulled from KPI data, the following graph shows a dramatic reduction in lost work

days/missed shifts following the training. As the graph demonstrates, AMR peaked at 80

missed work shifts in April 2004. Following the training of FTOs, which began in May, there

were no BLS missed shifts from June through August, and there was a 75% reduction in lost

works days/missed shifts. AMR can provide similar preventive data to the County, upon

request, under the new contract.

Safety Training

Employees are required to complete safety training during new employee orientation, and they

are also required to complete annual refresher trainings. Major categories within the health

and safety curriculum include:

Safety Fundamentals

Physical Hazards

Musculoskeletal Injury Prevention

Vehicle Safety

Workplace Security & Patient

Restraint

Codes of Safe Practice

Hazard Communications

Hazardous Materials

Infection Control

Bloodborne Pathogens

Airborne, Droplet, & Contact

Pathogens

Respiratory Protection and Fit

Testing

Contra Costa Lost Work Days

0 10 20 30 40 50 60 70 80 90

Jan Feb Mar Apr May Jun Jul Aug

ALS

BLS


45

As further commitment to our intensive training, we provide all supervisors with a strong

foundation in safety and risk management, with instruction covering:

How to assist employees with on-the-job injuries

Employee Assistance Programs

Bloodborne and airborne pathogens

Contact exposures to ensure employees receive timely and proper treatment

Accident investigation and who to notify in the event of an incident

Personal Protective Equipment

We provide our employees with a full complement of appropriate personal protective

equipment (PPE), as shown on the following table. Under the new contract, we will also

provide our employees with helmets, specialty jackets, and hearing protection.

PPE

Exam gloves in appropriate sizes Easily accessible sharps disposal containers

Eye protection on person, in carry-in bags,

and in the unit

Red biohazard and yellow infectious linen

bags

N95 respirators Water-soluble (melt-away) laundry bags

Bag valve masks and personal pocket

masks

Labeled bags for blood specimen tubes

Combination visor-masks Disposable absorbent barriers (chux)

Impervious gowns and shoe covers Waterless virucidal hand cleaner and

towelettes

Field employees are trained and fit-tested in the proper use of National Institute of

Occupational Safety and Health (NIOSH)-approved respirators for tuberculosis (TB)

protection. Special emphasis is placed on the early identification of patients who are

considered suspect TB cases so that employees can take appropriate precautions in advance of

significant exposure. We also offer non-latex PPE for those employees and patients who may

be allergic to latex.


46

Ensuring Driver Safety

In addition to our new hire driver

training program, described in

Section 3.3, we provide remedial

training for employees who have

been involved in a preventable

collision, have deficient driving

skills, or who need additional skills. This remediation can include driving with an FTO as a

third person, attending a remedial EVOC, driving with a Safety Coordinator or Safety

Manager, viewing and being tested on an instructional CD, or attending a driving simulator

class.

AMR recognizes that minimizing disruptions during driving also helps to ensure safe driving

practices. To help our drivers maintain safe practices, AMR will provide them with cellular

phone head sets so they can focus on driving and vehicle handling, rather than on holding and

handling a cellular phone.

Finally, AMR subscribes to the California Department of Motor Vehicles’ “Pull Notice”

Program, which tracks employee infractions of the California Vehicle Code. If a violation is

committed, supervisors investigate the incident to determine if the issue has been cleared and

to determine the circumstances involving the incident. Once facts are gathered, the supervisor

consults with our leadership team and appropriate actions are taken.

National Safety Initiative

Maintaining a corporate emphasis on safety, our company has developed and implemented a

nation-wide initiative to enhance the safety of each operation. Every month, local supervisors

personally contact every field employee to discuss an identified safety theme. Examples of

recent safety topics include intersection safety, lifting techniques, and stretching while posting.

These safety-related discussions increase safety awareness by our employees and enhance

rapport between supervisors and field personnel. Supervisors are required to document their

discussions, and these contacts are monitored.


47

The national initiative uses a combination of media to carry the selected message to the

workforce, including those listed below. Samples are included in Section 3 attachments.

Custom posters displayed in each location for the entire month.

Letters to each Supervisor and employee detailing each month’s safety theme.

A pocket card featuring related talking points to facilitate supervisor discussions with field

employees.

Immunizations and TB Testing

As a chief component of our infection control program, we track and monitor the hepatitis-B

and influenza immunization status for field employees. We offer the hepatitis-B immunization

series to each employee before initial assignment, at no cost to the employee. We then track

employees’ hepatitis-B titers and provide booster immunizations as needed. This

immunization program is compliant with OSHA mandates and exceeds current Centers for

Disease Control and Prevention (CDC) recommendations.

AMR also has a comprehensive TB control program, including a skin-test process. After

initial baseline skin testing at the time of hire, each employee is required to complete a health

questionnaire and a TB skin test annually. This program facilitates early identification of

employees with TB infection, increasing the efficacy of prophylactic drug therapies that are

usually successful in preventing active TB disease. In addition to the skin-test program, each

employee receives initial and annual refresher training that covers the various control measures

that are effective in reducing or preventing the risk of TB transmission in the field setting.


48

Section 4: Operations Management

As the incumbent emergency ambulance provider, AMR offers unparalleled experience in this

clinically focused, high-performance EMS system. Under the new contract, we propose the

following key operational initiatives:

• Reduced response time standards

• 31 ambulances deployed during times of peak demand, as well as 4 Quick Response Vehicles

• 12 non-system units, available to supplement the system in the event of unusual demand

• Subcontracts with fire agencies to deploy 6 Supplemental Transport Ambulance Resource

(STAR) Cars

• An enhanced staffing model, with dual paramedic staffing offered for Zones A and E

• New, roomier Type III ambulances, which will be serviced at our fleet maintenance center in

Concord

• A partnership with Consolidated Fire Communications, enabling Consolidated Fire to become

the primary dispatch center for all of AMR’s Advanced Life Support (ALS) units serving the

county

4.1 Response Time Standards

AMR is proud to have met or exceeded response time standards countywide for the previous five

years. In addition, to prepare for the new zone structure, in September 2004, we adjusted our

deployment and posting plans to conform to the new structure. The following table demonstrates

our Code 3 response time compliance for September in the new response zone structure:

Code 3 Compliance, September 2004

Compliance Standard

Zone A

(95%) 10:00 min.

Zone B

(90%) 11:59 min.

Zone C

(90%) 11:59 min.

Zone D

(90%) 11:59 min.

Zone E

(90%) 11:59 min.

Rural

(90%) 20:00 min.

Responses 699 588 1,379 768 197 146

Delays 33 42 75 45 14 4

Compliance 95.28% 92.86% 94.56% 94.14% 92.89% 97.26%


49

Under the new contract AMR proposes the following lower response time standards:

• Zones B, C, D, and E – In order to offer greater parity in urban/suburban areas, we

propose a lower Priority 1 response time standard of 11:45 minutes (instead of

11:59 minutes)

• Bethel Island and Discovery Bay – While the RFP designates Bethel Island and

Discovery Bay as rural response areas, AMR recognizes that they are growing

communities, and thus we propose a significantly lower Priority 1 response time standard

of 16:45 minutes (instead of 20:00 minutes) for these cities

The following chart shows these enhanced response time standards.

AMR’s Response Time Compliance Commitment

Priority Level

ER Zone Compliance Urban/ Suburban

RFP Requirement

AMR Proposed Standard

Rural/ Unincorporated RFP Standard

AMR Proposed Standard

Priority 1

B, C, D, E

90% 11:59 min. 11:45 min. N/A N/A

Priority 1

Bethel Island and Discovery

Bay (Zone E)

90%

N/A

N/A

20:00 min

16:45 min

Data Tracking and Reporting

Under the new contract AMR will continue reporting response time compliance data by the

calendar month, with the understanding that the County reserves the right to examine any 30-

day period. With our proposal to have Consolidated Fire dispatch all AMR’s system units (see

Section 4.5 for details), the County’s CAD system will record response time data. AMR will

interface with Consolidated Fire’s CAD system, which will transmit accurate, timely response

data on a daily basis. In our agreement with Consolidated Fire to provide dispatching services

under the new contract, AMR will delineate the code set that must be captured to allow us to

produce these comprehensive reports for the County. Before contract implementation, we will


50

meet with the County to learn what specific data is desired so that the Consolidated Fire CAD

system captures all necessary data.

In addition to the required performance reviews, AMR can also provide customized reports

should the County desire. For example, we can provide a one-page Key Performance Indicator

(KPI) report that sorts calls by type or by clinically significant events. Per RFP requirements,

AMR will provide the County with greater detail in those rare instances we request

exemptions. Further, we will begin trending this data for review and recommendation by our

System Status Committee.

4.2 Deployment Plan

AMR has a wealth of experience with EMS system design and redesign in Contra Costa County,

as well as other high performance systems. Our deployment plans offer real-world solutions to

real-world challenges in terms of county geography and population. For example, both a high-end

urgent care center and a hospital are scheduled to open in East Contra Costa County in 2005 and

2007, respectively. Although these facilities do not yet affect our deployment plan, we remain

alert to the future impact of these facilities on the allocation of system resources.

Under the new contract, AMR will deploy 4,024 weekly transport unit hours in order to meet

the proposed stricter response time standards. A map of our proposed deployment is included in

Section 4 attachments showing proposed post locations.

Our resources will include ambulances, as well as Paramedic Quick Response Vehicles (QRVs)

strategically posted in areas that experience low call volume. We will continue to deploy four

QRVs from fire stations in Discovery Bay/Byron, Bethel Island/Oakley, and Crockett. We also

propose additional system resources, as shown on the following table:

Type of Resource Number of Units

at Peak Deployment

Weekly Unit Hours

AMR Ambulances 31 4,024

AMR QRVs 4 672

Fire-based STAR Cars 6 N/A

AMR ALS Field Supervisors 3 N/A


51

Our System Status Plans (SSPs) are continually examined by our System Status Committee to

continuously adjust our plan to meet anticipated demand. The committee is comprised of our

EMTs and Paramedics, who have daily experience navigating the roadways of Contra Costa

County, as well as deployment analysts. Under the new contract, AMR will invite Consolidated

Fire dispatching personnel to participate in AMR’s System Status Committee.

Supplemental Transport Resources – STAR Cars

As further evidence of our commitment to the EMS system and to enhance our service to the

community, AMR will subcontract with local fire agencies to deploy six ambulances known as

Supplemental Transport Ambulance Resource (STAR) Cars in locations determined by the

Integrated Quality Leadership Council. STAR Cars are transport-capable, rescue-type vehicles

that will be staffed by fire agency personnel and will only be used in pre-defined and urgent

circumstances. Because the STAR Car units will only be used to supplement our company’s

transport resources, they will bring a substantial number of new response resources into the

local system. When fire agencies run the call, AMR will pay them a negotiated transport rate.

Additional Resources

In addition to our system ambulances, QRVs, and STAR Cars, AMR also offers a host of

additional resources to ensure all residents of the county have access to rapid prehospital care,

including:

AMR Paramedic staffing on a Contra Costa County Sheriff’s patrol boat during select

weekends and holidays

Critical Care Transport (CCT) units that can transport patients out of Emergency

Departments, freeing up hospital beds and avoiding diversions – with our ability to also

have our CCT units respond to large multi-casualty incidents

AMR bicycle teams at large events to ensure that a Paramedic initiates patient care until

other responders can arrive on scene and maneuver through crowds

A Bariatric ambulance unit, designed to safely transport patients who weigh more than

600 pounds


52

A Special Response Vehicle that can serve as a communications and medical command

center during a disaster

A school bus or similar vehicle to provide transportation to multiple ambulatory patients in

the event of a large-scale incident

BLS Resources

To supplement the system in the event of unusual demand, AMR will staff a portion of our

non-system units using the 1:1 staffing model. Thus, approximately five AMR non-emergent

units staffed with a Paramedic will be available on any given day should unusually high

demand exhaust system resources. In addition, all of our non-system BLS units would be

available to assist during times of unusually high demand.

Staffing Model

AMR proposes the following ambulance staffing model:

One EMT and one Paramedic in Emergency Response Zones C and D

A phased in approach to 1:1 staffing for Zone B, to accommodate the fire agency transition

to Paramedic staffing

Dual Paramedic staffing as required by the RFP for Zone A

Dual Paramedic staffing for Zone E – an enhancement to RFP requirements

Deployment Option

AMR offers Contra Costa County a deployment option, with even lower response times for

Bethel Island and Discovery Bay. We will provide Priority 1 response times to these two

growing communities of 11:45 minutes (instead of the RFP requirement of 20:00 minutes).

With this option, we will deploy a total of 4,494 weekly transport unit hours. The following

table compares our core proposal with this deployment option. Pricing for this option can be

found in Section 8.


53

Item RFP Requirement AMR Core Proposal

AMR Optional Proposal

Priority 1 Response Times

20:00 minutes 16:45 minutes 11:45 minutes

Weekly Transport Unit Hours

N/A 4,024 4,494

4.3 Ambulance and Support Vehicle Fleet

AMR understands that high-quality vehicles and ongoing fleet maintenance play a critical role in

employee satisfaction and the success of the local EMS system.

Ambulance Fleet

AMR will furnish 39 new Type III ambulances. Type III vehicles provide a large modular

patient compartment that gives the crew more room to maneuver, and a much larger storage

capacity for equipment and supplies. The ambulances also have an extended cab space that

allows the driver and passenger to position themselves more comfortably by extending and

reclining their seats. These improvements will enhance the ability of our field personnel to

provide high-quality care for one or more patients.

AMR recently hosted a road show throughout Contra Costa County, giving our personnel the

opportunity to tour one of the proposed Type III vehicles. Feedback on the new vehicles was

overwhelmingly positive, and crews were impressed with the increased leg room, reclining

seats, and extra storage capacity, as well as the additional rear space for enhanced patient care.

The units also feature a HEPA filtration system that removes 99.97% of airborne particles,

including bacteria. Other new features include ducted heat and air conditioning in the patient

area, allowing more even air distribution, and LED lighting for vehicle safety and reliability.

In an effort to exceed the County’s minimum standards of 200,000 miles to replace vehicles,

AMR will place all front-line ambulances into reserve status at 195,000 miles.


54

Field Supervisor Units and QRVs

AMR will provide three Field Supervisor vehicles, allowing us to deploy three supervisor units

24 hours a day. We will continue using Ford Expeditions as our Field Supervisor and QRV

vehicles.

Opticom Devices

All AMR vehicles will be equipped with Opticom-compatible devices. These emitter devices

allow ambulances to change traffic signals in their favor up to a distance of a quarter mile,

speeding their Code 3 arrival on scene and at the receiving hospital, while lessening motorists’

confusion at intersections and preventing collisions. Many intersections in Contra Costa

County are already equipped with receivers for the Opticom system. Since many public safety

agencies also have the Opticom devices in place, the system prioritizes for multiple vehicles

entering the intersection.

4.4 Equipment and Fleet Maintenance

Rather than simply performing scheduled routine maintenance to keep our vehicles in superior

condition, AMR has developed a comprehensive preventive maintenance program, unrivaled in

our industry, to ensure the reliability and safety of our vehicles. Our preventive maintenance

program focuses on inspections and maintenance at four intervals. If at any point in the process

equipment does not meet standards, it is placed out of service for repair, upgrade, or replacement.

Each day, crews check, inspect, clean and test all equipment before beginning their shift, reporting

any problems to the Field Supervisor immediately. They also inspect the appearance of each

vehicle at the start and end of each shift. Any damage is reported immediately, and the vehicle is

removed from service as soon as possible. When completing the daily vehicle inventory, field

personnel use the inventory checklist found in Section 4 attachments.

If any repairs are needed, crews report the problem using the forms found in Section 4

attachments. Once repairs are completed, a copy of the order documenting completion is filed at

the fleet maintenance office and another copy is kept with the vehicle.

AMR will continue to perform scheduled maintenance as detailed in Section 4 attachments, where

vehicles are serviced every 5,000 miles, with additional tasks performed every 15,000, 30,000 and


55

60,000 miles. Mechanics use the Preventive Maintenance

Inspection form included in Section 4 attachments.

AMR’s Fleet Manager and Field Supervisors meet weekly to

discuss maintenance schedules. Field Supervisors also

perform frequent vehicle spot checks.

Fleet Service Center

AMR vehicles for our Contra Costa County operation will continue to be maintained at our

company’s fleet center in Concord. We perform routine maintenance, tune-ups, brake service,

transmission replacement, differential rebuilding, front-end work, steering and suspension

repair, complete tire service, and minor body repairs — all in one location. Additionally, we

have seven other maintenance facilities throughout Northern California that can provide back-

up services, parts, and even mechanics if assistance is ever required for the Concord team.

AMR’s fleet service uses a sophisticated computer system for parts inventory, vehicle records,

and cost evaluation. We also use diagnostic scanning technology that interfaces with onboard

computer-based systems, allowing efficient diagnosis of key vehicle systems such as engine

injector problems or transmission shifting errors.

The opportunity to work with our sophisticated vehicle diagnostic scanning technology

enables us to retain a skilled fleet maintenance team that is at the top of its field. We also offer

a competitive compensation package, which includes paying for employees to obtain

specialized training through the Ford Motor Company and the National Institute for

Automotive Service Excellence (ASE).

Fleet Record Keeping and Data Analysis

AMR uses a commercial fleet maintenance software package known as Ron Turley and

Associates (RTA) to document service and repairs, track mileage, and generate a full range of

reports, including vehicle service schedules. As the preventive maintenance work is

performed and the data posted, RTA updates the vehicle maintenance history, deducts the parts

used from inventory, and tracks maintenance costs. As a result, our mechanics have at their

fingertips the entire maintenance history of the vehicle – from the last oil change to any repair


56

performed – enabling them to be thorough and precise, while efficiently using their time. We

use our RTA software nationally, so we are able to quickly see patterns and get information on

potential issues from our fleet of more than 4,000 ambulances.

Our Fleet Manager monitors and logs the mileage of our vehicles weekly to schedule

preventive maintenance inspections every 5,000 miles – the length of time our research shows

that we can obtain the maximum use of our vehicles without any impact on reliability. This

fleet data becomes part of our weekly Key Performance Indicators (KPI) report, giving us

continuing hard data about all elements of our operation, such as vehicle mileage and how

vehicle parts perform. Every week, all directors throughout our company participate in a

group conference call to review these KPI reports, allowing them to monitor our operation and

pinpoint any emerging trends. A sample KPI report is included in Section 4 attachments. We

can provide the County with a monthly detailed report showing all preventative maintenance

and repair information.

Finally, our proven vehicle maintenance program enables AMR to sustain our exceptionally

high reliability rate. We define reliability in terms of critical failure — any situation that

requires substitution of one ambulance for another due to a malfunction while on a call. Our

failure rate is far less than 1%, a testament to our constant effort to achieve our goal of 100%

reliability.

4.5 Dispatch Center Operations

On October 13, 2004, AMR met with Contra Costa County Consolidated Fire Communications to

discuss their desired plan for dispatching services under the new contract. Based on that meeting,

AMR proposes a partnership wherein Consolidated Fire will become the primary dispatch center

for all AMR’s Advanced Life Support (ALS) units serving the county. As part of an integrated

response system, Consolidated Fire will use System Status Management (SSM) technology to

dispatch and re-position AMR resources as system levels dictate. Development, monitoring, and

maintenance of the System Status Plan (SSP) will remain the responsibility of AMR.

We believe this partnership will benefit Contra Costa County residents in several ways. For

example, Consolidated Fire will be able to immediately dispatch fire and ALS resources

simultaneously, rather than transferring ALS calls to an AMR communications center. Further,


57

Consolidated Fire dispatchers will know where all fire agency and ALS resources are located in

relation to incident locations, through AVL integration.

Disaster Recovery Plan

AMR proposes to offer our Burlingame Communications Center as a back-up resource in the

event that Consolidated Fire needs assistance in catastrophic situations or if the center needs to

be evacuated. Our Burlingame center has 60 employees and 19 consoles, including one for

supervisory staff. The center handles an approximate 300,000 transports and an approximate

1 million ingoing and outgoing telephone transactions each year. Conveniently located off

Highway 101 adjacent to San Francisco airport, the center provides Emergency Medical

Dispatching (EMD) services for the City and County of San Francisco.

Community Service

Although AMR is proposing that all EMS system calls be dispatched at Consolidated Fire, we

will continue to facilitate participation in the statewide Amber Alert program, which is a

collaborative effort with the California Highway Patrol (CHP). All AMR communications

centers throughout California are automatically notified when an alert has been issued in the

state. Our communications centers then re-broadcast the alert via a group page to our

personnel. With AMR’s substantial statewide presence, we are able to alert a large number of

people any time an Amber Alert is issued. Under the new contract, AMR will notify

Consolidated Fire upon receipt of an alert and work cooperatively with that communications

center to establish the most efficient process to notify ALS crews.

4.6 Communications System

Under our existing contract, AMR dispatches ALS calls for Contra Costa County from our

Communications Center in Burlingame. When Consolidated Fire’s new Computer Aided

Dispatch (CAD) system is fully operational, currently scheduled for February 1, 2005, AMR will

work with Consolidated Fire to test connectivity between AMR vehicles and Consolidated Fire.

Thus, we anticipate a five-month timeframe between new CAD rollout and implementation of the

new contract, during which we will work with Consolidated Fire to ensure a smooth transition of

primary dispatching responsibilities.


58

Onboard Communications Equipment

With dispatching performed by Consolidated Fire, all AMR vehicles will use county radios

and frequencies. Under the new contract, AMR proposes to provide and maintain the

following in-vehicle communications equipment:

Alphanumeric pagers that can interface with any paging company in the market place.

AMR only partners with paging companies that can provide us with customer-priority

pages.

Automatic Vehicle Locators (AVLs) with mobile applications in every vehicle. A map

showing the vehicle location, incident location and the quickest path to the destination

based on street directions and speed limits will appear on a small laptop computer screen.

In addition, the status button will allow crews to provide the dispatch center with instant

en-route or on-scene confirmation (in-vehicle messaging) with the push of a button,

without a crew member verbally providing the information. AMR will work with

Consolidated Fire to choose the technology that will interface best with their CAD system.

Onboard satellite telephones in all Field Supervisor units and the operations center to

allow for uninterrupted ability to communicate with Disaster Medical Assistance Team

(DMAT) or other designated agencies in the event of a critical system failure or

catastrophic event.

Commitment to Advanced Technology

AMR offers advanced technology in the following areas:

Type of Technology Proposal Section

ePCR 2.6

Onboard AVL system 4.6

Virtual Solutions Manager (internet-based continuing education)

2.2

Opticom-compatible devices 4.3

LifePak 12 monitor/defibrillators with capnography and non-invasive blood pressure capability

2.5


59

4.8 Quick Response Vehicles

In a collaborative effort to ensure equitable response times among residents in semi-urban areas

and provide a timelier, more cost-effective ALS response, AMR has partnered with a variety of

fire agencies in the county for several years to provide Paramedic Quick Response Vehicles

(QRVs) in areas that experience low call volume. QRVs are currently deployed from fire stations

in Discovery Bay/Byron, Bethel Island, Oakley, and Crockett. Under the new contract, we will

continue to deploy these valuable resources to better serve local communities. Proposed post

locations and our comprehensive deployment plan are discussed in more detail in Section 4.2 of

this document.

The non-transport QRVs, which are fully equipped Advanced Life Support (ALS) vehicles, are

staffed with one Paramedic. AMR’s QRVs are strategically deployed to meet response time

requirements in zones that do not have engine-based Paramedic First Responders. The QRVs are

dispatched simultaneously with BLS First Responders and the AMR transporting unit. Just as we

devise a posting plan for our ambulances, we use a combination of historical data, dynamic

deployment, System Status Management, and station availability in choosing post locations for

these units.

Historical Overview

Since 1992, AMR has deployed a QRV in Discovery Bay/Byron. In 2002, when the Bethel

Island Fire Department merged with the East Diablo and Oakley fire departments to become

the East Contra Costa Fire Department, effectively disbanding the engine-based Paramedic

Program in Bethel Island, AMR added a second unit in Bethel Island/Oakley at the request of

the EMS Agency. To meet our contract extension requirements, on September 1, 2004, AMR

added two additional QRVs to the system. These two units are currently deployed out of the

Oakley and Crockett fire stations, serving fire districts that do not have engine-based

Paramedic First Responders.


60

Specialized Training

Any employee permanently assigned to a QRV unit will meet with a Chief Officer or designee

of the Fire Protection District in which the QRV is posted to discuss fire station rules, safety,

and expectations.

Paramedics assigned to QRVs must have the training and experience necessary to function

safely as the sole care provider until other resources arrive. Prior to functioning solo as a

Paramedic First Responder, the employee must complete the following:

Field orientation with the Paramedic First Responder Field Training Officer

A Boat Patrol/Boat Safety Orientation with the East Contra Costa County Fire Protection

District and/or the Contra Costa County Sheriff Boat Patrol

The Paramedic must also demonstrate competency in the following:

Customer service and team building

Community partnership activities, such as blood pressure checks or presentations at

schools, churches, and social organizations

Inter-agency decorum and relationships, such as participation in public safety agency

training, sometimes serving as instructor

System status management for First Responders

These employees must meet certain additional criteria, such as:

Current Paramedic accreditation in Contra Costa County

Service in at least three of the last four years as a field Paramedic

At least two years experience as a full-time field Paramedic in Contra Costa County

Proof that no state licensure actions have been taken in the preceding two years

Status as a full-time employee with AMR’s Contra Costa County operation

Personnel assigned to work on QRVs are selected from AMR’s highly seasoned work force.

As call volume on QRVs is typically low, these personnel may also work on EMS system

enhancement projects, including:


61

Working on special education projects, such as authoring articles for company newsletters

and other internal media to educate other field employees

Auditing charts and recommending changes to EMS and company policies

Developing field care audit content and syllabuses for educational and training events

Additional AMR First Responder Units

In addition to our QRV units, AMR also provides Paramedic staffing on a Contra Costa

County Sheriff’s patrol boat during select weekends and holidays. When needed, our QRV

Paramedics may be transported by East Contra Costa Fire Department boats to remote

locations inaccessible by land, such as the many delta islands, in order to provide patient care.

These Paramedics receive special training, and AMR donates these staffing hours. We only

bill for services if a rescue results in a transport by an AMR ambulance.

In addition, we have bicycle teams that can serve at festivals and other large events. These

teams help to ensure that a Paramedic initiates patient care until a fire agency First Responder

or ALS transport vehicle and crew can arrive on scene.

In addition, three AMR Field Supervisor units will be available 24 hours a day, 7 days a

week, staffed by Paramedic-level supervisors and equipped with ALS supplies. They can

function as a First Responder when necessary.


62

Section 5: Commitment to EMS System and Community

AMR is an active participant in the evolution of the Contra Costa County EMS system and has

been throughout our history of service to the community. We have worked with all the local

stakeholders to ensure their needs are met, including the County, our local fire agency partners,

law enforcement, hospitals, and community groups. The result has been the building of a great

deal of trust in AMR’s ability to serve the community, either through a system redesign, through

community outreach, or through our unparalleled disaster resources. We believe AMR has

demonstrated a significant commitment to the community and to the County, which we further

believe has created an effective foundation for the future evolution of the EMS system.

5.1 Participation in EMS System Development

AMR partners with stakeholders in the Contra Costa EMS community on a regular basis to

identify and participate in efforts to enrich and protect the lives of county residents. The following

are some examples of these partnerships:

• 1992 – Implementation of Paramedic Quick Response Vehicles (QRVs) in the communities of

Byron and Discovery Bay. This program has been expanded to include a total of four QRVs

deployed in the county.

• 1997 – Partnered with the Contra Costa Consolidated Fire Protection District to implement an

engine-based ALS First Responder program, including the establishment of joint training

programs.

• 1998 – Partnered with local fire agencies, including San Ramon and Moraga-Orinda, for

Paramedic certification programs, offering shared and expanded training locations and

instructors.

• 2001 – Partnered with El Cerrito Fire Department and Kensington Fire Protection District to

extend AMR’s national purchasing discounts for supplies and equipment as these agencies

launched their own Paramedic First Responder program. AMR received an award for our

efforts, a copy of which is provided in Section 5 attachments.

Most recently, we worked with the County following the release of its consultant’s report and

offered a plan to the County and our system partners by which we could begin implementing the


63

recommended changes immediately and work toward achieving the County’s vision of an

integrated system. Throughout the process, we proactively approached community leaders to help

identify their specific needs for the new system and worked to create specific solutions to meet

those needs. Following approval of the draft plan, AMR began implementing the new system

requirements in September 2004, nearly a year before the new contract start date. Because of this

early start, we have been able to begin making the transition to the one Paramedic/one EMT

program by actively involving our employees in the process and gaining their support, and by

transitioning to the new staffing configuration through attrition – with no negative impact on our

workforce.

The following are further practical and real-life examples of AMR’s commitment to working with

our system partners in Contra Costa County to create and implement innovative solutions for the

continued evolution of the EMS system:

• We provided financial support to the successful Measure D campaign to keep open Doctor’s

Medical Center in San Pablo, and we were a key partner in a joint study to evaluate and

communicate to the community the impacts of these closures.

• Members of our team meet monthly with the Petrochemical Board to conduct skills training

and drills, and we are an active partner in the Shelter in Place (SIP) program.

• AMR participates in “after action” reports and debriefing events at refineries, holding similar

exercises with Bay Area Rapid Transit (BART). A video developed by AMR and BART

about responding to medical emergencies involving BART is now a regular part of AMR’s

and BART’s orientation programs.

• AMR personnel actively participate in the Bay Area Disaster Medical Assistance Team

(DMAT) CA-6, sponsored by the Contra Costa County EMS Agency with oversight by the

U.S. Department of Homeland Security.

• AMR works with a number of law-enforcement agencies – the California Highway Patrol

(CHP) to develop and implement plans related to the transportation infrastructure, including

mitigation strategies for issues ranging from congestion management to the mitigation of

terrorist threats; the Contra Costa County Sheriff’s Department to provide AMR

Paramedics on the Sheriff’s patrol boat during peak demand times; and the Antioch Police


64

Department Emergency Services Division for disaster planning, domestic violence, and

safety programs.

• We support and sit on a variety of County Board of Supervisors’ task forces and

subcommittees, which have a significant effect on our communities and customers. Examples

include the Emergency Medical Care Committee Casino San Pablo impact study and the

SafeBaby program that provides education regarding where and how troubled mothers can

surrender their newborn infants without consequences.

Public-Private Partnerships

AMR is recognized as a committed industry pioneer, working with other EMS system

stakeholders to develop more efficient, clinically sophisticated EMS systems that raise

industry standards and public expectations. In addition to our work in Contra Costa County,

we have helped set the standard for creating innovative and ground-breaking partnerships with

public safety agencies, including those described next.

SANTA CLARA COUNTY

AMR was the principal partner in the innovative system design initiative in Santa Clara

County in 1994. Our experience there provided the foundation for many other public-

private partnership models now implemented throughout the nation. The agreement was

renewed and supplemented in 2001 such that AMR now contracts directly with local

government agencies to provide First Responder services, thus providing an enhanced

level of accountability to the system.

Elements of this award-winning system design include:

Revenue sharing with First Responder agencies in recognition of their value-added

ALS services

Reduced response times for ALS intervention

Supplemental Fire Department-staffed ambulance units within the County for use in

the case of unusual system demand

Creation of full-time First Responder Liaison position

Shared quality assurance and purchasing agreements


65

SAN MATEO COUNTY

Shortly after implementation of the system redesign in Santa Clara County, AMR was the

successful proposer in San Mateo County’s Request for Proposal process, which included

an extensive system redesign, including an option to build on the Santa Clara system.

Innovative elements of San Mateo County system include the following:

Contracting with a Joint Powers Authority (JPA) composed of 17 cities and fire

agencies to provide Paramedic First Responders on all engines.

System accountability rests solely with AMR, which is entirely responsible for meeting

the county’s response time requirements and is the sole contact for the County. In

addition, AMR provides four fully equipped ambulances, which are staffed by fire

personnel in remote and hard-to-serve areas of the county.

AMR provides a variety of support services for the fire agencies, such as quality

improvement program oversight, EMS education and training, medical equipment, and

monitoring of Fire personnel certifications.

Use of a single resource management plan using a sophisticated “move-up” system so

that dispatchers can shift resources to meet anticipated demand; introduction,

implementation and development of our proprietary MEDS ePCR™ system in

San Mateo County.

ALAMEDA COUNTY

AMR pioneered the use of laptop computers in the field for Alameda County. The initial

installation allowed Supervisors to view CAD data and check and modify system status

from the field.

5.2 Public Education Programs

AMR proposes an enhanced community education and outreach effort in Contra Costa County.

Based on epidemiological research, our community outreach programs will evolve as Contra

Costa County’s needs evolve. To develop meaningful programs for the residents of Contra Costa

County, we will use clinical data as the basis for designing and evaluating our community

education programs – all under the oversight of a full-time Community Outreach Coordinator,


66

the Integrated Quality Leadership Council (IQLC), and the County’s Medical Advisory

Committee.

Over the past several years, AMR actively partnered with Contra Costa County by developing and

supporting numerous community programs and events. Some of our activities have included:

• Career fairs at local community colleges to discuss careers in EMS

• Holiday events to promote safety

• Participation in Relay for Life, a local run to promote breast cancer awareness

• Participation in the ‘Every 15 Minutes’ program, in which local authorities work jointly to

educate high school students about the dangerous effects of driving under the influence

• Disaster preparedness programs in schools

• Participation in the Amber Alert Program, broadcasting missing children alerts to all units in

the field

As we go forward, AMR will continue to provide these valued community programs, while

expanding programs focused on identified, local epidemiological trends.

AMR will achieve this through the appointment of a full-time Community Outreach Coordinator,

whose primary responsibilities will be to interpret EMS-related data for Contra Costa County and

coordinate all local community education efforts with the County and our EMS partners. Our

EMS Epidemiologist/Clinical Data Analyst will assist with these tasks. A job description for the

Community Outreach Coordinator can be found in Section 5 attachments.

Measuring and Monitoring Results

On an ongoing basis, we will evaluate the effectiveness of our community education program

by measuring both our activities and the impacts of those activities. Just measuring activities,

however, does not provide a true measure of effectiveness. AMR commits to developing a

relevant and statistically significant system of evaluation with the Contra Costa County

Department of Public Health to measure the actual effectiveness of these activities in meeting

community goals. Such measures may include:

Trend analysis on pediatric admissions after child seat education


67

Increase in quality-of-life index for stroke survivors

Increase in percentage of AED usage in cardiac arrest situations

Increase in percentage of bystander CPR within the community.

To further monitor our progress and educate the public, AMR proposes to publish a quarterly

community involvement report. The report will identify the community events in which we

participated, the sentinel responses in which we have been involved, a targeted prevention area

for the coming year, and the role of the EMS system in meeting identified challenges that lie

ahead for the coming year.

Proposed Outreach Programs

As described, AMR will implement outreach programs targeted at identified community

needs. We also commit to developing programs and seeking out grant funding in collaboration

with the County, local fire agencies, hospitals, and community service groups. These

programs will include the following:

Automated External Defibrillator (AED) Donations. AMR proposes to place 15 AEDs

per year in locations throughout the community as part of the County EMS Public Access

Defibrillation program. Our intent is to garner the support of fire agencies to provide, or

assist in providing, ongoing monitoring and maintenance of this program.

Heart Attack and Stroke Prevention. We will create programs and teach community

residents about early warning signs of a stroke or heart attack. They will also learn the

benefits of early defibrillation and what to do in the event of an emergency.

Fall Prevention. Targeted at older residents, AMR will provide presentations on home

safety checks, educating seniors about how to prevent falls.

Child Safety Seat Program. Because vehicle collisions are

the number-one cause of death in children under 15, AMR

believes child safety seat training is an important program to

launch throughout the County. Our instructors help parents

understand the safest way to install child seats in their

vehicles, as well as how to select the child seat best suited to

their needs.


68

CPR Instruction. AMR will provide American Heart Association CPR training courses

to Contra Costa County residents at regular intervals throughout the year.

School Programs. We will provide injury prevention information to students on topics

affecting children, such as poisoning and drowning.

In partnership with the County and our fellow EMS system stakeholders, AMR is committed

to making Contra Costa County’s community education program one with meaningful,

tangible results and recognized as a model of excellence.

5.3 Customer Service Monitoring and Improvement

AMR seeks the highest quality service in all our interactions with customers, peers and

stakeholders. We continually evaluate our systems and processes to build on our strong

foundation of customer satisfaction and continually improve on our efforts. This continual

improvement focuses on tracking and evaluating our customer contacts and building training

experiences that enhance our ability to meet our customers’ needs.

Tracking and Resolving Concerns

AMR recently implemented our Communications Encounter QA application. This Web-

based customer relations management tool allows us to enter and maintain information

including contacts, complaints, compliments, and lost property reports. Using this tool, we

can identify trends, training needs and areas of our delivery system that require improvement.

This data also allows us to provide monthly customer feedback reports to the County,

providing increased levels of accountability.

AMR reviews all incident reports and concerns submitted by field or supervisory personnel, as

well as any report that comes from a customer or system partner. Incident reports are divided

into two categories — clinical and operational. Copies of our incident report and service

complaint forms are provided in Section 5 attachments. Our Operations Manager is

responsible for investigating and acting on all operational incidents. Our local CES

Coordinator investigates all clinical incidents. Each clinical event is entered into our clinical

incident-tracking database, after which it is reviewed by our Medical Director and/or our

proposed Quality Leadership Council. Reported clinical incidents are forwarded to the County


69

EMS Medical Director within 24 hours. AMR seeks to investigate and resolve concerns

within 24 hours of customer contact for most issues.

In addition, as an ongoing customer service program, AMR will conduct regular surveys with

patients, hospital staff, First Responders and other system partners about the quality of

the services we provide. We will provide the County with an annual report summarizing the

results of these customer and stakeholder surveys. A copy of the proposed survey is included


Additionally, AMR is committed to continuing to train all Supervisors in investigation

techniques and consistent customer feedback approaches. Our supervisors meet frequently

and systematically with key personnel from the EMS Agency, fire agencies, and hospitals to

gain verbal feedback about AMR’s performance and professionalism. These meetings also

give us the ability to seek relevant customer input, allowing us to identify our strengths and

opportunities, enabling the entire AMR team to identify performance areas that can be

improved.

Service Promise Plan

AMR is proposing to create a Service Promise Plan for the County and our various system

partners to help us clearly identify and meet their service goals and expectations. AMR will

work with the County to design and implement the Service Promise Plan, which will then

allow us to focus on and monitor key performance areas and identify areas for service

improvement.

To elaborate on AMR’s customer service and direct involvement with the community, letters of

support and testimonials from a variety local customers are included in Section 5 attachments.

5.4 First Responder Program Integration

AMR is the recognized industry leader in developing and implementing innovative and high

quality public-private partnerships that involve the integration of Fire Department and Public

Safety First Responders. Our partnerships are designed with the essential goals of:

• Enhancing patient care


70

• Providing system integration and focus of accountability

• Developing appropriate recognition of compensation for ALS

First Responder services

• Implementing sustainable patient care delivery systems

During the month of October 2004, AMR met with

representatives from Contra Costa County Consolidated Fire

Protection District (including Communications leadership), El Cerrito-Kensington Fire

Department, Rodeo/Hercules Fire Department, Pinole Fire Department, Richmond Fire

Department, Crockett/Carquinez Fire Department, and the East Contra Costa County Fire

Protection District to discuss opportunities for innovative partnerships that can meet the needs of

the community as well as the system goals articulated above. As a result of these discussions,

AMR is pleased to propose the following elements:

• Integrated Quality Leadership Council (IQLC) – Central to our integration proposal is a

fully integrated leadership structure for the stakeholders of the EMS delivery system. Our

successful experience in other communities has demonstrated that this form of integrated

system leadership is essential for the long-term sustainability of excellence within an EMS

system. As such, we are proposing that operational and equipment issues of the EMS system

be identified and evaluated, and solutions developed by the IQLC. The Council will be

comprised of personnel from the Contra Costa Consolidated Fire Protection District, the East

County Fire Protection District, Rodeo/Hercules Fire Department, Pinole Fire Department, the

Kensington/El Cerrito Fire Department, AMR, and others as necessary and appropriate.

• First Responder Liaison – AMR’s Operations Manager will function as our First Responder

Liaison. Mr. Borghelli has considerable experience working with our fire agency partners and

has developed an excellent working relationship with the various agency leaders.

• Supply Restocking and Logistics – Driven by the need to provide a high quality system and

partnership, AMR proposes to develop and establish a logistics supply system that provides for

rapid and accurate replenishment of disposable medical supplies and equipment. This

mechanism will include using AMR assets and, where appropriate, contracting with fire

agencies for space to locate geographically relevant re-supply caches and/or use existing fire

service networks and capacity to meet the system’s needs. This will eliminate the need for a


71

First Responder unit to travel a great distance for restocking while maximizing the amount of

time the units are available and reducing the overall costs of supply replenishment.

• Coordination of Data Gathering and Quality Improvement Efforts – As more fire

agencies in the county implement SunPro-Ather software for electronic data collection, AMR

recognizes the importance of finding a technological solution that allows the SunPro product

and AMR’s proprietary MEDS ePCR™ system to interface. AMR is proposing a full

integration of electronic records and alignment of data sets system wide, in cooperation with

the County and our system partners. This will allow for quantitative reporting of overall

clinical performance, which can be tied to providing integrated EMS system patient care

solutions, training and community prevention, meaningful data comparison, and greater

collaborative research opportunities. In addition, we will provide system data to our Fire

Department partners so they can use real-time data to conduct their own CQI activities.

• Return Firefighters to their Engine Companies – The repatriation of fire agency

Paramedics to their response areas and assigned apparatus is an essential element of

maintaining the high quality of our EMS system as it evolves. AMR proposes providing a

dedicated and pre-arranged car service to return firefighters promptly to their engine company.

• AVL Integration with Consolidated Fire’s CAD System – AMR proposes to place

Automatic Vehicle Locator (AVL) technology with mobile applications in our ambulances. In

Section 4.5, we propose that Contra Costa County Consolidated Fire become the primary

dispatch center for all Advanced Life Support units serving the county. We will work with

Consolidated Fire to choose an AVL technology with mobile applications that will interface

best with its CAD.

• STAR Cars – AMR is proposing six transport-capable, rescue-type vehicles for deployment

throughout the County. These units — known as Supplemental Transport Ambulance

Resource (STAR) Cars — will be staffed with existing fire agency personnel and will

transport in pre-defined and urgent circumstances. STAR Car units will be used as a

supplement to AMR’s transport resources, and bring a substantial number of new response

resources into the local system.

• Sponsored Training – AMR will use our Northern California Training Institute (NCTI) to

establish a regional EMS training program within Contra Costa County. Through this


72

program, we will provide a full spectrum of continuing education opportunities to both AMR

and fire service personnel, including the following:

Pediatric Education for Prehospital Care Providers

Advanced Cardiac Life Support

Basic Trauma Life Support or Prehospital Trauma Life Support

Basic Life Support CPR for the Professional Rescuer

Infrequent Skills Practicum

Additionally, AMR will work with our fire service partners and NCTI staff to accredit fire service

personnel as instructors for the various class offerings at NCTI. We will provide remuneration to

those instructors or their agencies depending on the exact nature of the agreed-on relationship.

AMR further proposes an equipment exchange program with our law enforcement partners. When

AMR responds to a 5150 call in which an immobilization safe restraint wrap is used, we will

provide the law enforcement responder with our wrap so they are ready to respond to the next call

that requires a restraint to protect the safety of the patient and officer. AMR will also sanitize and

maintain the equipment.

5.5 EMS System Stakeholder Commitment

AMR will continue to partner with all stakeholders in the Contra Costa County EMS system to

understand what they value and perceive as beneficial for local communities. Under the new

contract, AMR commits to the following:

• Creating response-time equality among communities throughout the County, recognizing that

a system’s cost efficiency is determined by matching ambulance deployment with actual

demand.

• Continued collaboration with EMS system stakeholders, including city managers, mayors, and

the County Board of Supervisors, to ensure continued public trust in community services.

• A proactive approach to identifying residents and communities at risk and working with our

public safety partners to create prevention programs that will reduce pain and suffering, as

well as provide a cost savings to county residents.


73

• Working to improve the existing system of community service “safety nets”, including training

and equipment, to ensure continuous service in the event of a catastrophic incident.

• Working with our Medical Directors and collaboratively with our seat of higher education,

NCTI, to stay abreast of technological advances and efficiencies, piloting new equipment.

• Creating a culture that reinforces and continuously monitors safe practices, thereby decreasing

workplace injuries.

• An atmosphere that provides motivation and inspiration to our workforce through programs

such as succession planning. We recognize that the job of EMT and Paramedic is frequently a

stepping stone in the career of prehospital medicine, and AMR will continue to encourage

personnel making the transition to Firefighter, Registered Nurse, physician, or management, as

well as supporting the career paths of professional Paramedics.

• Continued active involvement in community education. AMR is proud that so many of our

employees live in the communities in which they work, and our leadership team encourages

employees to participate in civic groups such as chambers of commerce or sporting clubs to

further represent AMR in the community.

• Providing compassionate care while maintaining patient confidentiality.

5.6 Disaster Planning

AMR’s resources have proven to be critically beneficial in many of the large-scale emergencies

and disasters affecting California communities, and equally beneficial in supplementing the state’s

public safety infrastructure. Working as a member of the overall EMS system, AMR has

responded to numerous incidents in the Bay Area and beyond, including the:

• 1989 Loma Prieta earthquake

• 1990 Oakland Hills fires

• 2001 Tosco and Chevron refinery incidents

• 2003 Southern California fires

• 2004 Martinez fire incident


74

Disaster Training

As a key system component, AMR commits to the following disaster preparedness training:

HazMat First Responder Awareness (FRA) training to all employees.

HazMat First Responder Operations (FRO) training for Field Supervisors and our

Operations Manager.

National Incident Management System (NIMS) – all state and local government agencies

that apply for federal funding must be NIMS compliant by fiscal year 2006.

Hazardous Materials (HazMat) Basic Awareness WMD program (required training for

Homeland Security funding).

Incident Command System (ICS) 100 for all field employees, with a commitment to

extend this training to our public safety partners.

ICS 200 and 300 or equivalent for our Field Supervisors and Operations Manager.

Ambulance Strike Team Leader training to select employees.

OES Mutual Aid Medical Plan training to our supervisors and other designated AMR

personnel.

Standardized Emergency Management Systems (SEMS) basic training for Field

Supervisors and Operations Manager.

We will also continue to orient all employees to the Contra Costa County Multi-Casualty

Incident (MCI) plan and participate in annual refresher training on the plan. Furthermore, we

will continue to participate in a) monthly meetings of the Petrochemical Mutual Aid

Organization (PMAO), b) the Contra Costa County Hospital Disaster Forum sponsored by the

Health Department, and c) several drills, including: the Contra Costa County Office of

Emergency Services annual drill; the Annual Statewide Medical and Health Disaster Exercise;

drills for many of the larger petrochemical companies and businesses occupying large

commercial spaces; yearly wildland drills at Camp Parks in neighboring Dublin; drills at

Buchanan Fields in Concord, and; tabletop exercises (mock simulations) with the County, such

as for the West Nile virus.


75

Disaster Response Vehicle/Equipment

AMR offers a variety of disaster response vehicles and equipment to supplement the public

safety infrastructure during times of need.

Supervisor Squads equipped to respond to a wide variety of emergency situations with

sophisticated technology, including real-time access to hospital diversion information and

communications equipment that allows for interaction with other public safety personnel.

Our supervisor units are not only capable of delivering additional supplies and personnel to

any major incident, but any of these modified Ford Expeditions can also act as a mobile

command unit.

Special Response Vehicle – AMR has a fully equipped Special Response Vehicle

available to respond to MCIs and disasters. A complete list of the vehicle’s medical and

communications equipment is included in Section 5 attachments.

Disaster Cache – AMR understands that the County has recently received federal grant

equipment to provide for large-scale incident caches (including HazMat and WMD

mitigation tools). We propose to develop a comprehensive plan with Contra Costa

Consolidated Fire to provide for the rotation and re-supply of equipment and supplies on a

regular and appropriate basis. Additionally, we propose to provide fully stocked caches in

strategic locations throughout in the county as determined by the IQLC described earlier in

this section.

Multi-Ambulatory-Patient Vehicle – AMR will obtain a school bus or similar vehicle to

provide transportation to multiple ambulatory patients in the event of a large-scale

incident.

WMD Equipment – AMR will stock all ambulances and support vehicles for WMD

responses and HazMat incidents, including equipment specified in the RFP, such as

Mark 1 injectors, escape hoods, safety helmets, and special clothing. We are working with

the County via a grant process to obtain some of this specialized equipment.

Internal Disaster Response Capabilities

When needed in a disaster, AMR can recall our Contra Costa County personnel, as well as

AMR employees from several neighboring counties, using company-issued pagers. With the


76

resources of our company’s operations in other counties, we can also recall approximately

400 employees and 50 vehicles from AMR operations in the San Francisco Bay Area, as well

as additional resources from operations in the Central Valley, Southern California, and the

Pacific Northwest.

No other provider besides AMR has the regional bench strength to seamlessly move a large

number of additional units to a disaster scene when needed. With three linked

communications centers in the region – in Burlingame, Modesto, and Sacramento – and with

AMR operations in Alameda, San Francisco, Marin, Sacramento, San Mateo, Santa Clara,

Stanislaus and San Joaquin Counties, we can assure Contra Costa County that AMR will be

there when needed.

We further commit to working with local hospitals in the event of a large-scale event, such

as a chemical release, to provide rapid transportation of patients between clinics and hospitals.

AMR can provide triaging and ALS care at clinic sites, which may become overtaxed during

large-scale incident.

External Incident Notification

Through pagers issued by AMR, we will continue to notify the EMS Agency of unusual

occurrences when we are the first point of contact. In addition, our Operations Director and

Operations Manager have additional means to notify County officials via cellular telephone or

Blackberry access.

Disaster Response History Demonstrates our Preparedness

AMR offers a wealth of experience in providing

supplemental support to the public safety infrastructure

during a disaster. No other provider can offer our

company’s ability to rapidly access, coordinate, and deploy

the sheer number of EMS resources offered by AMR.

For example, when a wildland fire threatened the City of

Martinez and the Contra Costa County Regional Medical

Center during June 2004, AMR mobilized our resources to


77

prepare for possible evacuation of 120 patients in the facility. Fortunately, no evacuation was

necessary; however, more than 20 AMR units were positioned for rapid deployment if needed.

Other large-scale local incidents in which AMR demonstrated our competency include:

Vasco Road multi-fatality incidents in June and September, 2004

Plane crash on I-680 in Pleasant Hill in April 2004

Runaway truck incident in El Cerrito in September 2003

Three MCIs in 2001 that involved the Tosco Refinery release, the Chevron Refinery fire,

and the Richmond Health Center

5.7 Mutual Aid and Stand-by Services

AMR has taken a lead in extending mutual aid to other areas when needed and providing stand-by

services within the county. As directed by the County, AMR will continue to respond to major

incidents in other jurisdictions.

Ambulance Strike Team

AMR will follow new Ambulance Strike Team procedures when requested. Our leadership

team has taken an active role at the state level to develop this program, ensuring that AMR

will be ready should the team be activated. We will supply a fully trained supervisor or

manager to function as Strike Team leader, and we will provide additional equipment and

personal items as needed to support the team for several days. An additional cache of medical

items will be maintained at our operations center in Concord. Course outlines for our Strike

Team training and our MCI Basic Field Operations course are included in Section 5

attachments.

Bay Area Disaster Medical Assistance Team

AMR will continue our participation with the Bay Area Disaster Medical Assistance Team

(DMAT) CA-6 sponsored by the Contra Costa EMS Agency with oversight by the U.S.

Department of Homeland Security. Several AMR employees from Contra Costa County

volunteer to serve on the team, which provides emergency medical care to communities and

augments local medical capabilities during times of disaster. The local team, formed in 1997,


78

has been used regionally to respond to the recent Santa Clara and the Benicia fires of 2003.

On a larger scale, the team provided assistance on missions to the Ukraine in 2002 and 2004,

and it responded to the devastating fires in Southern California in 2003 and the World Trade

Center Disaster in 2001.

Stand-by Service

We will continue to provide stand-by services to the County or other public safety agencies as

requested, as well as provide safety demonstrations. In addition, we are able to provide basic

rehabilitation services to fire agencies for large-scale incidents in our county, should that be

desired, as part of our overall commitment to area First Responders.

Ambulance Service Assistance

AMR will provide ambulance service on a mutual aid basis to San Ramon Valley and the

Orinda/Moraga fire agencies when instructed by the EMS Agency. With a large number of

inter- and intra-county resources, we have the ability to immediately provide services to those

areas without disruption to the contracted Contra Costa County service area. AMR already

responds in those areas when requested to assist with depleted resources or medical overloads.


79

Section 6: Management and Administration

AMR is positioned to quickly and efficiently implement the system enhancements identified

throughout the RFP. Our Contra Costa County leadership team, which has proven its long-term

commitment to the community, has worked closely with the EMS Agency and our public safety

partners over the years to develop innovative system enhancements, including many of those most

recently identified by the Fitch report released in 2004. We look forward to building on the

relationships and trust that have grown during our local tenure to help secure the County’s vision

of a truly integrated and progressive EMS system.

6.1 Key Personnel

AMR is proposing to keep in place our highly experienced and talented leadership team, which

averages more than 15 years of service to Contra Costa County. With its open and collaborative

management style, this team has been extremely successful in working with our employees and

system partners to manage the current EMS system in Contra Costa County and to implement the

new requirements. For example, they have worked well with our employees to effectively bring

about the transition to a one Paramedic/one EMT staffing plan, in line with the County’s vision.

All our employees have been or are in the process of being trained in their new roles.

AMR also offers Contra Costa the following management advantages:

• Five new leadership positions – an RN-level CQI Manager, an EMS Epidemiologist/Clinical

Data Analyst, and an Information Technologist to work with the County on quality

improvement issues, as well as a Community Outreach Coordinator and an Employee

Advocate.

• Broad industry experience – all current leadership personnel have worked in the field as

Paramedics and have complemented their training through the pursuit of higher education in

such fields as business and health care.

• Extensive oversight by our Medical Director, Dr. Gary Tamkin, a local emergency physician

and industry leader who actively participates in our training and quality improvement

programs. His curriculum vitae may be found in Section 2 attachments.


80

• A local leadership team that lives in the county and is immediately available for major events

or if additional services are required.

• Ability to call on additional expertise from our regional and national leadership teams for “best

practices” and the latest industry standards. This adds particular value with data collection and

trending for education, new technology, and new equipment access.

The following table lists our current and proposed local leadership team. These individuals will

oversee the implementation of contract enhancements, ensuring a seamless transition to the new

contract and continued oversight throughout the term of the contract. All the current leadership

team lives in the county and are available 24 hours a day. Their resumes can be found in Section 6

attachments.

Leslie Mueller Director of Operations

David Borghelli Operations Manager

Becky Hobson Administrative Supervisor

Mark Buell, Rich Silva, Linda Mulgrew, Chris Bonn and 5 TBD

Field Supervisors

Denise Cole Customer Account Manager

Yvette Byers Operations Assistant

Mike Austin Logistics Supervisor

TBD CQI Manager (RN)

Sam Bradley CES Paramedic Coordinator

Melissa Stoddard Paramedic Field Training Coordinator

TBD EMS Epidemiologist/Clinical Data Analyst

TBD Information Technologist

TBD Community Outreach Coordinator

TBD Employee Advocate

Contra Costa County also benefits from the expertise to be found among our regional and national

leadership teams. As part of a larger organization, our local team has access to, and support from,

industry specialists in finance, information services, safety and risk management, human

resources, and other support departments. Many of these professionals are based nearby at our


81

regional resource and support center in Livermore. Their resumes can be found in Section 6

attachments.

6.2 Compliance Plans and Policies

AMR has established what is recognized as an industry-leading Corporate Ethics and Compliance

Program led by our in-house Ethics and Compliance Department. The program has been in effect

since 1998, well before the Office of Inspector General (OIG) issued draft guidance for ambulance

compliance programs in March 2003, and is consistent with and upholds the “Seven Elements of

an Effective Compliance Program” federal guidelines set by the OIG. These seven standards are

included in Section 6 attachments. The spirit and foundation of the Compliance Program is based

on the overall goal of promoting a culture that encourages employees to conduct activities with

integrity, dignity, and care for those we serve. It covers all areas of compliance for the company,

including federal health care program compliance and HIPAA. Due to space constraints, we have

provided the following brief descriptions of our various compliance processes. Details may be

found in Section 6 attachments.

6.2.1 Federal Healthcare Program Compliance

The Compliance Department monitors changes in federal laws and regulations, as well as

government enforcement that affect AMR and our customers. It also implements our Code of

Business Conduct program, which is designed to promote ethical decision making and

professionalism in every aspect of our employees’ lives. Annual Code of Business Conduct

training is mandatory for all employees. Employees may also report compliance concerns

anonymously via our toll-free Ethics and Integrity Help Line. Topics covered in the Code of

Business Conduct training are included in Section 6 attachments.

6.2.2 HIPAA Compliance

The AMR Group has developed and implemented a comprehensive program to comply with

the HIPAA requirements for privacy. As part of our HIPAA Compliance Plan, we ensure that

Protected Health Information is released only as permitted under the HIPAA regulations such

as treatment, payment, or health care operations. Since HIPAA requires that all information be

transferred in the ANSI format, the AMR Group has led the way in system customization to

facilitate the HIPAA-compliant transfer of data to health care providers. In addition, we have


82

created training programs so that all personnel learn the practical applications of HIPAA on

their jobs. All employees receive this training during orientation and again during yearly

HIPAA update classes. Once the training is complete, all employees sign and submit an

acknowledgement form on the last page of the booklet.

Finally, the AMR Group has completed a series of risk analyses of our technical and physical

security capabilities to determine what, if any, changes need to be implemented to ensure

compliance with the Final Rule released on February 20, 2003. The AMR Group HIPAA

Committee and a technical security subcommittee are working with outside consultants to

complete these assessments. We will continue to develop and implement the necessary

procedures to ensure compliance with the security segment of HIPAA. Currently, the AMR

Group is well on its way to meeting the 2005 compliance deadline.

6.2.3 Compliance with Laws, Regulations, and Rules

Our insistence on quality control and quality improvement calls for a continuous local

compliance program that conducts specific localized training and implements billing

compliance chart audits of our Patient Care Report forms. Our local Clinical and Educational

Services (CES) Coordinators offer education programs to employees and receive periodic

oversight review by our national corporate compliance team.

6.2.4 OSHA and Other Compliance

AMR meets and exceeds all California Occupational Safety &

Health Administration (OSHA) standards. With the help of our

full-time Safety and Risk Management personnel, we will

continue to maintain these standards within Contra Costa

County, upgrading to meet additional requirements as needed.

Additionally, AMR has created a model infectious waste

management program, which we are offering as a resource to

system stakeholders, including local fire agencies, First

Responders, and communities.


83

6.3 Accreditation Commitment

AMR is fully committed to attaining Commission on Accreditation of Ambulance Services

(CAAS) accreditation for our Contra Costa County operation within 14 months of renewal of our

contract. AMR has been working actively to put in place the necessary programming and policies

in line with CAAS requirements, and we believe we already meet many of the CAAS standards.

If awarded the contract to continue serving the County, AMR will immediately assign a project

manager to oversee all activities related to AMR’s accreditation efforts within Contra Costa

County. This project manager will be supported by key leaders in our organization, who will

make Contra Costa’s accreditation a top priority. These leaders include Lawson Stuart, our CES

Director, who has been a CAAS site reviewer since 1992. His understanding of CAAS standards

will enable AMR’s local team to successfully navigate the process and achieve CAAS

accreditation in this expedited time frame.

Furthermore, our company’s experience in receiving CAAS accreditation is unmatched in the

industry, with 13 AMR operations accredited nationally. Several of these operations have held

CAAS accreditation for many years, re-accrediting on a regular basis. In addition, numerous other

AMR operations are in the process of gaining CAAS accreditation. We are also experienced in

obtaining accreditation from the National Academies of Emergency Dispatch (NAED), with seven

of our company’s dispatch centers currently holding that standard. This experience has allowed us

to develop a seasoned team of individuals who understand and are able to navigate the

accreditation process.

6.4 Billing and Collection Policies

Our billing and collection management philosophy is built on the knowledge that the people who

call for prehospital care are typically experiencing one of the most stressful times in their lives.

Thus, our billing and collection practices place extra emphasis on sensitivity to individuals in

these special situations. Moreover, we never attempt to collect fees at the time service is rendered.

The goal of our billing process is to collect the amount due from third-party payors and patients,

without unduly pressuring those who legitimately are unable to pay. Through our success in this

area, we are able to maximize reimbursement to fund the EMS system.


84

Entering the Billing System

With our MEDS ePCR system, discussed in detail in Section 2.6, all data regarding each

patient encounter is compiled into a single electronic patient record, which is automatically

uploaded to AMR’s billing system. This interface eliminates the need to re-enter data,

ensuring data accuracy and providing more complete billing data. For example, our MEDS

ePCR™ program compares dispatch data to PCR data and automatically flags any missing

PCRs for follow up by our prebilling staff. In addition, MEDS’ direct connectivity to our

billing database allows crew members to query the system for billing information from a

patient’s prior transport. If the patient has been transported previously by AMR, the crew has

the ability to auto-populate MEDS with correct billing information, reducing documentation

time and improving data accuracy.

Invoicing Process

With the help of our sophisticated billing system, known as AM2000, invoices are generated

to patients and third-party payors. All billing statements are itemized, and items charged to the

patient are listed separately and clearly explained. All accounts are checked for Medi-Cal

eligibility. Once these Medi-Cal eligible patients are flagged, we bill Medi-Cal rather than

burdening a customer with unnecessary paperwork and undue stress. All government billing,

such as Medicare and Medi-Cal, as well as a large percentage of commercial insurance claims,

are processed electronically.

Customer-focused Service

To enhance their ability to get answers about their bills or service, Contra Costa County

patients may call our local office in Concord or use a toll-free number to reach our main

billing office located in Modesto. At either location, callers are able to speak to an

experienced Customer Service Representative (CSR), who is able to guide them through the

billing process. Our CSRs have an average of five years experience in patient relationship

management, including billing and collection procedures, and receive extensive training in all

areas of customer relationship management. This training is supplemented with mandatory,

annual recurrent training and peer group learning experiences. The table of contents from our

Customer Service Unit’s procedure manual can be found in Section 6 attachments.


85

Should the CSR be unable to meet the needs of our customer, they immediately forward the

issue to a Supervisor, and then to a Customer Advocate, if necessary. AMR Customer

Advocates are empowered to act on the patients’ behalf. They research the patient’s complaint

and help find a solution that is mutually acceptable to both the patient and AMR.

Compassionate Care Program

For our customers who are financially challenged, we offer a Compassionate Care Program to

help patients pay their ambulance bills. Patients who can demonstrate insufficient assets or

financial hardship may receive a discount or write off of their charges. We undertake these

programs as a commitment to the local communities we serve, and will continue to enhance

programs as needs evolve.

6.5 Implementation Plan

As the incumbent emergency transport provider in Contra Costa County and a pioneer in EMS

system design and innovation, AMR, in partnership with key system stakeholders, will be able to

implement several enhancements following contract award, rather than waiting until July 1, 2005,

when the new contract goes into effect. In addition, we have worked during the recent extension

to implement a number of the system enhancements identified in the 2004 Fitch report. With these

enhancements and our extensive infrastructure already in place, we believe we are best prepared

for rapid implementation of the new contract and are ready to act as soon as the selection

committee has identified its needs.

The following table outlines the system enhancements and RFP requirements that AMR has

already put in place, as well as additional enhancements scheduled for implementation when the

new contract begins.

Already Implemented To Be Implemented

COMMITMENT TO CLINICAL QUALITY

2 CES positions – Paramedic CES

Coordinator and Paramedic Field Training

Coordinator

3 new CES positions, including an RN-level

CQI Manager

Peer Field Coaches (20 hours/month)


86


FTOs (80 hours/month)

MEDS ePCR system and analysis of

ePCR data

Local Medical Director

Integrated Quality Leadership Council

Full integration of ePCR system with fire

agencies and hospitals

Enhanced “real time” reporting of ePCR data

Virtual Solutions Manager (VSM), an internet-

based continuing education service

12-lead cardiac monitor-defibrillators with

capnography and non-invasive blood pressure

capability

Flex Guide ET tube introducers

COMMITMENT TO EMPLOYEES

Existing workforce of 140 full-time field

personnel

Compensation package that includes

401(k) savings plan with 100% employer

match to 5% of annual earnings

Diversity program based on local EMS

Cultural Disparities Project

Comprehensive safety program

Additional 42 full-time field personnel

Additional 5 Field Supervisors, for a total of 9

Labor-Management Partnership Program

Full-time Employee Advocate

Enhanced safety equipment, such as helmets

and safety jackets

Enhanced employee recognition programs

DEPLOYMENT AND DISPATCH

4 QRVs deployed from fire stations

Deployment in new five Emergency

Response Zone structure

Local BLS and CCT fleet to provide

disaster support

Lower response time standards

4,024 weekly unit hours

31 ambulances at peak deployment

6 fire-based STAR Cars

1:1 staffing for 5 of AMR’s interfacility units,

for backup capacity if needed

Partnership with Consolidated Fire

Communications to dispatch all of AMR’s

ALS units


87


STAFFING MODEL

1:1 staffing model implemented through

attrition in Zones C and D

Dual paramedic staffing in Zones A and E

Phased-in approach to 1:1 staffing in Zone B

VEHICLES AND EQUIPMENT

Fleet maintenance center in Concord New Type III modular ambulances

In-vehicle mapping capabilities through

Automatic Vehicle Locator (AVL) system

Opticom-compatible devices on all units

Bariatric ambulance

FIRST RESPONDER INTEGRATION

Restocking of supplies

Identification of stakeholder needs

First Responder Liaison

Logistics supply system

Return of firefighters to engine companies

Local EMS training program for all ALS

caregivers through NCTI at no cost

COMMITMENT TO COMMUNITY

EMS research projects

Participation in statewide Amber Alert

program

Participation in Relay for Life, Every 15

Minutes, and other local programs

Community Outreach Coordinator

Data-driven injury and illness prevention

programs focused on identified community

needs

Quarterly community involvement report

Seek grant funding to support community

education initiatives

Donation of 15 AEDs each year


88


DISASTER PLANNING

Participation in Petrochemical Mutual Aid

Organization and other disaster planning

groups

Special Disaster Response Vehicle

Ability to recall 400 Bay Area employees

and 50 vehicles

Expanded disaster training

Disaster supply caches in strategic locations

Disaster bus or similar vehicle to transport

multiple ambulatory patients

In addition to the items identified in the table, AMR intends to kick off the new contract with a

series of educational programs throughout Contra Costa County communities to let residents know

that the Board of Supervisors, in conjunction with key EMS system stakeholders, have collectively

developed a system designed to protect the public and save lives. We would like to invite system

stakeholders, including our fire agency partners, to jointly present these programs, thus giving the

community a first-hand look at how well the system partners work together to provide an

integrated approach to health care. Further, we aim to work with local media to recognize

individual stakeholders for their commitment to local communities.


89

Section 7: Organizational Requirements

7.1 Ownership and Legal Structure

The legal entity submitting this proposal is American Medical Response West (AMR West), a

California corporation doing business as American Medical Response (AMR), whose regional

headquarters are located in Livermore, California. AMR West is a wholly owned subsidiary of

American Medical Response Inc. (AMR Inc.), a Delaware corporation established in August 1992.

7.2 Organizational Background

Our local roots run deep as AMR and its predecessor companies have served Bay Area

communities since 1934, including more than 50 years of excellent service in Contra Costa

County. Our management team includes some of the most accomplished leaders in the industry,

and our experienced staff, record of service, and dedication to quality patient care sets AMR apart

among transportation providers.

Key accomplishments in Contra Costa County, both through AMR and through our predecessor

companies, are highlighted in the following table.

1977 Contra Costa County’s first Paramedic-staffed ambulances were provided by

Pomeroy, Michael’s, and Cadillac Ambulance –three AMR predecessor companies.

1983 A competitive bid process resulted in exclusive emergency contracts with Cadillac

and Regional Ambulance – two AMR predecessor companies, as well as East County

Ambulance.

1984 The County’s 10 ambulance zones were consolidated to 5 zones, with exclusive

contracts awarded to Cadillac and Regional Ambulance.

1986 Cadillac was purchased by Regional Ambulance and became the sole private

emergency ambulance provider in Contra Costa County.

1991 High performance ambulance contracts that included ALS response time standards

were initiated with Regional Ambulance and various fire agencies.


90

1992 A First Responder Paramedic program was funded by Measure H, and was

implemented by AMR in Byron and Discovery Bay using Quick Response Vehicles

(QRVs).

2001 AMR launched electronic Patient Care Report technology in Contra Costa County.

2002 The second AMR First Responder Paramedic unit was deployed in Bethel Island,

and AMR worked with the County to implement a Critical Care Transport-Paramedic

(CCT-P) program for interfacility transfers.

2004 AMR added two more QRV units to the County system to ensure a 10 minute or less

response time for a Paramedic at the patient’s side. One unit was added to the East

County in the city of Oakley and another to the West portion of the county covering

Crocket, Port Costa, Rodeo, and Hercules, bringing the total to 4 QRVs fully funded

by AMR.

AMR continues to find creative solutions with our community partners, addressing issues unique

to Contra Costa County. As we look forward to the privilege of serving Contra Costa County

residents in the future, we know our past experience will provide the County with a level of

insight and commitment unmatched by our competitors.

National Experience

The American Medical Response group of companies:

Is the nation’s largest multi-site ambulance service, operating in 32 states

Transports more than four million patients each year

Employs 18,000 Paramedics, Emergency Medical Technicians, and other support

personnel

Operates a fleet of approximately 4,000 ambulances and other vehicles

Serves more high-performance EMS systems than any other provider, and currently

manages 129 EMS contracts

Operates 52 dispatch centers, giving us a depth of experience in medical dispatching

services that is unsurpassed in our industry

We have provided a map of our Bay Area and national service areas in Section 7 attachments.


91

7.3. Similar Contracts

Across the nation, our company currently holds 129 contracts with profit and not-for-profit

agencies to provide emergency medical services. A list of these similar contracts can be found in

Section 7 attachments.

7.4 Incompletion of a Contract

AMR has never been asked to leave any community for reasons of early termination, breech of

contract, or failure to perform. We have also never refused to complete an agreement.

7.5 Financial Interests in Related Businesses

AMR West does not hold an equity interest in any other companies. AMR West operates the

Northern California Training Institute (NCTI) located in Roseville, California, as a division within

its operations. Although NCTI does not provide ambulance services, it is integral to the training

of Paramedic, EMT, and dispatch staff employed by AMR West and numerous fire agencies.

7.6 Business Partners and Associates

AMR West is a stand-alone entity. We have consolidated the following Northern California

operations under the legal name of AMR West within the past dozen years:

1992 Vanguard Ambulance Services

1995 Life Medical Industries, Inc.

Shirley Enterprises, Inc.

AMR West BLS

Doctors Ambulance of Modesto, Inc.

1999 Intensive Care Ambulance, Inc.

Santa Cruz Ambulance Service, Inc.

Pajaro Valley Ambulance Service, Inc.

Stanislaus County Emergency Medical

Communications

Peninsula Paramedic Services, Inc. Medevac, Inc.

Regional Ambulance, Inc. Stephens & Poletti Ambulance, Inc.

2002 911 Emergency Services, Inc.

2003 Golden Gate Associates San Francisco Ambulance Service, Inc.


92

7.7 Similar Experience

AMR has provided exceptional service to Contra Costa County for more than 50 years, and we

currently serve 19 counties throughout Northern California. In addition, our company currently

provides ambulance services to more than 4 million patients each year.

As communities grow and evolve, their needs and the manner in which they respond to these

needs change. AMR understands this. We constantly strive to find innovative and efficient

solutions to communities’ needs, never forgetting that patient care is the reason we exist.

Our experience in the Bay Area illustrates that partnerships nurture solutions. Details about our

innovative EMS experience in the following counties can be found in Section 5.1:

• Santa Clara County

• San Mateo County

• Alameda County

7.8 Equipment

Information regarding our equipment can be found in Section 2.5, with equipment lists found in

Section 2 attachments.

7.9 Financial Ability

The following financial statements can be found in Section 7 attachments, documenting the

financial condition of AMR West and its parent company:

• Audited financial statements for the year ended August 31, 2003 for American Medical

Response West, a California corporation, prepared by PricewaterhouseCoopers, LLP

• A comparative audit report for the years ended August 31, 2003 (Successor) and 2002

(Predecessor) for American Medical Response, Inc.

The audit reports for the year ended August 31, 2004 have yet to be finalized by our independent

auditor. We expect the reports to be issued during November and will forward copies to the

County by November 29th pursuant to guidance provided as part of the pre-bid conference.


93

Although the fresh-start accounting presentation breaks each report into two segments

(Predecessor and Successor) and adds complexity to any analysis, the primary indicator of

financial stability is net cash provided by operating activities which, for the 12 months ended

August, 31, 2003, was $39.8 million and $61.6 million for AMR West and AMR Inc.,

respectively. This cash flow was reinvested back into ambulance operations through the

acquisition of capital equipment totaling $8.4 million at AMR West and $48.5 million at

AMR Inc.

In terms of net worth, AMR West and AMR Inc. had balances of $1.5 million and $391 million,

respectively. Our company has sufficient internally generated cash flow and net worth to meet its

commitments as an integral part of the Contra Costa County emergency medical services safety

net.

7.10 Ability to Perform Contract

There are no known commitments or any other factor affecting our company’s ability to

implement a new contract with Contra Costa County. Each AMR operation is autonomous, local

leadership is empowered to make decisions, and by design, each operation has its own revenues,

its own budget, and its own overhead and operational costs. Each AMR operation, including

Contra Costa County, must be operationally sound.

7. 11 Business and Professional Licenses

Copies of business and professional licenses can be found in Section 7 attachments.

7.12 Working Capital

As the incumbent provider, AMR would require a $4.1 million investment in capital equipment

including a new fleet of Type III modular ambulances as described in Section 4.4. Our company

holds sufficient liquidity to support this investment as AMR West and AMR Inc. carried working

capital balances of $36.2 million and $181.3 million, respectively, at August 31, 2003.

Additionally, and as described in Section 7.9 above, our company’s operations produce significant

operating cash flow to meet working capital requirements as well as any unforeseen events among

our business units.


94

7.13 Regulatory Investigations

A history of regulatory investigations can be found in Section 7 attachments.

7.14 Litigation History

Information regarding our company’s litigation history can be found in Section 7 attachments.

7.15 Performance Security

As the incumbent, AMR has the demonstrated ability to provide Contra Costa County with the

required performance bond. On award of the new contract, AMR will commit to providing a

performance bond in the amount of $500,000, meeting the requirements of the RFP. A copy of the

existing bond can be found in Section 7 attachments, as evidence of our bonding capacity.


95

Section 8: Proposed Pricing

AMR is committed to providing Contra Costa County with a proposal that is financially

sustainable over the life of the contract, ensuring ongoing EMS system viability. In addition, we

are extremely pleased to offer a funding enhancement that will benefit caregivers and the

community.

Additional Funding for EMS System Enhancements

In partnership with the EMS Agency, AMR desires to promote an EMS system that gives back

to the community and embraces health care initiatives. We envision these efforts to include

community-based health care research, education, prevention models, and a methodology to

partner in funding these activities. The following are examples of potential system

enhancements that could receive funding:

Trauma conference/education

Joint system stakeholder research and education

Clinical technological research

Community education / injury and illness prevention

Following the award of the contract, and in cooperation with the EMS Agency, AMR proposes

to develop a specific methodology for the EMS contractor’s after-tax earnings cap, levels of

after-tax revenue sharing, distribution of funds, and the selection of activities to be funded.

Funding would be distributed each year upon approval by the County of the annual

independent auditors report.

8.1 Proposed Patient Charges

Our proposal includes significant system enhancements requiring increased capital and staffing

resources, with no subsidy, per RFP requirements. To demonstrate the impact of these changes,

we have provided the following comparison of system design metrics that identifies the resources

necessary to support new system design criteria. AMR’s local experience enables us to effectively

allocate resources, thereby improving service levels at a reasonable cost.


96

Comparison of System Design Metrics

System through

August 2004

Contract Extension Sept 04 to June 2005

Primary Proposal effective July 2005

Alternate Proposal Option B July 2005

Response Criteria Zone A - Urban 10:00 / 95% 10:00 / 95% 10:00 / 95% 10:00 / 95% Zone B - Urban 10:00 / 95% 11:59 / 90% 11:45 / 90% 11:45 / 90% Zone C - Urban 10:00 / 90% 11:59 / 90% 11:45 / 90% 11:45 / 90% Zone D - Urban 10:00 / 95% 11:59 / 90% 11:45 / 90% 11:45 / 90% Zone E - Urban 10:00 / 95% 11:59 / 90% 11:45 / 90% 11:45 / 90% Zone E - Rural 20:00 / 95% 20:00 / 90% 20:00 / 90% 20:00 / 90% Disc Bay/Bethel Island 20:00 / 95% 20:00 / 90% 16:45 / 90% 11:45 / 90% Deployment (Unit Hour) Weekly Transport UH 2,913 3,134 4,024 4,494 Weekly QRV UH 336 672 672 672 Peak / Minimum Transport Units Peak 22 25 31 35 Minimum @ 3:00 a.m. 14 16 19 21 Vehicles Transport ambulances 31 35 47 52 QRV units 2 4 4 4 Supervisor units 2 2 3 3 STAR units 0 0 6 6 Full-Time Headcount Paramedic 126 131 124 142 EMT 0 9 58 58 Field subtotal 126 140 182 200 Field Supervisor 4 4 9 9 Clinical 1 3 5 5 Support 12 12 18 18 143 159 214 232 Salaries & Benefits $ 11,959,408 $ 13,208,619 $ 17,155,155 $18,685,088 Capital Equipment $ 3,790,518 $ 4,285,300 $ 6,786,391 $ 7,388,337 *Select User Fees ALS1-E Base (Unbundled) $ 801.49 $ 877.69 $ 904.02 $ 970.76 Bundled ALS1-E Base $ 941.21 $ 1,030.69 $ 1,061.61 $ 1,139.99 * The contract extension provides a 3% increase on January 1, 2005.

Note that the required Patient Charges form can be found in our attachment binder behind the

“Required Documents” tab. In addition, the following chart provides an overview of ambulance


97

base rates of comparable EMS systems in the Bay Area, to assist reviewers in understanding our

proposal.

Comparative Unbundled ALS-1-E Base Rates

Alameda

ALS Santa

Clara ALS

San Mateo

ALS Monterey Santa Cruz

Sonoma

Contra Costa ALS (Proposed)

$930.40 $880.90 $1,070.15 $1,008.00 $897.61 $802.00 $904.02

As described throughout this proposal, the new system design and multi-zone compliance

structure significantly increases field deployment. Specifically, based on our years of experience

operating in the county, the enhanced Priority 2 (no lights and sirens) criteria requires a 28.4%

increase to weekly unit hour deployment. The additional 890 hours will increase AMR’s proposed

transport unit deployment to 4,024 weekly hours, with peak deployment of 31 ambulances.

Additionally, there will be 4 QRV units providing 24-hour, 7-day ALS coverage. With this

increased deployment and to ensure an effective First Responder interface, field supervision has

been expanded to continuous coverage provided by three on-duty supervisors, increasing the

dedicated Field Supervisor count to nine full-time employees.

In response to the RFP specification, AMR commits to assist the County in reducing the non-

medically necessary utilization of ambulance services by the CCHP program. Furthermore, we

acknowledge that the ambulance transportation provider will receive fee-for-service

reimbursement at the applicable Medicare or Medi-Cal allowable rates. The proposed user fees

account for this change to transport volume and reimbursement.

Alternative Deployment Proposal

To address the response time equity issues inherent to the East County’s geography, AMR

proposes the deployment option described in Section 4.2. The increased deployment

requirement to provide an 11:45 minutes Priority 1 response time at 90% compliance to

Bethel Island and Discovery Bay is an additional 470 transport unit hours per week at a cost of

approximately $1.8 million annually. This option would increase total deployment to 4,494

weekly transport unit hours, in addition to the baseline 672 weekly QRV hours. This

deployment option would also require the addition of 18 full-time Paramedic positions over


98

our core proposal. With expected 2006 volume of more than 49,000 patient transports, the

incremental average patient charge would increase by approximately $86, or 7.4% over our

core proposal. The following table identifies the alternative rate structure required to support

this deployment option.

A. Patient Charges Alternative Deployment

Proposal

* Proposed Itemized

Rate

Proposed Bundled

Rates BLS Base Rate $ 445.32 $ 478.50 BLS-Emergency Base Rate 445.32 583.57 ALS 1 Base Rate 970.76 1,075.84 ALS 1-Emergency Base Rate 970.76 1,139.99 ALS2 Base Rate 970.76 1,330.23 Loaded Ambulance Mile Rate 21.84 21.84 Treat and no transport charge 198.00 198.00 * Additional supply, drug, and procedure charges billed separately.

8.2 Proposed Service Charges

The required Service Price Sheet is located in our attachment binder behind the “Required

Documents” tab. It identifies the proposed annual cost of an ALS Quick Response Vehicle (QRV)

to be $414,335, or $47.30 per hour. These units are staffed by senior Paramedics who possess the

depth of experience to work in the field alone. Each unit is an ALS equipped Ford Expedition.

The marginal Paramedic ambulance hourly rate of $74.20 is based on a 24-hour deployment

model and includes the cost of staffing, equipment, maintenance, and supplies.

8.3 Optional Services Price List

The required Optional Services Price List is located in our attachment binder behind the

“Required Documents” tab.


99

Upgrading Ambulance Fleet

Although our primary proposal includes the deployment of frontline Type III Modular

ambulances, we have prepared the calculation of this incremental cost in the required Optional

Services Price List. The basis for the $150,400 total is a $16,000 cost differential for 47

ambulances depreciated over an estimated five year useful life. Note that cost of upgrading 39

of these units is already included in our primary proposal.

Deployment of Reserve Ambulance Fleet

The annual amortized cost of acquisition, insuring, maintaining, and equipping each potential

reserve ambulance is $21,424 for a Type II and $24,624 for a Type III ambulance.

Guaranteed Response Time Performance for East Contra Costa County

The annual cost estimate to provide the guaranteed Paramedic response time of 9:59 minutes

to the East County communities as set forth in the Optional Services Price List is $1,258,213.

In order to achieve the 9:59 standard, we would deploy an additional 252 Paramedic weekly

transport unit hours and the addition of a fifth QRV at 168 hour per week.