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HomeMy WebLinkAboutAgenda Report - November 21, 2007 E-182 AGENDA ITEM Ego 1 CITY OF LODI COUNCIL COMMUNICATION TM AGENDA TITLE: Approve Response to San Joaquin County Grand Jury Report Regarding its Investigation of the Request for Proposal Process Used by San Joaquin County Emergency Medical Services MEETING DATE: November 21,2007 PREPARED BY: Citv Attornev's Office RECOMMENDED ACTION: Approve response to the San Joaquin County Grand Jury Report Regarding its Investigation of the Request for Proposal Process Used by San Joaquin County Emergency Medical Services. BACKGROUND INFORMATION: The 2005/2006 Grand Jury investigated a complaint concerning the Requestfor Proposal process used in awarding the ambulance and dispatch contract by the San Joaquin County Board of Supervisors to American Medical Response (AMR), as well as formal complaints alleging serious dispatch failures by AMR that affected the response and provision of emergency medical services to the residents of San Joaquin County. The Grand Jury issued its Final Report on June 12, 2007 (Case No. 10-06) and requested that the Lodi City Council (in addition to Councils for the cities of Stockton and Manteca) respond to various findings and recommendations made by the Grand Jury. The City initially responded to the Grand Jury by indicating that a settlement with San Joaquin County over the dispatch of 911 -calls was imminent and that a resolution of the litigation would resolve the concerns raised in the Grand Jury's Report. Unfortunately, although it appears the City of Lodi may be able to resolve its disputes with the County, negotiations between the City of Stockton and the County have broken-down and the pending litigation is now going forward. In light of the current status of matters, it is necessary to respond to each of the findings made by the Grand Jury and to address implementation of the Grand Jury's recommendations. A copy of the proposed response is attached. FISCAL IMPACT: None. dJa ' D. gdich, Deputy City Attorney Attachments: Grand Jury Case No. 10-06 Final Report Draft Response to Grand Jury Findings and Recommendations cc: Mike Pretz, Fire Chief APPROVED:` 1 Blair 1<0. anager D]Z";k III '• CITY OF LODI CITY COUNCIL MEMORANDUM TM TO: The Honorable Richard J. Guiliani Presiding Judge, San Joaquin County FROM: City Council of the City of Lodi DATE: November 21, 2007 SUBJECT: Response to Grand Jury Final Report (Case No. 10-06) San Joaquin County Medical Services Pursuant to Penal Code sections 933(c) and 933.05, the City of Lodi's comments to the findings and recommendations of the San Joaquin County Grand Jury Final Report (Case No. 10-06), are set forth below. As noted, the City of Lodi respectfully disagrees with the findings of the Grand Jury and with the exception of continuing its efforts to resolve the pending litigation with San Joaquin County, contends that it is not in the best interest of the safety of the citizens of the City of Lodi to implement Grand Jury recommendations 1 and 2. The City believes public safety is best preserved by public, not-for-profit Public Safety Answering Points (PSAPS). Finding No. 1. City disagrees with this finding. The finding states in part, that the dispatch process of 9-1-1 calls is the same under the contract between the County and American Medical Response (AMR) as it was as prior to May 1, 2006, and as a consequence dispatch times and service should be compatible. This assumption is incorrect. First, at the time of the directive by County EMS concerning the dispatch of medical emergency calls became effective (May 1, 2006), the CAD to CAD interlink between the Stockton Fire Department (SFD) dispatch center and AMR's LifeCom dispatch center was not in place. As a result, response times for ambulance and paramedic services were unnecessarily delayed. It was not until November 2006 that the CAD to CAD system became operable (7 -months after LifeCom dispatching under its contract with the County). It is City's position that no change in dispatch protocol should have been ordered by County until LifeCom's CAD system was in place and operational. In addition, EMS Policy No. 3001 (Guidelines for EMS Call Screening by Primary Public Safety Answering Points) which was adopted by County EMS without input from public safety agencies within the County, created changes in dispatch protocols that have also resulted in response time delays by emergency personnel. Finding No. 2. City disagrees with a portion of this finding. City concurs with the Grand Jury's finding that the CAD to CAD system was set-up to transfer medical information, not fire information, and that as a result cellular calls (transferred directly from CHP to LifeCom) have not only been delayed, but critical information is now unavailable to SFD dispatchers to relay to fire personnel. The inability to obtain this critical information is the direct result of changes instituted by County EMS and has led to CHP's inability to timely transfer fire and emergency calls and allow the 9-1-1 caller to speak directly with an SFD dispatcher. Finding No. 3: City disagrees with a portion of this finding. The Grand Jury states that it has determined there are few dispatch failures by AMR which are affecting the response and provision of emergency medical services and minimizes the failures that have occurred by noting that similar problems occurred in the 1990's when SFD began dispatching. However, the Grand Jury failed to note the distinction between the technology available today and what was available 15 -years ago, by way of example, Geographic Information Systems (GIS) did not exist. This finding, while noting that the CAD -to -CAD system is now in place does not address why LifeCom was permitted to dispatch for over 7 -months without an operational CAD to CAD system in place and without current GIS data. In addition, the finding does not recognize that LifeCom is handling only 30% of the call volume that had been handled by the SFD dispatch center prior to the implementation of EMS Policy No. 3001. Finding No. 4: City disagrees with this finding. LifeCom's dispatchers were trained by the SJRUG members who have now concluded that LifeCom's dispatch delays are not inconsistent with cellular calls coming into the system. Nevertheless, delays in calls received by LifeCom are not acceptable to the agencies outside the SJRUG. Moreover, using the "average", which is a measure of central tendency, as an overall indicator for performance is an inadequate measure of performance. The deviations from the "average" can be significant and are the source of complaints from those users not currently under contract with LifeCom. City contends that LifeCom and the SJRUG should use fractal measurements and a 90th percentile criterion, not the 50th percentile currently in use, to evaluate the length of time required to dispatch emergency responders. Finding No. 5: City disagrees with a portion of this finding. Notwithstanding the finding of the Grand Jury on this issue, it must be noted that at the time of the directive of County EMS to PSAPS regarding the transfer of 9-1-1 medical emergency calls to LifeCom (effective May 1, 2007), LifeCom did not possess the necessary Geographic Information System (GIS) necessary to locate the caller or direct appropriate responders to the caller's location. In at least one incident LifeCom's system inadequacies resulted in a fatality. LifeCom did not have up-to-date GIS in place until some 7 -months after the County EMS directive on the transfer of medical emergency calls. Finding No. 6: City disagrees with a portion of this finding. Finding No. 6, cont. The City of Lodi's contractual obligations with the City of Stockton required that the City provide Stockton with a 1 -year notice prior to termination. County EMS Policy No. 3001, effective May 1, 2006, did not provide City with sufficient notice for City to terminate its contract with the City of Stockton. City would have been put in the untenable situation of being in breach of its contractual obligations with Stockton had it chosen to follow the EMS policy. Further, City made a decision, based on its authority under the Warren 9-1-1 Act, to maintain its fire and medical emergency dispatch with SFD because it continued to provide an efficient, effective and economical means of providing emergency response services to the citizens of the City of Lodi. It should also be noted that a fire based EMS dispatch system recommended by the County Fire Chiefs Association is used by over 97% of the largest 200 cities in the United States. City is unaware of any other EMS dispatch system that relies on a private out -of -county contractor to handle 9-1-1 calls. County's action in the implementation of Policy No. 3001 violated the Emergency Medical Services Act (EMS Act), the Warren 9-1-1 Act and the 1985 9-1-1 Agreement entered into among the County and the cities and public safety agencies (the primary PSAPS) in the County. In addition, decisions regarding who provides medical 9-1-1 secondary PSAP service is for the City to determine, not the County. However, County EMS can assume medical control over the clinical methods of the dispatch system, but under the Acts does not have the authority to direct who serves as a secondary PSAP for the cities and public safety agencies within its jurisdiction. It is also City's position, contrary to this particular finding of the Grand Jury, that any unusual occurrence reports that have been submitted by the City of Lodi since May 1, 2006, were submitted for legitimate reasons and accurately reflected the occurrences at issue; such reports were not submitted with the intent to exaggerate problems and response time delays, nor were they submitted in response to AMR's breach of its agreement with the cities of Lodi, Stockton and Manteca concerning the submittal of a joint RFP to the County concerning ambulance services within the county. Finding No. 7. City agrees with this finding. As noted by the Grand Jury in its finding, there is tension between the statutes at issue, namely the Warren 9-1-1 Act and the Emergency Medical Services Act which the parties seek to resolve in the pending litigation as discussed above in response to Finding No. 6. Finding No. 8. City disagrees with a portion of this finding. In this finding the Grand Jury invalidates charges concerning dispatch failures by LifeCom. City is unaware of the specifics of all charges made against AMR/LifeCom by SFD or others concerning dispatch failures; however, City is aware of published reports of several significant failures by LifeCom to dispatch emergency medical personnel to correct locations and that in at least one instance, such failure resulted in an individual dying before emergency medical personnel arrived on scene. Because the City contracts with SFD to dispatch fire and medical emergency calls within its jurisdiction, City contends that the proper parties to address the specifics points raised in the finding would be the complaining parties themselves. Finding No. 9. City disagrees with a portion of this finding. They City agrees that delays in transferring care from ambulances to emergency rooms poses a threat to residents and visitors of the County and has become an issue on a national level. However, it is City's contention that County EMS has exacerbated the problem by entering into an exclusive operating contract with AMR for dispatch and ambulance transport. In addition to delays in transferring care in the emergency rooms; calls originating from convalescent care facilities requesting patient transfers to hospitals have on at least two separate occasions resulted in delays for service, when AMR has had to use multiple ambulances to provide care and transport services. On both occasions, the patient was found to be suffering a medical emergency which required additional ambulances without the benefit of personnel supplied by the fire department. This utilization of multiple ambulances resulted in the reduction of emergency medical vehicles available to service the City's coverage area. Respectfully submitted. CASE # 10-06 FINAL REPORT SAN JOAQUIN COUNTY EMERGENCY MEDICAL SERVICES REASON FOR INVESTIGATION: The 2005106 Grand Jury investigated a comolaint concerning the Request for Proposal (RFP) process used in the awarding of the ambulance and dispatch contract bythe San Joaquin County Board of Supervisors (BOS). This procurement process included the provision of all emergency ambulance responses within the County, as well as the operation of the ambulance provider's dispatch center, which was to be an approved Emergency Medical Dispatch (EMD) center and 911 secondary answering point. The investigation of the 2005106 Grand Jury was focused upon the RFP process as it pertains to policy and procedures only and not upon the feasibility/viability of the services that may be delivered. The 2005106 Grand Jury recommended that the BOS should provide an analysis of the ambulance service at six and twelve month intervals to the succeeding Grand Jury in order to assess the impact of this change on the health and safety of County residents. The 2006107 Grand Jury decided to continue the review of ambulance and dispatch services based on that recommendation. Subsequently the members received two formal complaints alleging serious dispatch failures byAmerican Medical Response, Inc. (AMR)which have affected the response and provision of emergency medical services to the residents of San Joaquin County. One of the complaints submitted to the current Grand Jury was mostly a personal attack on the Emergency Medical Services Agency (EMS) and its Director. The management of the contract was called grossly negligent, covering up careless and dangerous practices of AMR. It also claimed that the transfer to a "lesser facility" was illegal, proven faulty and lethal. It noted that many of the problems have gone unreported in the media. In addition, it alleged that the Director of EMS has acted to protect AMR by manipulating response times and hiding the very careless behavior of AMR. In addition, the complaint called for the examination of the contract accountability by the EMS Agency and so called "misconduct" fines to be paid by the Company (AMR). BACKGROUND: San Joaquin County is served by seventeen fire departments. Prior to the AMR contract, three of the fire departments provided Advanced Life Support (ALS) services and fourteen provided Basic Life Support services. All emergency ambulance service dispatching as well as fire dispatching within the county before the awarding of the contract was done by the Stockton Fire Department's Regional Dispatch Center. On May 1,2006 services under the AMR contract began at 8 a.m. METHOD OF INVESTIGATION: Organizations Visited AMRILifeCom Call and Dispatch Center in Salida (two visits) City cf Stockton Fire Department Call and Dispatch Center City of Stockton Police Department Call and Dispatch Center California Highway Patrol Call and Dispatch Center San Joaquin County Sheriffs Call and Dispatch Center City cf Tracy Fire Department San Joaquin County Emergency Medical Services Office City of Manteca Fire Department City Ripon Consolidated Fire District City cf Lodi Fire Department At the call and dispatch centers we visited. in addition to interviewing call takers and dispatchers, the Grand Jury observed and listened to calls and dispatching. Peoole Interviewed AMR San Joaquin County Operations General Manager Vice President of LifeCom Support Director of Communications -LifeCom EMS & Fire Dispatch EMS Administrator EMS QI/Trauma Coordinator EMS Specialist President, Inspironics Corporation Deputy Chief, City of Stockton Fire Department Captain, Emergency Communications Director, City of Stockton Fire Department. Dispatch Supervisor, Stockton Police Department Chief, City of Tracy Fire Department Chief, City of Ripon Consolidated Fire District Chief, City of Manteca Fire Department Chief, City of Lodi Fire Department Lieutenant, San Joaquin County Call and Dispatch Center Supervisory Communications Dispatcher, SJC Call and Dispatch Center GIS Manager, SJC Community Development Department/GIS GIS Coordinator, City of Stockton Lieutenant, California Highway Patrol (CHP), Stockton Area Public Safety Dispatch Supervisor, CHP, Stockton Area Documents Reviewed: 1. San Joaquin County Emergency Medical Services Agency EMS Liaison Contact List 2. San Joaquin County EMS Quality Improvement Council Membership 3. Paramedic Services Agreement Between San Joaquin County and the City of Stockton, April 9, 1986 4. List of All ALS and BLS Fire Deparlments in San Joaquin County 5. Letter from AMR to EMS dated August 9,2006, Re: Appeal of fines for May and June 2006 6. Letter from EMS to AMR dated October 4, 2006, Re: Appeal of Fines for May and June 2006 7. Summaries from the EMS Incident Reporting System concerning Incidents Per Primary Incident Type, Incidents Per Reporting Company, Incidents Per Company Rpt Pertains To, 05/01/2006-01/31/2007 8. Incidents List, Detailed from the EMS Incident Reporling System for 05/01/2006- 12/31/2006 9. Incidents List, Detailed from the EMS Incident Reporting Sysiem for 01 /01 /2007- 01/31/2007 10. Incident Detail Report, Incident number: 06082553, Incident Date: 10/07/2003, 23:54:12 11. EMS Agency Report on the Exclusive Emergency Ambulance Provider Contract Compliance for AMR for the months of May and June, dated August 13, 2006 12. EMS Agency Report on the Exclusive Emergency Ambulance Provider Contract Compliance for American Medial Response for the months of July and August 2006, dated November 9,2006 13. EMS Agency Report on the Exclusive Emergency Ambulance Provider Contract Compliance for American Medial Response for the months of September and October 2006 14. EMS Agency Report on the Exclusive Emergency Ambulance Provider Contract Compliance for AMR for November and December 2006 15. Letter to EMS from Stockton Fire Department Consultant/[nvestigator re: Medical Dispatch -Keyser Drive dated November 8, 2006 16. Letter to the Chairman of the San Joaquin County Board of Supervisors from the Mayor of Stockton dated July 27, 2006 17. Tritech CAD -to -CAD (Computer Assisted Dispatch) Functional Specification Documents 18. Logisys CAD-toCAD Functional Specifications Documents 19. Unusual Occurrences Filed bythe Stockton Fire Departmentwith Delayed Calls Highlighted. 20. CAD -to -CAD Links report (Computer Assisted Dispatch)from AMRILifeCom to the Stockton Fire Department from September 9, 2006 to March 19, 2007 of responses that were two minutes or longer. 21. Structure Fire Call Times submitted by AMR/LifeCom to EMS that conflict with the times AMRILifeCorn submitted to the Stockton Fire Department. 22. Series of Letters (May 1 and May 2, 2006) from Chief Hittle, Stockton Fire Department to Kenneth Cohen. Director, San Joaquin County Health Care Services, detailing perceived dispatch and communication problems. 23. May 3`d Letter from Kenneth Cohen to Chief Hittle responding to Chief Hittle's letters of May I and May 2. 24. Series of Letters (May 5, May 9) from Chief Hittle to Kenneth Cohen detailing perceived EMS system failures. 25. Memorandum dated December 19, 2003 from the San Joaquin County Fire Chiefs Association to Chico Research Foundation with a subject of Redesign of County EMS System. 26. San Joaquin County EMS Agency Continuous Quality Improvement Meeting Rules 27. Letterfrom the Chief of the Tracy Fire Department, dated February 13,2007,to the Director of the Administrative Services Department for the City of Stockton concerning the issue of public safety radio frequencies 28. Letter from Chief Hittle of the Stockton Fired Department, dated February 26. 2007, to Chief Bosch of the Tracy Fire Department concerning the Public Safety Radio Frequencies. 29. Report to the Board of Supervisors by the Fire Chief, Ripon Fire District. Chairman, San Joaquin County Joint Radio Users Group (SJCJRUG) 30. March 29 communication from the Stockton Fire Department to EMS, Re: Information Exchange. 31. Unusual Occurrence Case 406489, Public Report, January 29,2007 Relevant Law and Regulations 32. Health and Safety Code, Division 2.5, Section 1797.200 33. Health and Safety Code, Division 2.5, Section 1797,204 34. Health and Safety Code, Division 2.5, section 1798 35. California Code of Regulations, Title 11, Division 9, Chapter 12, EMS System Quality Improvement Relevant San Joaauin County EMS Aaencv Policy and Procedures: 36. San Joaquin County EMS Policy No. 540.01 Unusual Occurrence 37. San Joaquin County EMS Agency No. 3001, Guidelines for EMS Call Screening by Primary Public Safety Answering Points 38. San Joaquin County EMS Agency No. 3001A, PSAP Call type Flow Sheet 39. San Joaquin County EMS Agency No. 3101, Emergency Ambulance Service Provider Dispatch Requirements 40. San Joaquin County EMSAgency No. 6620, Continuous Quality Improvement Process 41. EMS Form #6002, Unusual Occurrence Report. August 16, 2006 Relevant LifeCom EMS and Fire Dispatch Policies and Procedures 42. MPDS Implementation and EMD Call Processing 43. Emergency Call Taking and Law Enforcement/Fire/First Responder Call Notification 44. GISIGEO File Troubleshoot Procedure 45. Sentinel Event Notification Matrix 46. Letter from EMS to Stockton Fire Department dated November 22, 2006, Re: Unusual Occurrence Report, SJCEMSA Case #6459 47. Letter from EMS to Stockton Fire Department dated November 22, 2006 Re: Unusual Occurrence Report, SJCEMSA Case #6443 48. Data Reduction Methodology used by Inspironics for January 2007 49_ Listing of Unusual Occurrence Reports Categorized by Type for EMS Continuous Quality Improvement Meeting of March 15, 2007 FINDINGS: 1. The current method of dispatch has land line 911 calls going to primary Public Safety Access Points (PSAPs). Depending on the location of the call, the call goes to the Stockton Police Department for Stockton, Lodi Police Department for Lodi, etc., and anything in the unincorporated County area goes to the San Joaquin County Sheriffs Department. The fire and medical emergency calls for Stockton, Lodi and Manteca go to the Stockton Fire Department. Stockton dispatches these fire departments as before and at the same time informs the LifeCom center of the medical emergency. County 911 calls go to the Sheriffs Department with fire calls transferred to Stockton as before and medical calls transferred to AMR's LifeCom Center. Since this process is the same as before the new contract was implemented, the dispatch times and service should be comparable. 2. All 911 cell phone calls go to the California Highway Patrol (CHP). In the past the CHP would transfer fire and medical calls to the Stockton Fire Department for dispatch. Since May 2006 the CHP transfers fire and medical calls to AMR's LifeCom Center. As a result of this change some dispatch problems and delays have been occurring. If it is a medical emergency call, both the fire department and ambulance are dispatched virtually simultaneously over the CAD -to -CAD system between LifeCom and Stockton Regional Dispatch Centerwith a subsequent follow- up phone call. The CAD -to CAD system from LifeCom to Stockton was set up to transfer medical information, not fire information. So if the cell phone call is afire call, it has been necessary for LifeCom to phone Stockton with the fire information, causing delays longer than before the contract was implemented. 3. Following an extensive review and investigation of the allegation of serious dispatch failures, the Grand Jury has determined that there are at the present time few dispatch failures by AMR which are affecting the response and provision of emergency medical services to the residents of San Joaquin County; given the approximate 3,000 calls dispatched byAMR each month, the failure rate is very low. There were problems at the beginning of the contract; however, with the CAD -to - CAD communications now in place, significant dispatch delays for emergency medical service are not occurring. Many of the Fire Departments noted that there were similar problems in the 1990's when they began to be dispatched by Stockton. 4. In addition to the general investigation of the Emergency Medical Dispatch System, the Grand Jury investigated the specific allegations made by two Fire Departments as well as those contained in the original complaint. On March 20, the Grand Jury received a list of Structure Fire Incidents that purported to document unacceptable delays as a result of issues with the LifeCom Fire Dispatch Center operated by AMR in Salida. The document indicated that the average time from call receipt to dispatch on structure fires for the last year was 51 seconds. The Grand Jury already had the results of an investigation of these same incidents conducted by the San Joaquin County Radio Users Group(SJCRUG), which had concluded the following: "No delay exists that is inconsistent with those inherent calls coming into the systems from cellular phones." This group also discussed the inherent problems with cellular phone calls and the difficulty of determining location. The full report of this group's findings was presented to the County Board of Supervisors on February 6th, 2007, including a table noting the actual times LifeCom received the call and subsequent dispatch to Stockton. Of special note is the following conclusion from the report: "SJCRUG is pleased with the services we are receiving from LifeCom and are looking forward to our partnerships in the future." The SJCRUG is comprised of representatives from the following fire departments and districts: Escalon, Ripon, Lathrop -Manteca, Farmington, Linden -Peters, Clements, Woodbridge, Tracy, French Camp, Liberty, Mokelumne, Collegeville, Waterloo-Morada, Thornton, Montezuma, and Manteca. The Grand Jury therefore concludes that the current response time is acceptable. 5_ Another continuing allegation is that LifeCom does not have an up-to-date Geographic Information System (GIS) file and therefore does not have all of the addresses in the City of Stockton as well as the County. As noted in one Unusual Occurrence Report, there were problems with the GIS used by LifeCom from a private company. However, subsequent to that time, the GEO/GIS database was updated with the County and City Database on November 16, 2006_ This action was confirmed by the EMS Office in letters to the Stockton Fire Department dated November 22,2006. In addition, to confirm this update, the Grand Jury visited the LifeCom Center, observing that an update had been completed, and verifying itwith the Stockton GIS Coordinator and the GIS Manager for San Joaquin County. These databases are now transferred to LifeCom on the 15`n of each month using File Transfer Protocol (FTP). 6. The Grand Jury found in interviews with staff from the Stockton and Lodi Fire Departmentsthatthey believe a private company should not do emergency medical dispatch. Based on this presumption, these cities, plus Manteca, have refused to dispatch medical calls through LifeCom. Some of the background in this matter includes a Memorandum dated December 19, 2003,from the San Joaquin County Fire Chiefs Association to the Chico Research Foundation with a subject of Redesign of County EMS System which they believe was ignored. An earlier agreement between the Stockton Fire Department and AMR to submit a joint application for dispatch fell apart when AMR dropped out of that agreement and subsequently was awarded the contract for dispatch in San Joaquin County. The end result has been a continual process of submitting unusual occurrence reports, which often appear to exaggerate problems and response times. Based on the interviews, documents reviewed, and organizations visited, and as noted above, this process seems to have continued to this day including problems that have already been investigaled and/or resolved. Of particular note, of the 558 Unusual Occurrence reports for January, 117 were generated by the Stockton Fire Department complaining about LifeCom and 423 were generated by LifeCom complaining about the Stockton Fire Department. The remaining unusual occurrence reports, which did not contain so-called "dispatch" problems, have been resolved. A significant numberof these Unusual Occurrences were complaints about data missing from the CAD -to -CAD system. It now appears that after many months of replicated complaints about missing data, Stockton and AMR are going to be working on a Phase I I of the CAD -to -CAD systems that should include both medical as well as fire dispatch data. 7. Subsequent to the refusal of Stockton, Lodi, and Manteca to change the medical dispatch, San Joaquin County filed a lawsuit to make them comply. Part of the issue now focuses on allegedly contradicting statutes, with the cities noting that the 911 law says that local governments decide where 911 calls go and the County noting an EMS law that assigns responsibility for EMS questions to the County. 8. The Grand Jury investigated the allegations made in the complaint, including negligence, illegality. manipulation of data, and questions regardingthe "misconduct fines." a. The Grand Jury has found no validity in any of these charges. As to covering up problems, they are all examined in the compliance reports presented to the Board of Supervisors and the public has access to all reports on the County's website. In fact, this web site has a great amount cf relevant information. The Grand Jury found no indications of a cover-up. b. As to the manipulation of emergency call receipt, turn over of calls and dispatch, the Grand Jury's investigation found no such manipulation. On the contrary, all data is entered into a database which is immediately replicated a number of times both for back up but also for analysis and compilation by EMS. Only one EMS edit of any item is allowed and it is highlighted for later review. The response data itself is also analyzed and compiled by an outside contractor (Inspironics)who provides this service for five other counties. This data is then sent back to EMS for further review and submission to the Board of Supervisors. Thus the data is examined by both EMS and an outside company. To believe that this Company would jeopardize its reputation and/or contracts with other counties just to manipulate data does not seem reasonable. c. As to the so-called "misconduct fines," the only actions which have resulted in the reduction of fines are again publicly available on the internet with a letter from AMR to EMS dated August 9,2006, appealing the fines for May and June 2006. A follow-up letterfrom EMStoAMRdated October 4,2006 has the subject: Appealof Fines for May and June 2006. This letter notes that the fines were reduced after a review and recommendation by the Ambulance Contract Advisory Group (ACAG). No subsequent exceptions have been given nor fines reduced. 9. The Grand Jury finds that the only real threat which might affect the response and provision of emergency medical services to the residents of San Joaquin County has been identified by the EMS Agency itself in its Contract Compliance Report for November and December dated February 27, 2007. The problem identified is the growing problem of delays of transferring care from the ambulances to the emergencydepartments in the local hospitals. In some hospitals the transfer of care has exceeded four hours with six or more ambulance crews treating their patients in the emergency department hallways waiting for the hospital to accept the patients. The report notes that this problem can lead to AMR's request of more exemptions related to response time, but more importantly itsignificantly degrades the number of ambulances available for subsequent emergency service and transport. The Grand Jury supports the EMS Agency's efforts to resolve the growing problem of delays of transferring care in the emergency department. RECOMMENDATIONS: 1. It is time for all agencies to set aside their differences, stop using the Unusual Occurrence process to discredit each other and to work together on improving Emergency Medical and Fire Dispatch in San Joaquin County and resolving any problems that exist. A number of organizations are already in place to provide a forum for this cooperation, including the EMS Quality Improvement Council, the San Joaquin County Fire Chiefs group, the San Joaquin County Radio Users Group and the 911 Primary PSAP Organization. This collaborative process is crucial to the health and safety needs of the people of San Joaquin County. 2. The EMS Agency, AMR, and Stockton Fire Department need to ensure that Phase 11 of the CAD -to -CAD system goes forward quickly to resolve any missing data issues. 3. The Grand Jury recommends that the cities of Stockton. Lodi and Manteca immediately begin to have their Emergency Medical Needs dispatched byLifeCom. However, the members recognize that there is a litigation issue concerning the control of 911 calls by focal governments. When this litigation is decided, no mailer the outcome, these cities should reevaluate their stance on Emergency Medical Dispatch and work together to serve the residents of San Joaquin County. RESPONSE REQUIRED: Pursuant to Section 933.05 of the Penal Code: The Stockton City Council (all three recommendations), the Lodi City Council (recommendations #1 and #3), and the Manteca City Council (recommendations #1 and #3) shall report to the Presiding Judge of the San Joaquin County Superior Court, in writing and within 90 days of publication of this report, with a response as follow: As to each finding in the report a response indicating on the following: A. The respondent agrees with the finding B. The respondent disagrees with the finding, with an explanation of the reasons (herefore. As to each recommendation, a response indicating one of the following: A. The recommendation has been implemented, with a summary of the action taken B. The recommendation has not yet been implemented, but will be with a time frame for implementation. C. The recommendation requires further analysis, with an explanation of the scope of analysis and a time frame not to exceed (6) six months D. The recommendation will not be implemented, with an explanation therefore.