When it comes to life-threatening emergencies, such as a stroke or cardiac arrest, a patient's chance of survival can be measured by how fast she or he gets to a hospital, often down to the second. That's why cities and counties have response-time standards for 911 ambulance providers.
After tougher response-time standards were implemented last year, the city of San Diego ambulance provider, Rural/ Metro, increased its local fleet. Since October, the private company has brought on at least three and as many as six new ambulances, city officials and sources inside the company say.
"I would call it an enhancement to improve response times," said Alyssa Ross, program manager for the Fire Department's Emergency Medical Services, which oversees the ambulance company's contract compliance. "It will have an impact in that Rural / Metro has decided to add more units. To meet a higher demand, they added three additional units to meet the stricter standards."
Michael Simonsen, Rural / Metro's California director of public affairs, wouldn't confirm the addition of new ambulances, but said, via email, that Rural / Metro "is constantly evaluating demand for service in [the] San Diego EMS system and makes unit hour and staffing adjustments when necessary to ensure a continued prompt response."
But getting a true measure of an ambulence provider's performance can often be complicated by its contract terms.
For the most serious emergencies, the city of San Diego requires Rural / Metro to arrive within 12 minutes 90 percent of the time, measured quarterly, or face fines. For years, the city's compliance reports proudly showed that the Scottsdale, Arizona-based company met the standard about 97 percent of the time.
That storyline hit a speed bump last year when the city, facing public scrutiny, amended its contract with Rural / Metro to close a longstanding loophole. Until July, ambulances dispatched after 12 other ambulances were on the road weren't held to response-time standards. With more than 30 ambulances in the company's local fleet, the loophole resulted in thousands of exempted calls.
Rural / Metro maintained that the loophole didn't affect how it did business.
"We don't manage to the exemptions," Simonsen told CityBeat in August 2013. "We manage the system how it is."
After the city amended the contract last spring, Rural / Metro quickly announced it would station a new ambulance at the San Ysidro border crossing, an area where, without the exemptions, response times would have triggered a fine, according to a city analysis. About a month later, Mayor Kevin Faulconer held a press conference to celebrate improved response times at the border.
"The changes made last year to the city's ambulance contract have improved response times in the South Bay, and Rural / Metro has fully complied with the required performance measures under the current deal," said Craig Gustafson, the mayor's spokesperson.
However, since then, Rural / Metro has continued to add ambulances to its local fleet, although to considerably less fanfare.
The ambulances were added as Rural / Metro readied to face its second quarterly compliance report without the loophole. Released this month, the report showed the company has been flirting with noncompliance. From October to December, Rural / Metro's ambulances arrived on time to life-threatening emergencies in zone 1—which includes the border crossing—only 90.2 percent of the time.
Since the loophole was closed, Rural / Metro has responded to life-threatening emergencies citywide less than 92.7 percent of the time. Among the city's four zones, quarterly response-time compliance topped out at 93.7 percent.
Currently under negotiation, the city's contract with Rural / Metro could be about to get even more strict, including elimination of another little-known exemption.
"We are currently in negotiations for a contract extension with Rural / Metro and are looking at opportunities to work with Rural / Metro to provide even better service in the coming year," Gustafson said.
Under review has been a provision called "system upgrade," which allows more response time for calls upgraded to a life-threatening emergency while an ambulance is en route. The idea has been to compensate for the fact that ambulances on non-life-threatening calls can't use lights and sirens, slowing down response times.
However, it came to the attention of city regulators that many of these upgraded calls don't start as non-life-threatening calls but, rather, without any designated emergency level. In such cases, ambulances have been allowed to use lights and sirens, making the system-upgrade exemption in many cases unnecessary.
If approved, the higher standard would likely be applied in the next compliance report, Ross said.
"I think we've made tremendous efforts over the last few years," she said. "I think the language is going to be more specific now."
Part of the reason the city may be getting tougher with its ambulance provider is that officials recently realized they could be stuck with the company for several more years. Last August, the city tried to put its ambulance service up for bid, but state EMS officials intervened, stating that under the law, the county's Local Emergency Medical Services Agency (LEMSA) had to conduct the competitive-bidding process. The city hoped to reach a compromise before its contract with Rural / Metro expired this summer.
However, in late January, LEMSA released a memo that said state EMS officials have encouraged the city to extend its contract with Rural / Metro for at least two more years to "ensure uninterrupted" service.
That's especially frustrating for city officials because a request for proposals for ambulance service has been sitting on the shelf for years. In 2011, following allegations that the company embezzled more than $17 million from the city, officials dramatically restructured Rural / Metro's contract and prepared a competitive bidding process.
While a request for proposals was completed under Mayor Jerry Sanders, the document was never released. When Mayor Bob Filner took over, he further delayed the process to consider allowing the San Diego Fire Department to bid. By the time the city got around to issuing the bid, state officials had, based on a previous legal ruling, insisted that most counties take over the process.
While that freezes a major overhaul of the ambulance contract, the city will have a chance to tweak its agreement with Rural / Metro when it renews the agreement this summer.
Among other issues being reviewed is the performance standard for non-life-threatening emergencies. When the city tightened parts of its ambulance contract last year, it simultaneously loosened others. Specifically, compliance for urgent but non-life-threatening and non-emergency calls was significantly watered down. Instead of individually measuring the two categories, they were combined along with life-threatening calls for a citywide compliance category.
The change was seen as a compromise to help the company meet response-time standards with the elimination of the contract's loophole. However, at the urging of the city's Independent Budget Analyst, the performance data for the previous categories continued to be tracked. Since last July, response times for non-life-threatening emergencies, such as broken arms, fell below the former 90-percent standard in both quarters to 85.5 and 89.5 respectively.
Whether the city reinstates the higher standard for non-life-threatening emergencies, residents will have a better understanding of their ambulance service once contract negotiations wrap up in the next few months. The ambulance contract extension will then come before the City Council for approval before it expires on June 30.