Denver Health to City Auditor: You aren't the boss of us!
Denver Auditor Dennis Gallagher presented his office's long-awaited report on the city's emergency medical response system yesterday, saying that the information his team has compiled "speaks for itself." His choice of such a careful phrase to describe the scathing assessment is indicative of the bitter inter-agency politics that have hovered around the audit since it was announced ten months ago.
The report concludes that lack of comprehensive oversight of Denver's EMS system has resulted in lengthening response times, falling standards, call-center inefficiency and "systematic structural weaknesses" at the city's 9-1-1 Call Center. And it recommends the creation of an entity independent of the Denver Fire Department and Denver Health to supervise and refine the time it takes for fire crews and paramedics to respond to calls.
Fire officials weren't much of a presence at the packed, 8 a.m. audit committee meeting. But the top dogs from Denver Health - paramedic leadership, department heads, administrators - were out in force. They even distributed an inch-thick packet that included a recent hospital-commissioned study showing Denver Health to have one of the nation's best patient survival rates, a 39-page rebuttal to the Auditor's 43-page report, and a 5-page mini-rebuttal for journalists with short attention spans.
Good thing, because that way it didn't take me long to get to the essence of their response to Gallagher and his audit folk: You're not the boss of us. Or, to be precise, the city is not the boss of us.
Among other things, Denver Health points out that since 1994, it has been an Authority that, by state statute, "shall not be subject to administrative direction or control by any department, commission, board, bureau, or agency of state or local government."
But even if Denver Health is technically a "political subdivision of the State of Colorado" and nyah-nyah-nyah, it still holds a massive operating agreement with the city each year for a number of services, such as drunk pick-up, free clinics, pre-natal care for the uninsured -- and paramedic-staffed ambulances. In fact, Denver City Council members' concerns over paramedic response times threatened to derail the signing of the 2009 contract until everyone agreed to revisit the ambulance portion after the Auditor's report was released.
The conclusions of the audit reinforce many of the criticisms revealed by Westword in June - namely, that the operating agreements established between the City and Denver Health in 1997 "have been weakened over the past several years" to the point that Denver's standards are lower than the ones used by most other major cities. These lesser standards have been exacerbated by changes in how the hospital calculates response times, says the audit.
The clock used to start when the call was received. But four years ago, the start time was shifted to when the unit was dispatched - in contradiction to the expectation laid out in city contracts. This has enabled Denver Health to shave off a significant chunk of time in what is finally reported to the city.
The audit also points out that the hospital's increased use of "data scrubbing" to cull certain lengthy responses from the final numbers could serve to "eliminate calls that are longer than the parameters of any performance measure."
What this means is that Denver Health has been able to make its ambulance response times look good on paper even as the actual length of responses has increased dramatically. Data analyzed by the Auditor's Office based on NFPA standards found that Denver Health's responses in 2007 shot up to an average of 15:48, 90 percent of the time.
Audit work determined that in 2007, the total time for an ambulance to arrive on the scene from reception of the 9-1-1 call was within 15:48, 90% of the time. The City's ambulance (Denver Health) response time was significantly longer than the NFPA goal of responding within 10:30, 90% of the time. Additionally, the City's BLS (Denver Fire) response time of 10:29, 90% of the time, was significantly longer than the NFPA goal of responding within 6:30, 90% of the time.
The greatest increase has been during call-processing time, which rose 37 percent from 3:10 in 2004 to 4:00 in 2007. Much of this is taken up in what the audit calls the "Dispatch Time Gap," the time between when enough patient and location information has been gathered to dispatch an ambulance and when an ambulance is finally sent. Last year, this dead time lasted on average 1:31.
"One possible contributing cause for this time gap may concern ambulance availability," says the audit. "Denver Health personnel acknowledged that there are peak periods where no Denver Health ambulances are available . . . long dispatch times may indicate that a dispatcher must search for an available unit or wait for a unit to become available."
But Denver's emergency medical response operates under a two-tiered system, which means that the Denver Fire Department issues Basic Life Support while the Paramedic Division administers Advanced Life Support. The audit found that neither is meeting the National Fire Protection Agency response time standards that the City adopted in 2004.
Moreover, the fractured nature of the system -- split between Denver 9-1-1, Fire and Denver Health, with each agency collecting and analyzing its own portion of data based on its own requirements and self-interest -- makes it difficult to approach response times holistically.
Bottom line, as the audit points out: the true response time is the one perceived by citizens from when they call 9-1-1 for help to when paramedics reach them. Right now, there is no accurate way to measure that. And even if there were, no person or entity exists with the responsibility to oversee true response times and report back to the public and decision makers on how our EMS system is performing.
Some parts of the system have changed since Gallagher began this audit. Katherine Archuleta, senior adviser to Mayor John Hickenlooper, wrote in an audit-response letter that the Mayor's Office plans to immediately established an "EMRS Monitoring Group." That group -- comprising officials from the Mayor's Office, Denver Health, denver City Council, Denver Manager of Safety's office and the Department of Environmental Health - will establish standards, assessment measures, etc, and issue quarterly updates to the Mayor.
Even Denver Health seems open to the idea of oversight - that is, if it gets to oversee itself. In one of its many detailed responses to the Auditor's findings, the hospital suggests that its own Medical Director, Chris Colwell, should be the overseer of the entire EMS system. (After all, it's not like he erroneously asserted to journalists that his ambulance response times were being calculated from the time the call was received, NOT when it was finally dispatched.)
And so far, the Hickenlooper administration has seemed willing to let Denver Health essentially dictate its own systematic reduction in response time standards, and leave the Department of Environmental Health out of the loop.
"Denver Health would say, we think we need to take a look at the language within the operating agreement to be discussed for a change," Archuleta said in a June interview. "Technically that falls under the Denver Environmental Health agency and their manager. But really that comes to me and the Mayor's Office. We would oversee whether there's any disagreements or changes or issues that are raised."
The oversight was so lax for so long that a key requirement of a response time aggregate average of 6:45 was misprinted for seven years without anyone noticing. Another key "agreement" with the city was not much of an agreement at all. Denver Health continually references a 2004 meeting with Denver Fire and DEH officials when the city allegedly decided to shift response start times to the moment a call is dispatched, rather than received - a change that turned out to have a huge impact on reported times.
But the minutes of that September 29 meeting clearly show that the intent was to establish two different sets of response times "for both the Mayor's (and public) perspective and the individual agencies' perspectives."
"From the Mayor's perspective: from the time the CAD Emergency Call Taking screen is opened until the arrival of the first unit (agency specific) is documented as arriving on scene. This time should essentially represent the time from when the caller makes contact with the 911 system until the time they see help arrive. This will allow the City to provide the public with realistic assessments and expectations regarding its emergency services."
The "Mayor's perspective" was the same time frame that Denver Health had always been providing to the city. There is no mention in the meeting minutes that the hospital would begin using the shorter "agencies' perspective" in its annual reports. Then-Deputy Manager of Safety Steve Browne - the only non-Fire, non-Paramedic official at the meeting, says he has no recollections of such decisions being made, and that he wasn't the person who would make such decisions, anyway - that would be the Mayor's Office.
But according to Archuleta, the Mayor's Office was not involved with negotiating the change - that was a choice between the hospital and the Fire Department. So in other words, Denver Health simply decided on its own to begin reporting a more lax time to the city. And when Westword broke the news of this discrepancy this summer, the Mayor's Office bought right in to the hospital's explanation and obligingly changed the Operating Agreement. Whoops!
Any ERMS Monitoring Group created by the Mayor's Office should also include an oversight entity similar to the Office of Independent Monitor at the Denver Police Department. This is a position that was created in 2005 in response to several controversial police shootings and what some perceived was an inability for the DPD to properly investigate itself.
Today, whenever a Denver officer intentionally shoots at a human being, the incident is also investigated by the OIM, which then issues its own findings and recommendations. It has gone a long way to fostering openness and trust in the community that police shooting investigations are conducted properly.
It's a route that should be followed if Denver is to fix the problems the Auditor found in the emergency medical response system. -- Jared Jacang Maher