In the next three to five years, the District of Columbia will have one of the premier fire and EMS systems in the United States. Before you say that the Washington Nationals have a better chance at taking the World Series than D.C. Fire and EMS does of being recognized by its peers and the media, read further.

Five years ago, I wrote an article that was critical of the agency and soon after I received a lot of comments from its personnel. One captain even took the time to pen — not e-mail — a letter to me. It was at that point that I realized there still was passion and commitment within the organization.

The January 2006 death of New York Times Washington Bureau reporter David Rosenbaum during a violent street crime — after which the inspector general's office sharply rebuked the department for failing to respond properly — forced the agency to make serious changes. Those changes were already in progress — due to USA Today's 2005 examination of EMS in 50 cities, which placed the District of Columbia in the bottom tier — but the Rosenbaum case was the tipping point that gave the organization a mandate with financial and political support.

Under the leadership of Mayor Adrian M. Fenty and Chief Dennis L. Rubin, the district created an EMS task force and issued a comprehensive strategic document for system improvement. Despite being cannon fodder for the local media, the management team has demonstrated true grit in its efforts to make D.C. Fire and EMS the pride of the country.

Though the agency isn't perfect, it is moving forward and compares favorably against most fire-based EMS systems of comparable size in this country. It has committed to certifying every member with the National Registry. At press time, 99.9% of paramedics and 55% of EMTs had completed this requirement, and the department is expected to reach full completion by the end of 2010. For a department of this size, this is a huge commitment of time and financial resources.

In addition, the department is working with the IAFF to create a coaching environment that de-emphasizes punitive action.

Management's philosophy of driving out fear and focusing on remediation has been a key factor in its successful turnaround. Performance data and accountability mechanisms are in place and accessible to medical and field supervisors. The medical director is now a fire department employee and not a contract worker, which increases accountability. Dr. Jim Augustine is one of the most experience fire department medical directors in the country. He is a great educator who is neither too afraid nor too busy to get in the field.

A return of clinical sophistication with evidence-based practice has brought a comprehensive protocol revision that includes continuous positive airway pressure machines and distribution of controlled substances previously thought to be too risky to be accounted for in this system. Data from the electronic patient-care reporting system shows the agency's compliance with the clinical performance measures created by the Eagles, a consortium of U.S. and international major metropolitan medical directors.

Clinical performance reports now are generated on CHF, STEMI, chest pain, and stroke care. Unlike five years ago, D.C. Fire and EMS can accurately report its cardiac-arrest survival rate. For instance, the cardiac-arrest return of spontaneous circulation (ROSC) rate is 28%, which is above the 27% benchmark set by the International City/County Management Association and slightly below the 32% standard set by Centers for Disease Control's Cardiac Arrest Registry to Enhanced Survival (CARES). The agency has spearheaded a successful effort to enroll all District of Columbia hospitals in the CARES registry, so that they can report survival rates using Utstein criteria.

While most people look at clinical performance, D.C. Fire and EMS also has looked at operational issues. The agency is rolling out a layer of EMS field supervision that is rivaled only by Memphis, Tenn., and senior staffers are measuring the number of calls to which EMS field supervisors respond. EMS response times are mapped using GIS to ensure that benchmarks are met in every neighborhood of the city.

D.C. Fire and EMS also is employing important social solutions. Most EMS systems tolerate the “frequent flyers,” who become a source of liability and frustration in the field and in the emergency room. D.C. Fire and EMS has employed a creative solution called the Street Calls program, which identifies those patients who call often and account for a significant call volume. The program finds solutions other than an ambulance ride and an ER bed. This has resulted in a 50% reduction of repeat transports for patients enrolled in this program.

Lastly, the stakeholders seem to be quite pleased with the service D.C. Fire and EMS is providing. This year, the department began an aggressive effort to measure customer satisfaction among patients and hospital staff. The most recent customer-satisfaction rating for transported patients indicates that 95% were “very satisfied” or “satisfied” with the EMS service. While there is more work to be done, the mere existence of these assessments to establish a baseline is more than most fire-based EMS agencies are accomplishing.

All of this would not have happened without good leadership. Rubin has attained the Chief Medical Officer designation from the Centers for Public Safety Excellence. EMS staff members frequently attend National Fire Academy courses. The department is introducing advanced leadership training via the International Public Safety Leadership and Ethics Program and its aggressive recruitment of outside fire and EMS providers is bringing in new ideas and new blood.

While about 90% of EMS providers in the department are sworn, uniformed firefighters, the agency is committed to evolving into a unified all-hazards agency, by equalizing training requirements, pension, benefits and pay for the remaining single-role civilian EMS personnel.

Nowhere else in the country is EMS under such scrutiny — the district is home to the national press corps, is accountable to Congress and squarely is in the cross hairs of terrorists. It has undergone a complex consolidation of services. The dynamics of these issues would be exhausting to most people.

Would you feel safe with D.C. Fire and EMS taking care of your family? The Rosenbaum family can rest assured that the EMS system has improved and that one man's tragic death may have saved thousands. Other agencies now can look to D.C. Fire and EMS as a showcase of how government can reinvent itself and deliver state-of-the-art clinical and operational emergency medical services.

Bruce Evans is the EMS chief for the North Las Vegas (Nev.) Fire Department. He also is the fire science program coordinator at the Community College of Southern Nevada and an adjunct faculty member for the National Fire Academy's EMS and injury prevention courses. He has an associate's degree in fire management and a master's degree in public administration.

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