It’s unfortunate that there is so much focus on response times, when more evidence-based patient outcome data could be evaluated, such as those contemplated in the Joint Position Statement from 16 EMS, fire, public policy and patient safety organizations on EMS Performance Measures Beyond Response Times (https://www.tandfonline.com/doi/full/10.1080/10903127.2024.2375739).
Measures for clinical care, patient and provider safety, patient and provider experience and financial outcomes would provide a more balanced evaluation of provider performance.
Still, response times goals and measurements, when evaluated as an operational process measure, should be evidence-based, and tracked and reported from a patient-centric perspective, starting when the call is received by the dispatch center, and ending at patient contact.
Individual time durations such as call processing, activation, drive, and patient access can then be trended over time to identify opportunities for enhancement.
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Contract dispute with Sonoma County Fire District delays release of key ambulance performance data
County and fire district officials are locked in a dispute over how to calculate response times, a key component in evaluating how local ambulance service is performing.
March 29, 2025
https://www.pressdemocrat.com/article/news/sonoma-county-fire-discrict-ambulance-contract-dispute/
Three things to know:
- Sonoma County's contract with the Sonoma County Fire District for ambulance services is under dispute, affecting the timely release of performance data.
- The fire district is arguing the contract does not cover requirements for low-priority calls and wants them thrown out of 2024 performance data.
- The county argues that low priority calls make up 40% of all ambulance calls and removing them from the equation would erode public trust.
It’s been a year since Sonoma County Fire District took over the exclusive contract to provide ambulance service in the county’s central core. Those exclusive rights — worth $30 million annually for at least five years — come with response time standards and data reporting requirements.
That data is only now trickling out, and on the surface it shows the providers met response time thresholds during the last three months of 2024, which fire district officials say outperforms the previous provider’s “anemic” service.
But that may not tell the complete story.
Behind the scenes, officials and the district are locked in a dispute over the fundamental criteria used to calculate response times, a key component of the district’s performance evaluation.
That means the average Sonoma County resident may have no way of knowing for sure whether response times are better or worse than they were a year ago.
The disagreement, which started last May, has for months hamstrung the county’s ability to monitor and enforce the contract, which calls for periodic compliance reviews.
Compliance data is a critical information source both for the county officials, who are tasked with ensuring the district is meeting requirements, and district officials who need to make sure the system is operating efficiently. At the center are patients ― the public ― who are reliant on ambulances to reach them quickly.
“An EMS system is essentially bringing the hospital to a patient's door and making a lot of the interventions that would exist at a hospital available to you right there on the scene,” said Gabriel Kaplan, assistant director for the county’s health services department, which oversees the contract.
The dispute over compliance requirements is laid out in a series of letters exchanged between officials and attorneys and obtained by The Press Democrat through a public records request.
Feb 25 Letter from District Attorney to Solito.pdf
One of the key disagreements is whether the contract holds the district accountable for low priority calls, which amount to 40% of calls for ambulance services. Such calls, referred to as “Code 2,” are still considered urgent but do not require lights and sirens.
The county says it has always enforced standards for Code 2 calls, the terms of which are spelled out in the contract. Jennifer Solito, interim health services director, made that clear in the correspondence.
March 3 Letter from Solito to Fire District Attorney.pdf
“The County cannot and will not bend on this requirement because a lack of a response time requirement would erode public trust in both DHS and SCFD,” Solito wrote to Sonoma County Fire District Chief Mark Heine in a March 3 letter.
But the district says the contract is ambiguous and has accused the county of being “unreasonable” and risking “breach of contract.” In multiple letters, an attorney representing the district said the county’s stance “is unfairly prejudicial to SCFD by moving the proverbial goalposts.”
A representative of the county’s previous exclusive ambulance contractor pushed back on any attempt to loosen response time requirements.
Jason Sorrick, a spokesman for American Medical Response, locally known as Sonoma Life Support, said Code 2 calls may not require lights and sirens but still need urgent medical attention and require some type of performance measurement.
He questioned the fire district’s high marks.
“We believe that the system is likely 30% understaffed, and it is our opinion that the demands of the system were underestimated in the bid,” he said.
Disputed chart
When the Board of Supervisors approved the district’s contract in June 2023 after months of contentious debate, both county and fire district officials heralded their partnership as a significant step toward bringing ambulance services under public domain. The benefits would include transparency, accountability and enhanced emergency response.
Landing the contract was a major coup for the relatively new fire district, which was created in 2019 through a series of local fire agency consolidations. Its firefighting territory at the time included Windsor, Rincon Valley, Bennett Valley, Bodega Bay, Guerneville and Forestville.
The five-year deal provides exclusive rights covering the county’s most populated areas. On a single day in March 2025, for example, the county’s 911 dispatch system received more than 300 ambulance calls.
To help cover the significantly larger territory under the county contract, the fire district brought in a subcontractor, Vallejo-based Medic Ambulance.
This map shows Sonoma County Fire District’s newly expanded ambulance service area, covering most of Sonoma County. Service in the area shaded in pink begins Jan. 16, 2024. (Dennis Bolt/ For The Press Democrat)
The district’s contract took effect mid-January last year and offered a three-month grace period before penalties for failure to meet compliance standards kicked in.
In a single compliance period, the district must meet response times at least 90% of the time. The number of minutes an ambulance has to reach a patient varies depending on the severity of the call and whether the location is in a rural, semirural or urban area.
The contract outlines a sliding scale of penalties if the district is out of compliance in any of the six zones that make up the coverage territory.
A few months into the new contract, a dispute erupted between the district and county as officials began to review the district’s performance during the first three months of operation, according to a Feb. 25 letter an attorney representing the district sent to Solito.
“At that meeting, and in subsequent discussions, it became clear that the parties were interpreting the … response time standards tables differently,” the attorney, Andrew Schouten of Wright, L’Estrange and Ergastolo, wrote, referring to a May meeting.
The county and district disagreed on four points regarding how to calculate response times: when the clock starts during a call; how to measure calls that do not come through the 911 system; how to calculate response times for a call where the severity is downgraded over the course of the call; and ― the biggest point of contention ― whether the district should be held to Code 2 response time standards for its 2024 performance.
The Code 2 disagreement boils down to a single chart in the 134-page contract.
That chart outlines the response time thresholds broken down by the severity of the emergency and by the six coverage zones that make up the district’s territory. Its title includes a set of parentheses that includes only “Code 3.”
The district says there is no “Code 2” table in the contract.
The county counters that response times for Code 2 calls are clearly listed in the body of the chart.
The county has acknowledged in correspondence with the fire district that “(Code 3)” is an error, but maintain the contents of the table cover requirements for all calls, including Code 2.
“Our position is … that all calls have a response time requirement, including Code 2 calls,” Solito told The Press Democrat.
But the district has argued that the Code 3 label means the chart only applies to the higher acuity calls, even though the lowest acuity calls, called Alpha and Bravo, are listed in the chart with response times.
In letters to the county, Schouten, the attorney for the fire district, said that “ambiguity” could create an unsafe situation for responding ambulance crews, patients and the general public if calls that are considered Code 2, are tied to response times in the same Code 3 chart.
But in the Feb. 25 letter, Schouten also noted the district added the “Code 3” parenthetical to the first draft of the contract, which was negotiated over a six-month period.
“Given its silence during negotiations and acceptance of SCFD’s proposed language, SCFD reasonably believed County interpreted the response time standards charts to apply to Code 3 responses only,” Schouten wrote.
An oral agreement
Heine acknowledged there should be time standards for low priority calls and called it “good public policy,” but stressed that such requirements should be spelled out clearly in the contract.
“Where I have to draw the line is when you decide you don’t like what’s in the contract, or that it’s missing something, and you want to impose it upon us without successfully negotiating,” Heine said. “That’s a problem.”
Last summer, the district attempted to negotiate with the county on Code 2 response times, going back and forth over a few months.
Following a mid-August meeting, Heine believed the two parties had reached a resolution. He said former county health services director Tina Rivera, who was overseeing the contract, had agreed to extend the amount of time they are allowed to respond to low priority calls by seven minutes.
Not long after that meeting, Rivera left her post with the health services department. She had announced her resignation and impending departure a month earlier.
The district believed Rivera’s agreement amounted to a binding revision of the contract.
But in an interview last week, county officials relayed a different version of that discussion.
County lawyers said changing the table would potentially be a substantive change to the contract, Kaplan said. Such a change would risk the county having to start the competitive contracting process over again at the direction of the state’s Emergency Medical Services Authority.
Sorrick, AMR’s spokesperson, agreed.
“This could be in violation of the State EMS Act and the State EMS Authority’s approval of the RFP,” he said.
The county has only recently dragged itself out of a painful yearslong bidding process that began after the county’s contract with its previous provider, American Medical Response, expired in 2019.
The county repeatedly extended AMR’s contract as it struggled to launch a new competitive process and attributed the delay to complications from the wildfires and pandemic.
The bidding delays sparked lawsuits and eventually drew the attention of the state authority throwing the core operating area’s exclusivity into question.
“We're providing a franchise monopoly on a provider to operate in the exclusive operating area and in order to do that, you need state blessing, because otherwise it’s an antitrust violation,” Kaplan said. “And counties don't have the legal authority to be exempt from antitrust violations, but states do.”
The county was under a lot of pressure from the state agency to execute the competitive bid for the exclusive contract, Kaplan said.
Questioning the data
Under the new contract, which went into effect mid-January 2024, the fire district and county officials must review monthly compliance data and produce a public report. By mid-December, nearly a year into the contract, data still had not been publicly released.
On Dec. 17, 2024, The Press Democrat submitted a public records request for data covering the first year of the district’s performance. The county did not provide any records related to that request until March 4 and so far has only provided data covering last October, November and December.
The report shows the district scored 98% overall, exceeding compliance requirements. Though locked in a debate about how to measure response times, both county and district officials said the district has been successful.
But for some in the local emergency response industry, the delay has raised questions about whether the behind-the-scenes dispute will weaken the standards applied to the district.
A former emergency medical services agency official with detailed knowledge of county ambulance contracts said the district’s high score is unusual. The official, who requested anonymity in order to speak freely, said scores in the low to mid-90s are more common in the industry.
Traditionally, the official said, the clock starts ticking on ambulance response times when ambulances are dispatched and ends when the crew arrives at the scene of the emergency. Beginning the clock after the dispatcher has finished interviewing the caller to determine a priority level, can leave anywhere from 30 seconds to minutes off the clock, the official said.
“If they’re getting two or three extra minutes, you would expect them to be on time more,” the official said.
Data for the bulk of 2024 remains pending as county and district officials debate how to evaluate the compliance data. Those officials were due to present a proposed contract amendment to the Board of
Supervisors on March 25, but that discussion was delayed because the related documents could not be completed in time to comply with the state’s open meeting law requirements.
