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File #: 2021-1232   
Type: Consent Calendar Item Status: Agenda Ready
File created: 10/20/2021 In control: Health Services
On agenda: 11/2/2021 Final action:
Title: Emergency Medical Services Exclusive Operating Agreement Request for Proposal Revisions
Department or Agency Name(s): Health Services
Attachments: 1. Summary Report, 2. Attachment 1 – Draft Request for Proposals with Revisions
Date Action ByActionResultAction DetailsMeeting DetailsVideo
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To: Board of Supervisors of Sonoma County

Department or Agency Name(s): Department of Health Services

Staff Name and Phone Number: Tina Rivera, 565-4774

Vote Requirement: Majority

Supervisorial District(s): Countywide




Emergency Medical Services Exclusive Operating Agreement Request for Proposal Revisions



Recommended Action:

Recommended action

A)                     Approve the revisions to the Request for Proposal (RFP) approved by the Board on April 13, 2021.

B)                     Authorize the Director of the Department of Health Services resubmit the RFP to California Emergency Medical Services Authority (EMSA).

C)                     Authorize the Director of the Department of Health Services to make minor modifications prior to RFP release for non-substantive changes.

D)                     Authorize the Director of the Department of Health Services to release the RFP for responses.



Executive Summary:

On April 13, 2021 the Board of Supervisors deliberated on the proposed components of the draft RFP for Exclusive Operating Area #1 (EOA 1) for the purposes of submitting the RFP to the California Emergency Medical Services Authority (EMSA) for approval based on the provision of Sonoma County Code Chapter 28-17, adopted by the Board on November 12, 2019. At that meeting, the Board directed staff to submit the draft RFP to EMSA.

EMSA declined approval of the RFP as submitted due to concerns around selection procedures contained within the document, as well as some differing requirements for public and private organizations that submit proposals in response to the RFP.

Staff worked with County Counsel and the Emergency Medical Services (EMS) Ad Hoc committee, and EndPoint EMS Consulting, LLC to revise the RFP to address the legal issues raised by EMSA. Staff also consulted with the Ad Hoc committee for guidance on how to best follow the policy direction of the Board when drafting any revisions to the RFP needed to gain State approval.

The draft RFP submitted to your Board contains revisions needed to achieve EMSA approval. EMSA approval is required to gain state action immunity for establishment of an Exclusive Operating Area. Staff believe the policy direction of the Board has been followed to ensure a fair and transparent process while conducting an RFP with the goal of procuring a highly qualified vendor from the widest possible group of proposers capable of serving the community.



Division 2.5 of the California Health and Safety Code (HSC) “the EMS Act” § 1797.224 allows Local EMS Agencies (LEMSAs) to enter into formal agreements for provision of ambulance service through the creation of Exclusive Operating Areas (EOAs). HSC 1797.224 states:

A local EMS agency may create one or more exclusive operating areas in the development of a local plan, if a competitive process is utilized to select the provider or providers of the services pursuant to the plan. No competitive process is required if the local EMS agency develops or implements a local plan that continues the use of existing providers operating within a local EMS area in the manner and scope in which the services have been provided without interruption since January 1, 1981. A local EMS agency which elects to create one or more exclusive operating areas in the development of a local plan shall develop and submit for approval to the authority, as part of the local EMS plan, its competitive process for selecting providers and determining the scope of their operations. This plan shall include provisions for a competitive process held at periodic intervals. Nothing in this section supersedes Section 1797.201.

Sonoma County designates the Department of Health Services as the LEMSA for Sonoma County. Within the Department, EMS Agency functions are the responsibility of Coastal Valleys EMS Agency, which is organized within the Public Health Division of the Department. In 1991, the LEMSA, under direction of the Sonoma County Board of Supervisors, established an EOA to serve the cities of Santa Rosa, Sebastopol, Rohnert Park, Cotati, and the surrounding unincorporated areas. At this time, this is the only EOA for ambulance service in Sonoma County. The County will be conducting its fourth request for proposals (RFP) since developing this EOA. The existing EOA has been extended to June 30, 2022.

Although the EOA as currently designated covers the densely populated center of the County, and the majority of Sonoma County’s 911 calls occur within that zone, much more of the geography of Sonoma County is outside of the EOA. The EOA is surrounded by a mix of provider agencies including city and district fire service providers that provide ambulance service, a community services district and a healthcare district as well as two private ambulance services. The agencies that provide service to their local communities, including the EOA provider, rely on each other for mutual support and routinely collaborate with their neighbors on system issues that affect the entire County. Selection of a highly competent provider with sufficient capacity will help ensure timely and effective mutual aid when needed across the County.

In early 2018, Coastal Valleys EMS Agency (CVEMSA) and the Department of Health Services created an Emergency Medical Services EOA Development Project committee. The purpose of the committee was to receive input from interested stakeholders on the proposed structure of the RFP for Ground Emergency Ambulance Service within the Sonoma County EOA. The committee also provided valuable input into an updated EMS System Ordinance which included direction on EOA development and provider selection processes. Oversight of the ordinance revision process was provided by an EMS Ad Hoc committee established by the Sonoma County Board of Supervisors. The EMS Ad Hoc committee met regularly with Department leadership and EMS Agency staff to provide guidance and policy direction. The Ordinance was adopted by the Sonoma County Board of Supervisors in November 2019.

Initial RFP Development Process

In October 2019, Sonoma County Department of Health Services contracted the services of EndPoint EMS Consulting, LLC (EndPoint) to assist CVEMSA and the County in completing the RFP process. This included facilitating a stakeholder process, producing a draft RFP for Board approval, and assisting in the negotiations of an agreement with the successful proposer. EndPoint mapped out a three-phase process to achieve the goals of the County. Phase One has been completed, comprising a high-level system assessment and stakeholder input process. Phase Two, which is currently being conducted, develops and conducts the ambulance EOA procurement process, and Phase Three will assists with contract negotiation and development with the awarded provider. Endpoint completed Phase One in July of 2021. Based on stakeholder input guidance from the EMS Ad Hoc committee, the Department of Health Services developed a draft RFP for consideration by the Board of Supervisors.

During the RFP development process, the County’s EMS system participants: fire departments, ambulance providers, hospitals, and community leaders were offered an opportunity to provide input into the next ambulance RFP. In the process of working with stakeholders and county staff, a number of key areas of stakeholder interest were identified by the consulting team. During the RFP input sessions, Stakeholders expressed support for a more inclusive range of potential vendors to include public agencies seeking to complete, allowing for subcontracting of portions of the service delivery by the winning bidder and potential expansion of the EOA boundary. In addition to expanding the range of potential vendors, several other system-of-care enhancements were proposed by stakeholders and supported by the EMS Ad Hoc committee. These enhancements include:

1)                     Using advanced technology and the ability to leverage EMS data to drive quality improvement.

2)                     Setting expectations for clinical performance in addition to response time performance.

3)                     Limiting the exclusivity of the EOA to emergency ambulance services while allowing non-emergency ambulance services to market services to health system partners.

Following the March 23, 2021 presentation of the draft RFP to the Board of Supervisors, staff were directed to respond to a series of public comments made by system stakeholders. Staff brought revision recommendations to the EMS AdHoc committee for approval and for submission to the Board for final approval prior to seek state approval of the competitive process required by HSC 1797.224.

During the March 23, 2021 meeting, the Board also provided direction to accept the Ad Hoc committee’s recommendation to revise the EOA boundary which will exclude the proposed northern expansion of the EOA into the area currently and historically served by Bell’s Ambulance Service. The revised boundary proposed for submission to the California EMS Authority is reflected in the draft RFP to include the current EOA 1 zone and adding the West County community of Occidental and surrounding area noted in the 2018 EMS Plan VeriHealth (Falck) that has been vacant of a designated primary ambulance responder since June of 2020.

On April 13, 2021, staff returned to the Board with revisions to the RFP that addressed the issues raised in the public comment process. The proposed revisions were presented to the Board with the support of the EMS Ad Hoc committee. The Board authorized the Department of Health Services to submit the revised RFP to the California EMS Authority for approval.

Subsequent Process; EMSA Denial and Revisions

On April 15, 2021, the Department of Health Services submitted the draft RFP to EMSA for review and approval. EMSA responded with a letter indicating the RFP was not approved as submitted. EMSA issues included:

1)                     The scoring process in the RFP allowed the County to award the Exclusive Operating Area to an entity other than the highest scoring proposer. EMSA stated that the scoring criteria as applied by the review committee must determine the outcome of the competitive process to ensure the award is based solely on the results of the process.

2)                     The RFP had different requirements for public and private proposers. EMSA stated that the process must have the same entry and evaluation requirements for all proposers regardless of organizational structure.

3)                     The RFP had inadequate evaluation scoring directions. EMSA required additional descriptive language to differentiate between awarded scores to limit subjectivity in scoring.

In response to EMSA’s letter, Department staff worked under the guidance of the EMS Ad Hoc committee and County Counsel to address the EMSA concerns.

Staff moved yes/no scoring criteria to a “Minimum Requirements” section and modified the scoring sheet in order to directly correlate with the RFP requirements section. Staff also reviewed and modified scoring values to better reflect the guidance of the Ad Hoc committee while retaining the EMSA’s recommendations. As a result, the scoring sheet now correlates directly to the RFP requirements section and the minimum requirements evaluation is now separated from the scoring evaluation. Lastly, staff provided significant additional guidance to the proposal review committee in the form of overall an overall vision and values statement, Clear and detailed scoring instructions, guidance on issues to consider when rating, and clear descriptions of rating values.

Recommended Revisions to the RFP

Staff addressed the EMSA concerns through the following revisions:

1)                     The RFP evaluation process will produce an awardee solely based on the scoring of the Proposal Review Committee. The independent panel selected in conformity with Sonoma County Code section 28-17 will review and score each proposal. The Department of Health Services will draft a contract that is compliant with the terms of the RFP and recommend it to the Sonoma County Board of Supervisors for approval. If the Board authorizes the Department to enter into an agreement with the selected contractor, the resulting exclusive operating area agreement will meet state requirements for protection from anti-trust legal action in accordance with Health and Safety Code section 1797.224. The ultimate authority to enter into an agreement or not remains with the Board.

2)                     Structural revisions to scoring and additional clarification in RFP language. The scoresheet in the draft RFP has been improved through the addition of detailed scoring criteria and expanded references to RFP sections containing the required elements to be addressed in each proposal.

3)                     More granular scoring elements were added and scores were modified to better reflect the RFP’s intent. The EMS Ad Hoc committee and staff determined that adding more granular scoring elements will help the PRC to objectively and independently score proposals resulting in the best selection. The original score sheet contained broader categories, which have been broken into subcategories with more individually scored elements. The RFP now contains language directed to proposers, clarifying what materials should be provided to allow the PRC to successfully evaluate a proposer’s qualifications.

4)                     Addition of detailed guidance and instructions for the Proposal Review Committee. Staff added an overall vision and values statement to the RFP scoring section which includes language describing the policy goals of the EMS Ad Hoc committee such as the importance of considering innovation and community benefit when evaluating proposals. The RFP awards points for innovative programs and supplemental specialty training.

5)                     Equitable entry and scoring requirements for all proposers. The draft RFP rejected by the EMSA allowed different bonding, insurance and fiscal auditing practices based on a proposer’s organizational structure as a public or private entity. Staff have modified the elements identified by EMSA and have established consistent standards for all proposers. Staff and the Ad Hoc committee have determined that the minimum requirements meet the threshold for competence, establish a level baseline for competition, and allow the widest possible vendor engagement without taking on undue financial risk.

6)                     RFP Process Review: RFP processes were reviewed for conformance with Sonoma County procurement policies. Minor revisions were made to ensure alignment.


Prior Board Actions:

On April 13, 2021 the Board A) reviewed the Matrix of Public Comments and Staff responses and Recommendations; B) approved changes to be incorporated into the RFP; and C) approved the RFP for submission to California Emergency Medical Services Authority (EMSA).

On March 23, 2021 the Board deliberated on the proposed components of the draft RFP for Exclusive Operating Area #1 (EOA 1) for the purposes of submitting the RFP to the California EMS Authority for approval based on the provision of Sonoma County Code Chapter 28-17, adopted by the Board on November 12, 2019.

On October 22, 2019 the Board approved an agreement with Endpoint EMS Consulting, LLC for subject matter expertise and support in developing a request for proposals for an exclusive provider of emergency ground ambulance services in an amount not-to-exceed $161,000 through December 31, 2021.

On May 21, 2019 the Board approved the third amendment to an agreement with American Medical Response West for emergency ground ambulance services, providing for an extension of the term through June 30, 2022 with an additional two one-year options and authorizing service rate increases effective July 1, 2019.

On May 8, 2018 the Board authorized the Chair to submit a letter expressing County support for a one-year extension request of the California Emergency Medical Services Authority for the Exclusive Operating Area Ambulance Services Agreement covering central Sonoma County and work with the area's Assembly members and State Senator to support this request.

On December 16, 2008 the Board approved the Emergency Ground Ambulance Services Agreement with American Medical Response West.


Fiscal Summary


FY 21-22 Adopted

FY 22-23 Projected

FY 23-24 Projected

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Narrative Explanation of Fiscal Impacts:

There are no fiscal impacts directly associated with this item.


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Narrative Explanation of Staffing Impacts (If Required):




Attachment 1 - Draft Request for Proposals with Revisions


Related Items “On File” with the Clerk of the Board: