In August 2024, the Multnomah County Board of Commissioners unanimously approved an agreement with American Medical Response Northwest, Inc. (AMR) to make changes to staffing models intended to improve slow ambulance response times.
On Tuesday, Sept. 9, AMR returned to brief the Board on the steps it had taken to achieve contract compliance in the year since the agreement went into effect. Their briefing revealed both successes and concerns as the County and AMR continue to chart a path toward faster emergency response times.
The settlement agreement’s primary objective of improving response times has largely been met. Before the agreement, AMR consistently fell short on timely response to critical and non-critical calls — those standards generally are eight minutes or less for life threatening responses and 20 minutes or less for non-immediate responses in urban zones. With the new staffing model, AMR is now meeting benchmarks for lower acuity calls, and nearing the 90% benchmark for life threatening responses.
“Since the implementation of the new staffing model and the other terms of the agreement, you can see a consistent and significant recovery in AMR’s response performance,” County Emergency Medical Services (EMS) Administrator Aaron Monnig said.
Monnig explained that a key factor in this improvement is due to “a significant increase in the number of ambulances on the road, rising from an average of 46 to 67 per day in July.”
While response times have improved, concerns about the well-being of frontline workers have emerged. Presenters from the Teamsters Local 223, the union representing AMR staff, testified about the immense pressure and stress they are facing.
“While some of the recent changes in Multnomah County have indeed improved aspects of our system, such as expanding our fleet and reducing individual call loads, there have also been unintended negative consequences that cannot be overlooked,” said AMR paramedic Hillary Davis.
“Over the past 18 months, the focus of my work has shifted away from providing high-quality, compassionate care — our true mission — and toward meeting seemingly arbitrary metrics and navigating layers of oversight that often work against efficiency and safety.”
Davis also said that training for new Emergency Medical Technicians (EMTs) and paramedics has suffered due to accelerated timelines and compliance pressures. EMTs are being placed in the field with as little as eight days of training while paramedics with less than a year of experience are being placed into leadership roles before they feel ready.
“This has resulted in increased vehicle accidents [and] inexperienced crews and paramedics like myself being unable to rely on partners to safely drive or effectively assist during calls,” said Davis. “This is not only a safety issue for us as providers, it is a risk to patient care and to our professional licenses.”
Monnig said that despite AMR’s reported increase in full-time paramedics, the net number of paramedics has actually dropped by nine, largely due to part-time paramedics leaving the system. While AMR’s current turnover rate of 22-24% is still below the national average, it represents a significant increase for Multnomah County.
The quality of care provided to patients during the last year has also come under scrutiny. When the Board approved changes to ambulance staffing in 2024, County EMS cautioned about potential adverse consequences and made a plan to monitor impacts.
Quality EMS Director Dr. Matt Neth said that midway through 2025, the County has already received 18 complaints, already nearly matching the 22 complaints the County received in both 2023 and 2024. At this rate, the number of complaints is on track to be double that of previous years. These complaints concern the technical aspects of care, Dr. Neth said, but also relate to customer service and how care is perceived by the patients, families, hospitals and other community stakeholders.
Additionally, between January and mid-July of this year, AMR has experienced 44 vehicle incidents, which include accidents and mechanical vehicle failures. If the trend continues, AMR could finish 2025 with more than twice as many vehicle incidents as all of last year, which also totaled 44.
Dr. Neth said the increase in public complaints and vehicle incidents has led the team to perceive a “decline in the quality of care being delivered both in terms of direct patient care and overall operational performance.”
Performance targets for critical clinical outcomes, such as the time it takes for an ambulance to arrive for stroke and trauma patients, are also not being met consistently, according to Dr. Neth.
“While we've made incredible improvements, we've not met the contract requirements and to be completely transparent with you all, this has been harder than we anticipated,” said AMR Regional Director Rob McDonald. Staffing efforts, specifically gaining more paramedic leads, are the key to getting AMR into compliance, he said.
Both AMR and Multnomah County EMS acknowledged that any system’s success must balance timely response and quality of care. The current ambulance staffing model will continue to be in effect, but there is a clear call for action to address the quality of care and staff retention issues. AMR committed to working with the County’s EMS team to:
- Improve training and mentorship: A redesign of training programs and enhanced medical director oversight is in progress.
- Increase paramedic recruitment: AMR is actively pursuing new recruitment methods, including an international program for Australian paramedics, and has invested over $1 million in scholarships.
- Strengthen system oversight: Multnomah County will continue rigorous monitoring and public reporting, and an early reassessment of the entire EMS system is underway to identify and address long-term deficiencies.
Board comments
“It seems like the very real need to improve response times — which I am not discarding as being incredibly important — may have contributed to a very heavy focus there and some of the results are somewhat predictable if the overwhelming drive is response time,” said Commissioner Meghan Moyer.
“I think when you have that level of a new workforce as the percentage of an overall workforce, that creates a lot of strain on your veterans. It can create increased accidents, all of the things that I think were pointed as serious concerns.”
Referring to the County’s Ambulance Service Plan, which is currently under review Commissioner Vince Jones-Dixon said, “I look forward to it coming back before the Board. As I mentioned back in April, I just want to make sure that the four cities participate in that process.” The Board of County Commissioners voted in early 2024 to reevaluate the plan two years ahead of schedule.
“We need AMR to live up to their contract, which is to show up on time in a timely way and to provide quality of care,” Commissioner Julia Brim-Edwards said after the meeting. “I'm very concerned about what I heard, and the Chair needs to take action to compel AMR — not ask them politely, but to compel them — to live up to their contract that they've agreed to."
Commissioner Brim-Edwards also called for the County to hold AMR accountable for meeting contract requirements in terms of quality of care and response times and to require AMR to meet recruitment and retention benchmarks if County Chair Jessica Vega Pederson is going to waive any of the $8 million in fines that AMR has amassed due to missing contract requirements on response times.
“I heard some concerning trends about quality of care, but I am also hearing that these things are solvable if we work together and if we put the right resources into place. And so that's what I want us to really lean into,” said Chair Vega Pederson.
“All of us take the responsibility we have to our community to support a high-quality system very seriously so that people have a system that they can count out when they need it. It requires all of us working in partnership in order to create that system and do that work. So I really appreciate the balanced assessment that we've heard about how things are going today. We have to be able to understand it in order to know how we're gonna be able to fix it.”