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, response times were in decline, but with the new staffing model, they are now nearing the 90% benchmark.
“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 the dramatic decrease in "Level Zero” events — times when no ambulance is immediately available for dispatch. He attributed that improvement 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.
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 that 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 over the last percentage point to being completely compliant, he said.
Both AMR and Multnomah County EMS acknowledged that the system’s success must be a balance between response times and quality of care. The current settlement agreement continues to be in effect, but there is a clear call for action to address the quality of care and staff retention issues. The County’s EMS team and AMR have committed to working together 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 comment
“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 hasn’t been reviewed in a decade, 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.
Commissioner Julia Brim-Edwards said that she appreciated “that the EMS team and leadership at the County always were saying that we can’t just get response times down and shift this new staffing model while potentially sacrificing quality of care.” said Commissioner Julia Brim-Edwards.
She noted that despite those intentions, “it looks like in some ways that might have occurred. I'm concerned that the settlement agreement that was agreed to, which was to allow for more hybrid ambulances (which had a mix of EMTs and a paramedic, versus the two paramedic model) to fill the gap and build on that base of the two-paramedic model… actually we've had almost a complete reverse. Now the one EMT, one paramedic model is the majority of the hours worked.”
“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 Jessica 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.”