HomeMy WebLinkAboutAgreement A-23-323 with Valley Childrens Hospital.pdf Agreement No. 23-323
1 SERVICE AGREEMENT
2 This Service Agreement ("Agreement") is dated 20 June, 2023 and is between
3 Valley Children's Hospital, a California non-profit public benefit corporation ("Contractor"), and
4 the County of Fresno, a political subdivision of the State of California ("County").
5 Recitals
6 A. County's Department of Public Health's Emergency Medical Services (EMS) Division, is
7 the designated Local EMS Agency (hereinafter referred to as the "EMS Agency") for the
8 Counties of Fresno, Kings, Madera and Tulare, as provided in Health & Safety Code section
9 1797.200.
10 B. County and EMS Agency recognize a continuous need for a Level II Pediatric Trauma
11 Center to serve pediatric trauma victims in Fresno, Kings, Madera and Tulare Counties
12 C. Contractor desires that the local EMS Agency designate Contractor as a Level II
13 Pediatric Trauma Center in accordance with Title 22, Division 9, Chapter 7 of the California
14 Code of Regulations, entitled "Trauma Care Systems" (§§ 100236 et seq.; hereinafter referred
15 to as the "Trauma Care Regulations"), and the Emergency Medical Services System and the
16 Prehospital Emergency Medical Care Personnel Act (Health & Safety Code, §§ 1797 et seq.;
17 hereinafter referred to as the "EMS Act").
18 D. In order for Contractor to be designated by the EMS Agency as a Level II Pediatric
19 Trauma Center, Contractor is required to have a written agreement with the EMS Agency for the
20 provision of such services, as provided by Trauma Care Regulation, section 100255(g).
21 E. Contractor has continuously been designated by the County as a Level II Pediatric
22 Trauma Center since 2016.
23 F. Contractor represents that it will maintain and operate a qualifying trauma center, in
24 accordance with the Trauma Care Regulations and the EMS Act, and is agreeable to such
25 designation by the EMS Agency.
26 The parties therefore agree as follows:
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1
1 Article 1
2 EMS System/Designation of Contractor
3 A. The parties acknowledge and agree that the EMS Agency has the authority to plan,
4 implement and evaluate an emergency medical services system in Fresno, Kings, Madera, and
5 Tulare Counties pursuant to Health and Safety Code sections 1797.200 and 1797.204.
6 B. The parties acknowledge and agree that the EMS Agency has the authority to implement
7 and update a trauma care system for the EMS System, including the authority to designate a
8 Level II Pediatric Trauma Center for the EMS System, pursuant to Health & Safety Code
9 sections 1798.160 et seq. of the EMS Act, and the Trauma Care Regulations.
10 C. The parties acknowledge and agree that the EMS Agency Medical Director (including his
11 or her Assistant Medical Directors) of the EMS Agency has the authority of medical control of
12 the EMS System, including the trauma care system, and the authority to assure medical
13 accountability through the planning, implementation and evaluation of the EMS System,
14 including the trauma care system, set forth in Health and Safety Code section 1797.202.
15 D. The parties acknowledge and agree that the service area for the Contractor's Level II
16 Pediatric Trauma Center is Fresno, Kings, Madera, and Tulare Counties.
17 E. Contractor acknowledges and agrees that neither the County nor the EMS Agency
18 makes any representation, warranty or guarantee, and cannot and do not assure contractor
19 that any minimum number of trauma patients will be delivered or referred to Contractor's
20 facilities.
21 F. Contractor acknowledges and agrees that the EMS Agency's designation of Contractor
22 as a Level I I Pediatric Trauma Center for the EMS System is made on a non-exclusive basis,
23 and that the EMS Agency reserves the right to designate any other qualifying hospitals, at any
24 time, as a Level 1, 11, III or IV Trauma Center or Level I or 11 Pediatric Trauma Center for the
25 EMS System. Contractor acknowledges that the EMS Agency has previously designated
26 Community Regional Medical Center as a Level I Trauma Center and Kaweah Delta Medical
27 Center, in Visalia, as a Level III Trauma Center for the EMS System, as provided in the
28 Regional Trauma Plan.
2
1 Article 2
2 Contractor's Responsibilities
3 2.1 Scope of Services. The Contractor shall perform all of the services provided in
4 Exhibit A to this Agreement, titled "Contractor's Responsibilities."
5 2.2 Representation. The Contractor represents that it is qualified, ready, willing, and
6 able to perform all of the services provided in this Agreement.
7 2.3 Compliance with Laws. The Contractor shall, at its own cost, comply with all
8 applicable federal, state, and local laws and regulations in the performance of its obligations
9 under this Agreement, including but not limited to workers compensation, labor, and
10 confidentiality laws and regulations.
11 Article 3
12 County's Responsibilities
13 3.1 The County's shall, at its own expense, at all times during the term of this Agreement
14 cause and/or request the EMS Agency to:
15 A. Develop, implement and monitor trauma care system policies and procedures.
16 B. Develop and implement triage procedures, which include injury severity assessment and
17 the determination of patient destination.
18 C. Provide appropriate information and data to Contractor on the Trauma Care System.
19 D. Perform periodic announced or unannounced site visits to Contractor's facilities for the
20 purpose of monitoring Contractor's performance under and compliance with this Agreement.
21 Site visits shall not unnecessarily interrupt Contractor or Contractor's personnel.
22 E. Develop and implement, with input from Contractor, a Trauma Registry Program and
23 Trauma Registry database for the purpose of data collection, monitoring of trauma centers'
24 compliance with the Trauma Center Standards in the Regional Trauma Plan and evaluation of
25 the trauma care system.
26 F. Perform all other obligations of County under this Agreement.
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3
1 Article 4
2 Compensation/Consideration
3 4.1 No Monetary Compensation. Contractor's Level II Pediatric Trauma Center
4 functions, services and activities conducted pursuant to the terms and conditions of this
5 Agreement shall be performed without the payment of any monetary compensation by County to
6 Contractor. County shall not be liable for any costs or expenses incurred by Contractor to satisfy
7 its obligations under this Agreement.
8 4.2 Consideration. The parties acknowledge and agree that their respective covenants
9 made to the other party and benefits received from the other party under this Agreement shall
10 form the basis of the consideration exchanged between them under this Agreement.
11 Article 5
12 Term of Agreement
13 5.1 Term. This Agreement is effective on July 1, 2023 and terminates on June 30, 2026,
14 except as provided in section 5.2, "Extension," or Article 6, "Termination and Suspension,"
15 below.
16 5.2 Extension. The term of this Agreement shall automatically be extended for an
17 unlimited number of one (1) year extensions upon the same terms and conditions herein set
18 forth, unless written notice of non-renewal is given by either of the parties to the other party no
19 later than 30 days prior to the expiration of the then-current term of this Agreement. The
20 extension of this Agreement by the County is not a waiver or compromise of any default or
21 breach of this Agreement by the Contractor existing at the time of the extension whether or not
22 known to the County.
23 Article 6
24 Notices
25 6.1 Contact Information. The persons and their addresses having authority to give and
26 receive notices provided for or permitted under this Agreement include the following:
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For the County:
28 Director, Department of Public Health
County of Fresno
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1 P.O. Box 11867
Fresno, CA 93775
2 CCEMSA(a)fresnocountyca.gov
Fax: (559) 600-7691
3
For the Contractor:
4 President
Valley Children's Hospital
5 9300 Valley Children's Place
Madera, CA 93636
6 Email: isuntrapak(a)-valleychildrens.org
Fax: (559): 353-5311
7
With a copy to:
8 Chief Legal Officer
Valley Children's Hospital
9 9300 Valley Children's Place
Madera, CA 93636
10 Email: wchaltraw anvalleychildrens.org
Fax: (559) 353-5311
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6.2 Change of Contact Information. Either party may change the information in section
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6.1 by giving notice as provided in section 6.3.
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6.3 Method of Delivery. Each notice between the County and the Contractor provided
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for or permitted under this Agreement must be in writing, state that it is a notice provided under
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this Agreement, and be delivered either by personal service, by first-class United States mail, by
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an overnight commercial courier service, by telephonic facsimile transmission, or by Portable
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Document Format (PDF) document attached to an email.
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(A) A notice delivered by personal service is effective upon service to the recipient.
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(B) A notice delivered by first-class United States mail is effective three County
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business days after deposit in the United States mail, postage prepaid, addressed to the
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recipient.
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(C)A notice delivered by an overnight commercial courier service is effective one
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County business day after deposit with the overnight commercial courier service,
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delivery fees prepaid, with delivery instructions given for next day delivery, addressed to
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the recipient.
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(D)A notice delivered by telephonic facsimile transmission or by PDF document
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attached to an email is effective when transmission to the recipient is completed (but, if
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such transmission is completed outside of County business hours, then such delivery is
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1 deemed to be effective at the next beginning of a County business day), provided that
2 the sender maintains a machine record of the completed transmission.
3 6.4 Claims Presentation. For all claims arising from or related to this Agreement,
4 nothing in this Agreement establishes, waives, or modifies any claims presentation
5 requirements or procedures provided by law, including the Government Claims Act (Division 3.6
6 of Title 1 of the Government Code, beginning with section 810).
7 Article 7
8 Termination and Suspension
9 7.1 Termination for Non-Allocation of Funds. The terms of this Agreement are
10 contingent on the approval of funds by the appropriating government agency. If sufficient funds
11 are not allocated, then the County, upon at least 30 days' advance written notice to the
12 Contractor, may:
13 (A) Modify the services provided by the Contractor under this Agreement; or
14 (B) Terminate this Agreement.
15 7.2 Termination for Breach.
16 (A) Upon determining that a breach (as defined in paragraph (C) below) has
17 occurred, the County may give written notice of the breach to the Contractor. The written
18 notice may suspend performance under this Agreement, and must provide at least 30
19 days for the Contractor to cure the breach.
20 (B) If the Contractor fails to cure the breach to the County's satisfaction within the
21 time stated in the written notice, the County may terminate this Agreement immediately.
22 (C) For purposes of this section, a breach occurs when, in the determination of the
23 County, the Contractor has:
24 (1) Obtained or used funds illegally
25 (2) Failed to comply with any part of this Agreement;
26 (3) Submitted a substantially incorrect or incomplete report to the County; or
27 (4) Improperly performed any of its obligations under this Agreement.
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1 7.3 Termination without Cause. In circumstances other than those set forth above,
2 either Party may terminate this Agreement by giving at least 30 days advance written notice of
3 their intent to terminate.
4 7.4 No Penalty or Further Obligation. Any termination of this Agreement by the County
5 under this Article 7 is without penalty to or further obligation of the County.
6 Article 8
7 Independent Contractor
8 8.1 Status. In performing under this Agreement, the Contractor, including its officers,
9 agents, employees, and volunteers, is at all times acting and performing as an independent
10 contractor, in an independent capacity, and not as an officer, agent, servant, employee, joint
11 venturer, partner, or associate of the County.
12 8.2 Verifying Performance. The County has no right to control, supervise, or direct the
13 manner or method of the Contractor's performance under this Agreement, but the County may
14 verify that the Contractor is performing according to the terms of this Agreement.
15 8.3 Benefits. Because of its status as an independent contractor, the Contractor has no
16 right to employment rights or benefits available to County employees. The Contractor is solely
17 responsible for providing to its own employees all employee benefits required by law. The
18 Contractor shall save the County harmless from all matters relating to the payment of
19 Contractor's employees, including compliance with Social Security withholding and all related
20 regulations.
21 8.4 Services to Others. The parties acknowledge that, during the term of this
22 Agreement, the Contractor may provide services to others unrelated to the County.
23 Article 9
24 Indemnity and Defense
25 9.1 Indemnity for Contractor. The Contractor shall indemnify and hold harmless and
26 defend the County (including its officers, agents, employees, and volunteers) against all claims,
27 demands, injuries, damages, costs, expenses (including attorney fees and costs), fines,
28 penalties, and liabilities of any kind to the County, the Contractor, or any third party that arise
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1 from or relate to the performance or failure to perform by the Contractor (or any of its officers,
2 agents, subcontractors, or employees) under this Agreement. The County may conduct or
3 participate in its own defense without affecting the Contractor's obligation to indemnify and hold
4 harmless or defend the County.
5 9.2 Indemnity for County. The County shall indemnify and hold harmless and defend
6 the Contractor (including its officers, agents, employees, and volunteers) against all claims,
7 demands, injuries, damages, costs, expenses (including attorney fees and costs), fines,
8 penalties, and liabilities of any kind to the Contractor, the County, or any third party that arise
9 from or relate to the performance or failure to perform by the County (or any of its officers,
10 agents, subcontractors, or employees) under this Agreement. The Contractor may conduct or
11 participate in its own defense without affecting the County's obligation to indemnify and hold
12 harmless or defend the Contractor.
13 9.3 The aforesaid indemnity and hold harmless clauses by Contractor and County shall
14 apply to all damages and claims for damages of every kind suffered, or alleged to have been
15 suffered by the party to be indemnified, including but not limited to attorney fees, by reason of
16 the aforesaid operations of the indemnifying party, regardless of whether or not the insurance
17 policies of the indemnifying party shall have been determined to be applicable to any such
18 damages or claims for damages.
19 9.4 Survival. This Article 9 survives the termination of this Agreement.
20 Article 10
21 Insurance
22 10.1 The Contractor shall comply with all the insurance requirements in Exhibit C to this
23 Agreement.
24 Article 11
25 Inspections, Audits, and Public Records
26 11.1 Inspection of Documents. The Contractor shall make available to the County, and
27 the County may examine at any time during business hours and as often as the County deems
28 necessary, all of the Contractor's records and data with respect to the matters covered by this
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1 Agreement, excluding attorney-client privileged communications. The Contractor shall, upon
2 request by the County, permit the County to audit and inspect all of such records and data to
3 ensure the Contractor's compliance with the terms of this Agreement.
4 11.2 State Audit Requirements. If the compensation to be paid by the County under this
5 Agreement exceeds $10,000, the Contractor is subject to the examination and audit of the
6 California State Auditor, as provided in Government Code section 8546.7, for a period of three
7 years after final payment under this Agreement. This section survives the termination of this
8 Agreement.
9 11.3 Public Records. The County is not limited in any manner with respect to its public
10 disclosure of this Agreement or any record or data that the Contractor may provide to the
11 County. The County's public disclosure of this Agreement or any record or data that the
12 Contractor may provide to the County may include but is not limited to the following:
13 (A) The County may voluntarily, or upon request by any member of the public or
14 governmental agency, disclose this Agreement to the public or such governmental
15 agency.
16 (B) The County may voluntarily, or upon request by any member of the public or
17 governmental agency, disclose to the public or such governmental agency any record or
18 data that the Contractor may provide to the County, unless such disclosure is prohibited
19 by court order.
20 (C) This Agreement, and any record or data that the Contractor may provide to the
21 County, is subject to public disclosure under the Ralph M. Brown Act (California
22 Government Code, Title 5, Division 2, Part 1, Chapter 9, beginning with section 54950).
23 (D) This Agreement, and any record or data that the Contractor may provide to the
24 County, is subject to public disclosure as a public record under the California Public
25 Records Act (California Government Code, Title 1, Division 7, Chapter 3.5, beginning
26 with section 6250) ("CPRA").
27 (E) This Agreement, and any record or data that the Contractor may provide to the
28 County, is subject to public disclosure as information concerning the conduct of the
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1 people's business of the State of California under California Constitution, Article 1,
2 section 3, subdivision (b).
3 (F) Any marking of confidentiality or restricted access upon or otherwise made with
4 respect to any record or data that the Contractor may provide to the County shall be
5 disregarded and have no effect on the County's right or duty to disclose to the public or
6 governmental agency any such record or data.
7 11.4 Public Records Act Requests. If the County receives a written or oral request
8 under the CPRA to publicly disclose any record that is in the Contractor's possession or control,
9 and which the County has a right, under any provision of this Agreement or applicable law, to
10 possess or control, then the County may demand, in writing, that the Contractor deliver to the
11 County, for purposes of public disclosure, the requested records that may be in the possession
12 or control of the Contractor. Within five business days after the County's demand, the
13 Contractor shall (a) deliver to the County all of the requested records that are in the Contractor's
14 possession or control, together with a written statement that the Contractor, after conducting a
15 diligent search, has produced all requested records that are in the Contractor's possession or
16 control, or (b) provide to the County a written statement that the Contractor, after conducting a
17 diligent search, does not possess or control any of the requested records. The Contractor shall
18 cooperate with the County with respect to any County demand for such records. If the
19 Contractor wishes to assert that any specific record or data is exempt from disclosure under the
20 CPRA or other applicable law, it must deliver the record or data to the County and assert the
21 exemption by citation to specific legal authority within the written statement that it provides to
22 the County under this section. The Contractor's assertion of any exemption from disclosure is
23 not binding on the County, but the County will give at least 10 days' advance written notice to
24 the Contractor before disclosing any record subject to the Contractor's assertion of exemption
25 from disclosure. The Contractor shall indemnify the County for any court-ordered award of costs
26 or attorney's fees under the CPRA that results from the Contractor's delay, claim of exemption,
27 failure to produce any such records, or failure to cooperate with the County with respect to any
28 County demand for any such records.
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1 Article 12
2 Records/Reports
3 12.1 Contractor shall develop and maintain a Trauma Registry Program which is
4 approved by the EMS Agency. The Trauma Registry Program shall include all appropriate
5 trauma patient information and "hospital data" (as that term is defined in Trauma Regulation,
6 section 100257(c)) concerning such patients as set forth in EMS Policy#332 — Trauma System
7 Monitoring and the Regional Trauma Plan (See Exhibit D)All such records shall be complete
8 and accurate. The EMS Agency shall have access to all such records upon request. Contractor
9 shall provide trauma registry data and/or reports to the EMS Agency upon request and/or on a
10 regularly scheduled timetable such as monthly, quarterly, or annually, which will be agreed upon
11 between the EMS Agency and Contractor. In the event that the EMS Agency develops the
12 capability to directly access and retrieve trauma registry records through computer technology,
13 Contractor shall, at no cost to the EMS Agency, assist the EMS Agency in achieving such
14 access and retrieval of Contractor's Trauma Registry Program through such means.
15 Article 13
16 Licenses/Certificates
17 13.1 Contractor shall, at its own cost, throughout the term of this Agreement, maintain all
18 necessary licenses, permits and certificates necessary for the provision of services hereunder
19 and now or hereafter required by Federal, State and local laws and regulations, the EMS
20 Agency and any other applicable government agencies. This shall include, but not be limited to:
21 1) being licensed as a general acute care hospital, and 2) holding a special permit for basic or
22 comprehensive emergency services.
23 Article 14
24 Disclosure of Self-Dealing Transactions
25 14.1 Applicability. This Article 14 applies if the Contractor is operating as a corporation,
26 or changes its status to operate as a corporation.
27 14.2 Duty to Disclose. If any member of the Contractor's board of directors is party to a
28 self-dealing transaction, he or she shall disclose the transaction by completing and signing a
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1 "Self-Dealing Transaction Disclosure Form" (Exhibit B to this Agreement) and submitting it to the
2 County before commencing the transaction or immediately after.
3 14.3 Definition. "Self-dealing transaction" means a transaction to which the Contractor is
4 a party and in which one or more of its directors, as an individual, has a material financial
5 interest.
6 Article 15
7 Health Insurance Portability and Accountability Act (HIPAA)
8 15.1 County and Contractor each consider and represent themselves as covered entities
9 as defined by the U.S. Health Insurance Portability and Accountability Act of 1996, Public Law
10 104-191(HIPAA) and agree to use and disclose protected health information as required by law.
11 County and Contractor acknowledge that the exchange of protected health
12 information between them is only for treatment, payment, and health care operations.
13 County and Contractor intend to protect the privacy and provide for the security of
14 Protected Health Information (PHI) pursuant to the Agreement in compliance with HIPAA, the
15 Health Information Technology for Economic and Clinical Health Act, Public Law 111-005
16 (HITECH), and regulations promulgated thereunder by the U.S. Department of Health and
17 Human Services (HIPAA Regulations) and other applicable laws.
18 As part of the HIPAA Regulations, the Privacy Rule and the Security Rule require
19 Contractor to enter into a contract containing specific requirements prior to the disclosure of
20 PHI, as set forth in, but not limited to, Title 45, Sections 164.314(a), 164.502(e) and 164.504(e)
21 of the Code of Federal Regulations (CFR).
22 Article 16
23 Confidentiality and Data Security
24 16.1 Contractor shall adhere to all data protection requirements laid out in Exhibit E of this
25 Agreement.
26 Article 17
27 General Terms
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1 17.1 Modification. Except as provided in Article 6, "Termination and Suspension," this
2 Agreement may not be modified, and no waiver is effective, except by written agreement signed
3 by both parties. The Contractor acknowledges that County employees have no authority to
4 modify this Agreement except as expressly provided in this Agreement.
5 17.2 Non-Assignment. Neither party may assign its rights or delegate its obligations
6 under this Agreement without the prior written consent of the other party.
7 17.3 Governing Law. The laws of the State of California govern all matters arising from
8 or related to this Agreement.
9 17.4 Jurisdiction and Venue. This Agreement is signed and performed in Fresno
10 County, California. Contractor consents to California jurisdiction for actions arising from or
11 related to this Agreement, and, subject to the Government Claims Act, all such actions must be
12 brought and maintained in Fresno County.
13 17.5 Construction. The final form of this Agreement is the result of the parties' combined
14 efforts. If anything in this Agreement is found by a court of competent jurisdiction to be
15 ambiguous, that ambiguity shall not be resolved by construing the terms of this Agreement
16 against either party.
17 17.6 Days. Unless otherwise specified, "days" means calendar days.
18 17.7 Headings. The headings and section titles in this Agreement are for convenience
19 only and are not part of this Agreement.
20 17.8 Severability. If anything in this Agreement is found by a court of competent
21 jurisdiction to be unlawful or otherwise unenforceable, the balance of this Agreement remains in
22 effect, and the parties shall make best efforts to replace the unlawful or unenforceable part of
23 this Agreement with lawful and enforceable terms intended to accomplish the parties' original
24 intent.
25 17.9 Nondiscrimination. During the performance of this Agreement, the parties shall not
26 unlawfully discriminate against any employee or applicant for employment, or recipient of
27 services, because of race, religious creed, color, national origin, ancestry, physical disability,
28 mental disability, medical condition, genetic information, marital status, sex, gender, gender
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1 identity, gender expression, age, sexual orientation, military status or veteran status pursuant to
2 all applicable State of California and federal statutes and regulation.
3 17.10 No Waiver. Payment, waiver, or discharge by the County of any liability or obligation
4 of the Contractor under this Agreement on any one or more occasions is not a waiver of
5 performance of any continuing or other obligation of the Contractor and does not prohibit
6 enforcement by the County of any obligation on any other occasion.
7 17.11 Entire Agreement. This Agreement, including its exhibits, is the entire agreement
8 between the Contractor and the County with respect to the subject matter of this Agreement,
9 and it supersedes all previous negotiations, proposals, commitments, writings, advertisements,
10 publications, and understandings of any nature unless those things are expressly included in
11 this Agreement. If there is any inconsistency between the terms of this Agreement without its
12 exhibits and the terms of the exhibits, then the inconsistency will be resolved by giving
13 precedence first to the terms of this Agreement without its exhibits, and then to the terms of the
14 exhibits.
15 17.12 No Third-Party Beneficiaries. This Agreement does not and is not intended to
16 create any rights or obligations for any person or entity except for the parties.
17 17.13 Authorized Signature. The Contractor represents and warrants to the County that:
18 (A) The Contractor is duly authorized and empowered to sign and perform its
19 obligations under this Agreement.
20 (B) The individual signing this Agreement on behalf of the Contractor is duly
21 authorized to do so and his or her signature on this Agreement legally binds the
22 Contractor to the terms of this Agreement.
23 17.14 Electronic Signatures. The parties agree that this Agreement may be executed by
24 electronic signature as provided in this section.
25 (A) An "electronic signature" means any symbol or process intended by an individual
26 signing this Agreement to represent their signature, including but not limited to (1) a
27 digital signature; (2) a faxed version of an original handwritten signature; or (3) an
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1 electronically scanned and transmitted (for example by PDF document) version of an
2 original handwritten signature.
3 (B) Each electronic signature affixed or attached to this Agreement (1) is deemed
4 equivalent to a valid original handwritten signature of the person signing this Agreement
5 for all purposes, including but not limited to evidentiary proof in any administrative or
6 judicial proceeding, and (2) has the same force and effect as the valid original
7 handwritten signature of that person.
8 (C) The provisions of this section satisfy the requirements of Civil Code section
9 1633.5, subdivision (b), in the Uniform Electronic Transaction Act (Civil Code, Division 3,
10 Part 2, Title 2.5, beginning with section 1633.1).
11 (D) Each party using a digital signature represents that it has undertaken and
12 satisfied the requirements of Government Code section 16.5, subdivision (a),
13 paragraphs (1) through (5), and agrees that each other party may rely upon that
14 representation.
15 (E) This Agreement is not conditioned upon the parties conducting the transactions
16 under it by electronic means and either party may sign this Agreement with an original
17 handwritten signature.
18 17.15 Counterparts. This Agreement may be signed in counterparts, each of which is an
19 original, and all of which together constitute this Agreement.
20 17.16 Use of Name. County shall not make any written use of or reference to Contractor's
21 name for any marketing, public relations, advertising, display or other business purpose or make
22 any use of Contractor's facilities for any activity unrelated to the express business purposes and
23 interested of Contractor without the prior written consent of Contractor.
24 17.17 Exclusions/Suspensions. County confirms that it has not been excluded, debarred
25 or suspended from participation in any governmental program, including but not limited to
26 Medicare, Medicaid, or Medi-Cal payor programs, and is not the subject of any investigation
27 regarding participation in such programs, and has not been convicted of any crime relating to
28 any governmental program. County agrees to notify Contractor immediately if County becomes
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1 aware of any adverse action related to County's eligibility to participate in a governmental
2 program. This Agreement shall immediately terminate if County becomes ineligible.
3 [SIGNATURE PAGE FOLLOWS]
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1 The parties are signing this Agreement on the date stated in the introductory clause.
2
Valley C,ildreWc ospital COUNTY OF FRESNO
3
4 � / ra
5 Todd Suntrapak, President SiAl Q i er Chairman of the Board of
Supefvi f the County of Fresno
6 June 7, 2023
Attest:
7 Date Bernice E. Seidel
Clerk of the Board of Supervisors
8 Count of Fresno, State of California
9 ekwj-�,,, L=.
Corporate Secretary, Assistant Secretary, By:
10 Chief Financial Officer, or Assistant Deputy
Treasurer
11
12 June 7, 2023
Date
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14 9300 Valley Children's Place
Madera, CA 93638-8762
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Exhibit A
1 Contractor's Responsibilities
2 Contractor shall, at its own expense, at all times during the term of this Agreement:
3 A. Operate and function as a Level II Pediatric Trauma Center for all patients
4 presenting at Contractor's facilities, regardless of their ability to pay.
5 B. Provide and maintain the following as required to provide trauma center
6 services as a Level II Pediatric Trauma Center under this Agreement:
7 1. All facilities and resources, including, but not limited to, all necessary
8 utilities, supplies, equipment and furniture; and
9 2. All physicians, nurse and other professional personnel, and such
10 technical, administrative, allied and supportive paramedical personnel and such other personnel.
11 In this regard, Contractor specifically covenants that it will at all times comply with,
12 Trauma Care Regulations sections 100261 (entitled, "Level I and Level II Pediatric Trauma
13 Centers") which is incorporated herein by reference.
14 C. Take all necessary action to maintain the designation as a Level II Pediatric
15 Trauma Center in accordance with the EMS Act, the Trauma Care Regulations, and the EMS
16 Agency Policies and Procedures now in effect, or which may hereafter come into effect, all of
17 which are incorporated herein by reference.
18 D. Provide trauma center services as a Level II Pediatric Trauma Center in
19 accordance with all Federal, State, and local laws, and regulations now in effect, or which may
20 hereafter come into effect (including, but not limited to, the EMS Act and Trauma Center
21 Regulations), all of which are incorporated herein by reference.
22 E. Comply with all EMS Agency Policies and Procedures now in effect, or
23 which may hereafter come into effect, including, but not limited to, those policies and procedures
24 related to base hospital and trauma care (EMS Agency Policies #311 — Base Hospital Criteria,
25 #330 — Trauma System Overview, #331 — Trauma Facility Designation, #332 — Trauma System
26 Monitoring, #333 — Trauma Center Criteria, and #334 — Trauma Registry Data Collection) and
27 with the EMS System's continuous quality improvement process requirements now in effect, or
28 which may hereafter come into effect (EMS Agency Policies #703 and #704 adopted pursuant
A-1
Exhibit A
1 Trauma Care Regulation, sec. 100265, entitled "Quality Improvement"), all of which are attached
2 hereto as Exhibit D and incorporated herein by reference.
3 F. Continuously maintain, without interruption, American College of Surgeons
4 Committee on Trauma (ACS-COT) verification as a Level II Pediatric Trauma Center.
5 G. Actively and cooperatively participate as a member of the Regional Trauma
6 Audit Committee and the Central Region Trauma Coordinating Committee.
7 H. Develop and/or conduct periodic instructional and educational programs for
8 the benefit of the hospitals and pre-hospital care personnel throughout the EMS System that are
9 related to pre-hospital and in-hospital trauma care for patients.
10 I. Provide and maintain radio and communications equipment in Contractor's
11 facilities for communications with pre-hospital ambulance providers and hospitals throughout the
12 EMS region.
13 J. Maintain all licenses, permits and certificates necessary to operate as an
14 acute care hospital, which, at minimum, includes basic or comprehensive emergency services
15 available, pursuant to the Trauma Care Regulation, section 100261(c), and to maintain
16 accreditation by the Joint Commission on Accreditation of Healthcare Organizations, pursuant to
17 Trauma Care Regulation, section 100248, entitled, "Trauma Care Regulation."
18 K. Provide all appropriate medical direction and control as a Base Hospital,
19 when necessary, to emergency medical services personnel in the field in accordance with EMS
20 Agency Policies and Procedures, now in effect, or which may hereafter come into effect,
21 including but not limited to EMS Policy#311 — Base Hospital Criteria (See Exhibit D).
22 L. Take corrective action where there is a failure of Contractor to comply with
23 the Trauma Center Standards set forth in EMS Policy #333 (See Exhibit D). The minimum
24 acceptable period of time to correct a deviation from or deficiency in complying with the standard
25 or standards shall be determined by the EMS Agency's Director on a case-by-case basis
26 applicable to the situation. Notice of any deficiencies alleged against contractor, must be sent in
27 writing for review prior to any action taken. Contractor's failure to take such corrective action
28 within the time specified by the EMS Agency may, upon declaration thereof by County, result in
A-2
Exhibit A
1 breach of this Agreement.
2 L. Perform all other obligations of Contractor under this Agreement.
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
A-3
Exhibit B
Self-Dealing Transaction Disclosure Form
In order to conduct business with the County of Fresno ("County"), members of a
contractor's board of directors ("County Contractor"), must disclose any self-dealing transactions
that they are a party to while providing goods, performing services, or both for the County. A
self-dealing transaction is defined below:
"A self-dealing transaction means a transaction to which the corporation is a party and in
which one or more of its directors has a material financial interest."
The definition above will be used for purposes of completing this disclosure form.
Instructions
(1) Enter board member's name, job title (if applicable), and date this disclosure is being
made.
(2) Enter the board member's company/agency name and address.
(3) Describe in detail the nature of the self-dealing transaction that is being disclosed to the
County. At a minimum, include a description of the following:
a. The name of the agency/company with which the corporation has the transaction;
and
b. The nature of the material financial interest in the Corporation's transaction that
the board member has.
(4) Describe in detail why the self-dealing transaction is appropriate based on applicable
provisions of the Corporations Code.
The form must be signed by the board member that is involved in the self-dealing
transaction described in Sections (3) and (4).
B-1
Exhibit B
(1) Company Board Member Information:
Name: Date:
Job Title:
(2) Company/Agency Name and Address:
(3) Disclosure (Please describe the nature of the self-dealing transaction you are a
party to)
(4) Explain why this self-dealing transaction is consistent with the requirements of
Corporations Code § 5233 (a)
(5) Authorized Signature
Signature: Date:
B-2
Exhibit C
Insurance Requirements
1. Required Policies
Without limiting the right to obtain indemnification from the other party or any third parties, the
parties agree, at their sole expense, to maintain in full force and effect the following insurance
policies throughout the term of this Agreement.
(A) Commercial General Liability. Commercial general liability insurance with limits of not
less than Two Million Dollars ($2,000,000) per occurrence and an annual aggregate of
Four Million Dollars ($4,000,000). This policy must be issued on a per occurrence basis.
Coverage must include products, completed operations, property damage, bodily injury,
personal injury, and advertising injury.
(B) Automobile Liability. Automobile liability insurance with limits of not less than One
Million Dollars ($1,000,000) per occurrence for bodily injury and for property damages.
Coverage must include any auto used in connection with this Agreement.
(C)Workers Compensation. Workers compensation insurance as required by the laws of
the State of California with statutory limits.
(D) Employer's Liability. Employer's liability insurance with limits of not less than One
Million Dollars ($1,000,000) per occurrence for bodily injury and for disease.
(E) Professional Liability. Professional liability insurance with limits of not less than One
Million Dollars ($1,000,000) per occurrence and an annual aggregate of Three Million
Dollars ($3,000,000). If this is a claims-made policy, then (1) the retroactive date must
be prior to the date on which services began under this Agreement; (2) the parties shall
maintain the policy and provide to the other party annual evidence of insurance for not
less than three (3) years after completion of services under this Agreement; and (3) if the
policy is canceled or not renewed, and not replaced with another claims-made policy
with a retroactive date prior to the date on which services begin under this Agreement,
then the party shall purchase extended reporting coverage on its claims-made policy for
a minimum of three (3) years after completion of services under this Agreement.
(F) Sexual Misconduct Liability. Sexual misconduct liability insurance with limits of not
less than Two Million Dollars ($2,000,000) per occurrence, with an annual aggregate of
Four Million Dollars ($4,000,000). This policy must be issued on a per occurrence basis.
(G)Cyber Liability. Cyber liability insurance with limits of not less than Two Million Dollars
($2,000,000) per occurrence or an annual aggregate of Twenty Million Dollars
($20,000,000). Coverage must include claims involving Cyber Risks. The cyber liability
policy must be endorsed to cover the theft, loss, or unauthorized disclosure of any
information or data that is in the care, custody, or control of either party.
Definition of Cyber Risks. "Cyber Risks" include but are not limited to (i) Security
Breach, which may include Disclosure of Personal Information to an Unauthorized Third
Party; (ii) data breach; (iii) system failure; (iv) data recovery; (v) failure to timely disclose
data breach or Security Breach; (vi)failure to comply with privacy policy; (vii) invasion of
privacy, including release of private information; (viii) damage to or destruction or
alteration of electronic information; (ix) extortion related to the Contractor's obligations
C-1
Exhibit C
under this Agreement regarding electronic information, including Personal Information;
(x) fraudulent instruction; (xi)funds transfer fraud; (xii) telephone fraud; (xiii) network
security; (xiv) data breach response costs, including Security Breach response costs;
and (xv) credit monitoring expenses.
If the either party is a governmental entity, it may satisfy the policy requirements above through
a program of self-insurance, including an insurance pooling arrangement or joint exercise of
powers agreement.
2. Additional Requirements
(A) Verification of Coverage. Within 30 days after the Agreement is signed, and at any
time during the term of this Agreement as requested by either party, each party shall
deliver, or cause its broker or producer to deliver, if to the County; County Risk Manager,
at 2220 Tulare Street, 16th Floor, Fresno, California 93721, or
HRRiskManagement@fresnocountyca.gov, and by mail or email to the person identified
to receive notices under this Agreement, or if to the Contractor; to the person
certificates of insurance and endorsements for all of the coverages required under this
Agreement.
(i) Each insurance certificate must state that: (1) the insurance coverage has been
obtained and is in full force; (2) the other party, its officers, agents, employees,
and volunteers are not responsible for any premiums on the policy; and (3)the
providing party has waived its right to recover from the requesting party, its
officers, agents, employees, and volunteers any amounts paid under any
insurance policy required by this Agreement and that waiver does not invalidate
the insurance policy.
(ii) The automobile liability insurance certificate must state that the policy covers any
auto used in connection with this Agreement.
(iii) The professional liability insurance certificate, if it is a claims-made policy, must
also state the retroactive date of the policy, which must be prior to the date on
which services began under this Agreement.
(iv) The cyber liability insurance certificate must also state that it is endorsed, and
include an endorsement, to cover the full replacement value of damage to,
alteration of, loss of, or destruction of intangible property (including but not limited
to information or data) that is in the care, custody, or control of the Contractor.
(B) Acceptability of Insurers. All insurance policies required under this Agreement must be
issued by insurers authorized to do business in the State of California and possessing at
all times during the term of this Agreement an A.M. Best, Inc. rating of no less than A:
VI I.
(C) Notice of Cancellation or Change. For each insurance policy required under this
Agreement, the providing party shall ensure that the policy requires the insurer to
provide to the other party, written notice of any cancellation or change in the policy as
required in this paragraph. For cancellation of the policy for nonpayment of premium, the
party shall, or shall cause the insurer to, provide written notice to the other party not less
C-2
Exhibit C
than 10 days in advance of cancellation. For cancellation of the policy for any other
reason, and for any other change to the policy, the party shall, or shall cause the insurer
to, provide written notice to the other party not less than 30 days in advance of
cancellation or change. The parties, in their sole discretion, may determine that the
failure of the party or its insurer to timely provide a written notice required by this
paragraph is a breach of this Agreement.
(D)Waiver of Subrogation. The parties waive any right to recover from the other party, its
officers, agents, employees, and volunteers any amounts paid under the policy of
worker's compensation insurance required by this Agreement. The parties are solely
responsible to obtain any policy endorsement that may be necessary to accomplish that
waiver, but the party's waiver of subrogation under this paragraph is effective whether or
not the other party obtains such an endorsement.
(E) Remedy for Failure to Maintain. If either party fail to keep in effect at all times any
insurance coverage required under this Agreement, the other party may, in addition to
any other remedies it may have, suspend or terminate this Agreement upon the
occurrence of that failure, or purchase such insurance coverage, and charge the cost of
that coverage to the other party.
(F) Subcontractors. Each partyshall require and verify that all subcontractors used by the
parties to provide services under this Agreement maintain insurance meeting all
insurance requirements provided in this Agreement. This paragraph does not authorize
the parties to provide services under this Agreement using subcontractors.
C-3
CENTRAL CALIFORNIA
EMERGENCY MEDICAL SERVICES Exhibit D
A Division of the Fresno County Department of Public Health
Page 1 of 44
Manual Policy
Emergency Medical Services Number 311
Administrative Policies and Procedures
Page 1 of 4
Subject Base Hospital Criteria
References Title 22,Division 9,Chapter 4,Article 7 Effective
01/01/82
I. POLICY
Base Hospitals for the medical control of EMS Personnel shall be selected by the EMS Agency based upon
appropriate criteria and the needs of the EMS System.
II. PROCEDURE
A. BASE HOSPITAL MUST:
1. Be licensed by the State Department of Health as a general acute care hospital.
2. Be accredited by the Joint Commission on Accreditation of Hospitals.
3. Have a special permit for basic or comprehensive emergency medical service pursuant to the
provisions of Title 22,Division 5.
4. Have the approval and support of hospital administration,medical staff and Emergency
Department staff to participate as a Base Hospital.
5. Agree to provide care to all emergency patients regardless of ability to pay.
6. Demonstrate an on-call system that assures a promptly available specialist and admitting physician
and commitment for care of all critically ill patients regardless of ability to pay.
7. Agree to abide by the letter and intent of the Health and Safety Code,Division 2.5.
8. Comply with all County regulations and policies regarding Base Hospitals.
B. BASE HOSPITAL OPERATIONAL REQUIREMENTS
Base Hospitals designated as such and under contract with the EMS Agency must comply with the
following requirements:
Approved By Revision
Daniel J.Lynch
EMS Division Manager (Signature on File at EMS Agency) 04/01/2007
Jim Andrews,M.D.
EMS Medical Director (Signature on File at EMS Agency)
Exhibit D
Page 2 of 4 Page 2 of 44
Subject Base Hospital Criteria Policy
Number 311
1. Operations
a. Procure operational radio communications equipment meeting specifications established
by the County and install such equipment in the Emergency Department,for the purpose
of communications with prehospital and interfacility transport units operating pursuant to
this agreement. All radios and telephones to be used for communication with prehospital
personnel must be equipped with recording devices.
b. Assure that recordings are made on all prehospital communications concerning patient
care.
C. Maintain written records of Base Hospital/prehospital and interfacility runs for a
minimum of seven years or in accordance with hospital policy. Maintain the tapes of
paramedic calls for a minimum of 180 days.
d. Operate communications equipment as directed by procedures and protocols established
by the County and approved by the EMS Medical Director. Develop and utilize a
workable maintenance plan and repair policy for communications equipment.
e. Have a telephone immediately available in the Emergency Department for exclusive use
in contacting a Receiving Hospital to provide medical information on patient's enroute to
the receiving facility.
f. Designate a Mobile Intensive Care Nurse certified by the EMS Agency who is employed
by the Base Hospital as a Prehospital Liaison Nurse for the hospital.
g. Designate an Emergency Department Physician as a Base Hospital Medical Director.
Responsibilities are identified in the Base Hospital Director role description.
h. Facilitate interfacility transfers in an appropriate manner as described in EMS Policy.
i. Utilize the following which have been approved by the EMS Medical Director:
1. Paramedic Field Treatment Protocols and Guidelines
2. Base Hospital Report Form
3. Patient Care Report(Field Assessment Form)
j. Cooperate with the EMS Agency in gathering and providing statistics and information
needed for monitoring and evaluating EMS programs.
k. Comply with an infection control policy and notification procedure for all prehospital
care providers and first responders developed by the designated County Health Services
Agency.
1. Comply with procedures for decontamination of patients and rescuers exposed to
hazardous materials as outlined in the hazardous materials plan developed by the EMS
Agency.
in. Participate in EMS public education programs.
C. NEW BASE HOSPITALS
Newly designated Base Hospitals must establish a Base Hospital Committee within the hospital
composed of,at a minimum,the Base Hospital Medical Director,the Prehospital Liaison Nurse
Exhibit D
Page 3 of 44
Page 3 of 4
Subject Base Hospital Criteria Policy
Number 311
and a representative of hospital administration to meet and confer regarding operations of the Base
Hospital and maintain liaison with members of the Prehospital Care Team and the EMS Agency.
This committee will meet regularly for one year,or until Base Hospital operations are running
smoothly,whichever is longer.
D. BASE HOSPITAL STAFFING AND PERSONNEL
The Base-Hospital shall have:
1. A currently certified Mobile Intensive Care Nurse or Base Hospital Physician in the
Emergency Department immediately available at all times to give radio direction to
prehospital personnel or interfacility transfer personnel according to the standards and
protocols developed by the EMS Agency.
2. A Certified Base Hospital Physician available at all times to provide immediate medical
direction to the Mobile Intensive Care Nurses and/or prehospital personnel or
interfacility.
E. BASE HOSPITAL EDUCATION PROGRAMS,EVALUATION,AND QUALITY
IMPROVEMENT
The Base Hospital will:
1. Provide for the continuing education of certified prehospital personnel and Mobile
Intensive Care Nurses in accordance with criteria established by the EMS Medical
Director including supervised clinical exposure for paramedics in the Emergency
Department and other patient care divisions which would expand the paramedic's
understanding of medical management.
2. Encourage prehospital personnel to attend in-house lectures,classes,demonstrations,and
seminars which have been approved in advance by the EMS Agency for continuing
education credits.
3. Provide patient follow-up information for purposes of education to paramedics.
4. Recommend Mobile Intensive Care Nurses for certification and recertification.
6. Advise the EMS Agency of any change in employment status of Mobile Intensive Care
Nurses employed in the hospital.
7. Provide quality improvement of care provided by EMS personnel in accordance with
Policy.
F. BASE HOSPITAL INTERFACE WITH EMS SYSTEM
The Base Hospital will:
1. See that the Base Hospital Medical Director and the Prehospital Liaison Nurse are
scheduled to attend the Emergency Medical Services Operations Committee meetings
and other EMS System meetings where their expertise would be valuable,e.g.,Medical
Control Committee,Base Hospital Committee,Tape Reviews,Emergency Medical Care
Committee,and Continuous Quality Improvement.
Exhibit D
Page 4 of 4 Page 4 of 44
Subject Base Hospital Criteria Policy
Number 311
2. Base Hospitals will be authorized through agreements between the approved hospital and
the EMS Agency.
CENTRAL CALIFORNIA
EMERGENCY MEDICAL SERVICES
A Division of the Fresno County Department of Public Health
Exhibit D
Page 5 of 44
Manual Policy
Emergency Medical Services Number 330
Administrative Policies and Procedures
Page 1 of 5
Subject Trauma System Overview
Effective
References California Code of Regulations 11/01/2002
Title 22. Social Security
Division 9.Prehospital Emergency Medical Services
Chapter 7.Trauma Care Systems
I. POLICY
The Central California Emergency Medical Services Trauma Services System shall operate in accordance with
Health and Safety Code Division 2.5,and the California Code of Regulations Title 22,Division 9,Chapter 7 and
shall be implemented,monitored,and evaluated by the EMS Agency.
The Central California Emergency Medical Services Trauma System maintains a trauma plan and EMS policies and
procedures required by Section 100255 of the California Code of Regulations.The intent of the Trauma Plan and
EMS policies and procedures is to provide a clear understanding of the structure of the trauma system in a manner
that effectively utilizes the systems resources.
The following is a list of the policies required by Section 100255 of the California Code of Regulations and includes
brief description of the policy and a reference where further policy information can be located.
A. System Organization and Management
The EMS Division of the Fresno County Department of Public Health is the designated local EMS agency
for Fresno,Kings,Madera and Tulare Counties.The EMS Division is responsible for monitoring the
ongoing operation of the regional trauma care system. This is accomplished through the development of
EMS policies and procedures and by participating in the various EMS committees,including the Regional
Trauma Audit Committee.The EMS agency staff supervises the collection and analysis of trauma data,
including ongoing development of the trauma patient registry.
A Level I Trauma Center,Community Regional Medical Center(RMC),is located in Fresno and directly
receives prehospital trauma patients from within the region often bypassing other receiving hospitals.
A Level III Trauma Center,Kaweah Health Medical Center(KHMC),is located in Visalia and receives
prehospital trauma patients from within Tulare County and adjacent counties.
Approved By Revision
EMS Director 04/25/2023
EMS Medical Director
Exhibit D
Page 6 of 44
Page 2 of 5
Subject Trauma System Overview Policy
Number 330
A Level II Pediatric Trauma Center,Valley Children's Hospital(VCH)is located in Madera and receives
prehospital trauma patients from within Madera,Fresno,and adjacent Counties.
B. Trauma Care Coordination Within the Trauma System
The prehospital care and treatment of trauma patients shall be in accordance with EMS policy and
procedures to insure consistent application of trauma services through-out the EMS region.These policies
include EMS Policy#332—Trauma System Monitoring,EMS Policy#510-Basic Life Support Protocols,
EMS Policy#530-Paramedic Treatment Protocols,EMS Policy#547—Patient Destination,and other
EMS policies and procedures.
C. Trauma Care Coordination with Neighboring Jurisdictions
Coordination of Trauma Care with neighboring jurisdictions is addressed in the prehospital setting and also
the hospital setting. EMS Policy#405—EMS Dispatch Policy-Out of County Responses,and EMS
Policy#408—Helicopter Dispatch Policy,address the coordination of trauma response in the neighboring
jurisdictions outside of the Central California EMS region. Coordination of trauma care with neighboring
jurisdictions in the hospital setting is addressed in EMS Policy#341 —Patient Transfers Between Acute
Care Facilities,and EMS Policy#342—Transfer Agreements Between Acute Care Hospitals.
D. Collection and Management of Data
The designated trauma centers and non-trauma centers are responsible for submitting all required data to
the EMS Agency on a monthly basis or as determined by the EMS Agency. The minimum data set as
defined in the State Trauma Regulation Section 100257,is required by all participating trauma hospitals.
Collection and management of data for the Central California Emergency Medical Services Trauma System
is outlined in EMS Policy#332,and Policy#334. The trauma nurse coordinators/managers provide trauma
registry data,which is used by the Trauma Audit Committee and EMS Agency and is submitted to the
State's data system(CEMSIS/NEMSIS).
E. Trauma Center Fees for Designation/Redesignation/Evaluation
There are currently no fees for trauma center designation,redesignation,or trauma center evaluation in the
Central California Emergency Medical Services region.
F. Establishment of Service Areas for Trauma Centers
Community Regional Medical Center is the designated Level I trauma center in the Central California EMS
region.The service area encompasses the entirety of the Central California EMS region.In very specific
circumstances,such as airway compromise,a trauma patient may be transported to a receiving hospital for
stabilization before proceeding to the trauma center. Kaweah Health Medical Center is a designated Level
III Trauma Center and is the primary trauma destination for trauma patients in Tulare County.Valley
Children's Hospital is the Level 11 Pediatric Trauma Center and is one of two primary destinations for
pediatric patients.
G. Designation and Re-designation of a Trauma Center/including Agreements
The Local EMS Agency designates Trauma Centers within the EMS Region.Trauma center designation is
based upon the need for local and regional trauma care services.Trauma facility designation is outlined in
EMS Policy#331 —Trauma Facility Designation.
Exhibit D
Page 7 of 44
Page 3 of 5
Subject Trauma System Overview Policy
Number 330
H. Triage to the Appropriate Facility
The prehospital triage and transport decision process is very similar to the Centers for Disease Control
(CDC)field triage process and involves an assessment not only of the physiology and anatomy of the injury
but also the mechanism of the injury and special patient considerations. Seriously and moderately injured
patients are transported directly to RMC,KHMC,or VCH. EMS Policy#547—Patient Destination
outlines the required patient destination procedure for both trauma and medical patients.
I. Repatriation of Stable Trauma Service Health Plan Members
EMS Policy#547—Patient Destination requires prehospital personnel to attempt to transport stable patients
to the patient's health plan's participating facility. In 2008,The EMS Agency partnered with the Hospital
Council of Northern California and hospitals within the 4-county EMS region to create a patient transfer
committee.This committee meets regularly to discuss the issues and barriers with repatriation of patients.
Recognized as a best practice,the Committee developed an agreement signed by all hospitals that agrees to
criteria and conditions on repatriating patients in an effort to increase capacity at the Trauma Centers and
keep local patients in the local areas.
J. Inter-trauma Center&Inter-facility Transfer of the Trauma Patient
The EMS policies and procedures strictly address the coordination and management of Inter-trauma center
and inter-facility transfers of the trauma patient and are addressed in EMS Policy#341 —Patient Transfers
Between Acute Care Facilities,EMS Policy#342—Transfer Agreements Between Acute Care Hospitals,
and EMS Policy#553—ALS Interfacility Transfers.
K. Role of the Pediatric Trauma Center
Valley Children's Hospital is the Level II Pediatric Trauma Center and is the designated trauma center for
most pediatric patients. Community Regional Medical Center is the Level I Trauma Center and is also a
designated destination for pediatric trauma.
L. Resources for Trauma Team Response-Equipment&Staff
Trauma Centers are required by EMS Policy#333—Trauma Center Criteria to have internal hospital
policies and procedures governing"Trauma Center Medical and Physician Services",which include the
resources and staff required for a trauma team response.
M. Criteria for Activation of the Trauma Team
Trauma Centers are required by EMS Policy#333—Trauma Center Criteria,to have internal hospital
policies and procedures outlining the specific criteria for trauma team activation.
N. Availability of Trauma Specialists
Trauma Centers are required by EMS Policy#333—Trauma Center Criteria to have internal hospital
policies and procedures outlining the availability of trauma team personnel and specialists.
O. Quality Improvement and System Evaluation/include Multidisciplinary Peer Review Committee
Quality Improvement is a combined effort of hospitals,providers,and the EMS Agency.EMS Policies
#703—Continuous Quality Improvement,and#704—Quality Improvement Reporting address the access to
the continuous quality improvement process.The trauma services system is monitored through the
continuous quality improvement process and through EMS policy#332—Trauma System Monitoring.The
Exhibit D
Page 8 of 44
Page 4 of 5
Subject Trauma System Overview Policy
Number 330
trauma system is also monitored by a peer review committee,which is outlined in EMS Policy#703—
Continuous Quality Improvement.
P. Identification and Transportation of the Adult and Pediatric Trauma Center Candidate
Trauma center patients are identified by a decision process that is very similar to the Centers for Disease
Control(CDC)field triage process and involves an assessment not only of the physiology and anatomy of
the injury but also the mechanism of the injury and special patient considerations. Once the patient is
identified as a trauma center patient,the prehospital personnel transport the patient directly to the trauma
center in accordance with EMS Policy#547—Patient Destination.
Q. Trauma Triage Training of Prehospital Personnel
Prehospital Personnel and MICNs are trained in trauma triage through continuing education courses
available throughout the EMS System.Continuing education courses must be in accordance with EMS
Policy#701 —Continuing Education.
R. Public Information and Education on Trauma Systems
All public information and education requirements and services relative to the design,implementation,and
operational effectiveness of the trauma system will be coordinated through the EMS Agency. Public
information and educational activities will encompass trauma system design,citizen access,trauma system
capabilities,and mechanism for follow up and incident review as requested by the public and/or medical
community. Additional requirements will include:
1. A commitment to the establishment of a trauma system that supports the promotion of injury
prevention and safety education.
2. The facilitation of speakers to address public groups and serves as a resource for trauma information
and education.
3. Provide assistance to community and professional groups in the development and dissemination of
education to the public on such topics as injury prevention,safety education programs and access to
the trauma care system.
4. Each designated facility must participate in the development of public awareness and education
campaigns for their service area.
S. Provider Marketing and Advertising
California Health and Safety Code,Division 2.5,states in part, "no health care provider shall use the term
"trauma facility,""trauma hospital,""trauma center,""trauma care provider,""trauma care vehicle,"or
similar terminology in its signs or advertisements,or in printed materials and information it furnishes to the
general public,unless its use has been authorized by the EMS Agency.
All marketing and promotional plans,with respect to trauma center designation,shall be submitted to the
EMS Agency for review and approval,prior to implementation.
T. Collaborative Injury Prevention Efforts with the Public/Private Sector
Trauma Centers shall participate in injury prevention programs with public and private agencies. Trauma
Centers may produce their own Injury Prevention Programs based upon data analysis of the trauma center
review at their facility. Trauma Centers may utilize information developed by the EMS Agency as a result
Exhibit D
Page 9 of 44
Page 5 of 5
Subject Trauma System Overview Policy
Number 330
of system review to produce injury prevention programs for the public and private sector in their
communities.
CENTRAL CALIFORNIA
EMERGENCY MEDICAL SERVICES
A Division of the Fresno County Department of Public Health
Exhibit D
Page 10 of 44
Manual Policy
Emergency Medical Services Number 331
Administrative Policies and Procedures
Page 1 of 3
Subject Trauma Facility Designation
References California Code of Regulations,Title 22. Social Security Effective
Division 9.Prehospital Emergency Medical Services 11/01/86
Chapter 7.Trauma Care Systems
I. POLICY
Trauma Centers for the Central California EMS Region are designated by the Local EMS Agency based upon the
need for local and regional EMS trauma care services.
II. DESIGNATED TRAUMA CENTERS
The following hospitals have been designated as Trauma Centers:
Date of Original
Trauma Center Level of Designation Designation
Community Regional Medical Center Level I Trauma Center June 19, 1984
Kaweah Health Medical Center Level III Trauma Center January 26,2010
Valley Children's Hospital Level II Pediatric Trauma Center February 1,2016
III. PROCEDURE FOR DESIGNATION
A. The EMS Agency shall develop and update a plan for the provision of trauma care within the four-county
region. This plan shall minimally address the provision of trauma care services,triage mechanisms for
patient routing,the number and type of trauma hospitals needed for local and/or regional trauma care
needs,and the evaluation process for the trauma system.
B. The Regional Trauma Audit Committee will formalize recommendations to the EMS Agency concerning
all aspects of the trauma system,including the number and type of trauma hospitals needed for effective
system operation.
C. Any hospital wishing to gain a trauma designation shall notify the EMS Agency,in writing,of its intent to
seek trauma center designation. This documentation shall include the hospital's justification,plan,
proposed trauma patient volume,and anticipated timetable for implementation.
Approved By Revision
EMS Director DANIEL J.LYNCH (Signature on File at EMS Agency)
04/25/2023
EMS Medical Director JIM ANDREWS,M.D. (Signature on File at EMS Agency)
Exhibit D
Page 11 of 44
Page 2 of 3
Subject Trauma Facility Designation Policy
Number 331
D. Prior to designation as a trauma center,the hospital shall submit to the EMS Agency:
1. The Application for Trauma Designation with required documents.
2. A copy of the American College of Surgeons Committee on Trauma(ACS-COT)Consultative
Visit if done prior to designation.
3. Documentation that the Trauma Center Standards in Policy 333 have been met.
E. Applications shall be reviewed for their compliance with the State of California,local regulations and their
impact on the local trauma system. The Regional Trauma Audit Committee,Regional Medical Control
Committee,and each Emergency Medical Care Committee from each county in the region will be
consulted for its recommendation.
F. If more than one hospital competes for a role in the local system that is deemed necessary by the regional
Trauma Audit Committee and the EMS Agency,a Request for Proposal procedure may be necessary to
determine the successful applicant.
G. After review of the submitted application and documents,the EMS Agency will conduct a site review of
the facility as outlined in the Application for Trauma Designation. The cost of the site review shall be the
sole responsibility of the hospital applying for trauma destination.
H. Upon the completion of a satisfactory site review,the EMS Agency will designate the hospital as a Level I,
II,III,IV,or Pediatric I or II trauma center.
I. In the event that the hospital fails to meet the criteria for designation,the EMS Agency may elect to issue a
conditional designation that will be followed within six(6)to twelve(12)months by another evaluation of
the deficient areas.
J. Upon satisfactory completion of the second evaluation,the EMS Agency will authorize full designation of
the Trauma Center.
K. If the second evaluation is unsatisfactory,the EMS Agency may elect to continue the conditional
designation upon correction of the areas of deficiency or deny designation.
L. The hospital requesting designation and the EMS Agency will enter into a contract for designation of the
trauma center.
M. A designated trauma center shall obtain American College of Surgeons Committee on Trauma(ACS-COT)
verification within 2(two)years of their initial trauma center designation. The cost of the verification shall
be the sole responsibility of the hospital requesting such verification.
N. The EMS Agency shall determine a plan for Trauma Care Services.
O. Any change in designation will become part of the revised trauma plan and will be approved by the Local
EMS Agency prior to submission to the State EMS Authority.
IV PROCEDURE FOR RE-EVALUATION OF A TRAUMA CENTER'S STATUS
A. The EMS Agency shall evaluate the designated Trauma Centers' Status every three years for contractual
compliance and compliance with the California Code of Regulations,Title 22,Division 9,Chapter 7.
Exhibit D
Page 12 of 44
Page 3 of 3
Subject Policy
Trauma Facility Designation Number: 331
B. Designated Trauma Centers shall maintain verification with the ACS-COT. Trauma Centers shall submit
to the EMS Agency a copy of the re-verification visit summary from the ACS-COT every three years.
V. PROCEDURE FOR DE-DESIGNATION
A. Failure by a hospital to comply with applicable Local, State,and ACS-COT trauma requirements or
applicable recommendations by site survey teams approved by the EMS Agency or ACS-COT,may result
in forfeiture of their trauma designation.
B. Failure by a hospital to provide an adequate quality of care,as identified through medical audit and quality
audit procedures,may result in forfeiture of their trauma designation.
CENTRAL CALIFORNIA
EMERGENCY MEDICAL SERVICES
A Division of the Fresno County Department of Public Health
Exhibit D
Page 13 of 44
Manual Policy
Emergency Medical Services Number 332
Administrative Policies and Procedures
Page 1 of 4
Subject Trauma System Monitoring
References California Code of Regulations,Title 22. Social Security Effective
Division 9.Prehospital Emergency Medical Services 11/01/88
Chapter 7.Trauma Care Systems
I. POLICY
The trauma care administered to patients of the local trauma care system will be reviewed for appropriateness and
patient outcome. This review will be conducted through the use of the Regional Trauma Audit Committee and
Regional Medical Control Committee,both which are composed of health care and trauma care specialists.
II. PROCEDURE
A. TRAUMA REGISTRY
1. Definition
The Trauma Registry is a confidential database of patients who have sustained major injuries or
complications within the regional trauma system. This database is utilized for statistical reporting
on system activities and quality improvement review of patient outcome.Registry data includes
information from prehospital,emergency department,operative and intensive care,and the
patient's final disposition. Trauma centers and non-trauma centers will follow the criteria outlined
in Policy#334 regarding trauma registry data collection.
B. INTERNAL HOSPITAL REVIEW
The medical records(including prehospital)of each registry patient at trauma centers will be reviewed by
the Trauma Nurse Coordinator/Manager or designee for completeness,accuracy and presence of any
delays in evaluation and treatment. The hospital's Trauma Surgery Director or designee will review the
registry records for appropriateness of diagnostic procedures relative to the admitting diagnosis,timeliness
of care,appropriateness of operative therapy relative to diagnosis,complications,morbidity,and length of
stay relative to diagnosis.
The Trauma Surgery Director and Trauma Nurse Coordinator/Manager will present registry cases that meet
the established criteria to the hospital's appropriate reviewing committee. Trauma centers will utilize a
specific Trauma Review Committee whose membership shall minimally include:
Approved By Revision
EMS Director
05/25/2023
EMS Medical Director
Exhibit D
Page 14 of 44
Page 2 of 4
Subject Trauma System Monitoring Policy
Number 332
TRAUMA CENTER TRAUMA REVIEW COMMITTEE
Trauma Surgery Director Neurosurgeon
Emergency Medicine Representative Orthopedic Surgeon
Trauma Nurse Manager/Coordinator Hospital Administration
Emergency Department Manager/Supervisor Prehos ital Liaison Nurse
In addition to the members listed above,the Trauma Center should also consider the following
representatives:
Anesthesiology
General Surgeon
Nurse Manager-OR
Nurse Manager—ICU
Radiology Representative
Blood Bank Representative
Medical Records will be available to allow the committee to review all aspects of the patient's care and course
of hospital stay. The hospital Trauma Review Committee is responsible for reviewing the patient's care,
identifying problems, providing feedback to individuals involved in a specific patient's care, formulating
recommendations for hospital trauma operational procedures,and classification of deaths as mortality without
opportunity for improvement, anticipated mortality with opportunity for improvement, or unanticipated
mortality with opportunity for improvement. The committee shall forward unusual or problem cases to the
Regional Trauma Audit Committee and formulate recommendations on Trauma Care System and EMS
System operation.The definitions for the classifications of death are in accordance with the American College
of Surgeons criteria and are as follows:
1. Mortality without opportunity for improvement- An event or complication sequela of a procedure,
disease,illness,or injury for which reasonable and appropriate preventable steps had been taken.
2. Anticipated mortality with opportunity for improvement—An event or complication that is a sequela
of a procedure, disease, illness, or injury that has the potential to be prevented or substantially
ameliorated.
3. Unanticipated mortality with opportunity for improvement — An event or complication that is an
expected or unexpected sequela of a procedure, disease, illness, or injury that could have been
prevented or substantially ameliorated.
C. REGIONAL TRAUMA AUDIT COMMITTEE
1. Membership
The Regional Trauma Audit Committee is an advisory committee to the EMS Agency on issues
related to trauma care. The membership shall be broad-based and shall represent the participants in
the Trauma System and the local medical community. The Trauma Audit Committee membership
shall minimally include:
MEMBERSHIP OF THE REGIONAL TRAUMA AUDIT COMMITTEE(TAC)
Trauma Centers Non-Trauma Hospitals
Trauma Surgery Director Trauma Surgery Director
Emergency Department Physician Emergency Department Physician
Trauma Nurse Coordinator/Manager Trauma Nurse Coordinator/PLN
Exhibit D
Page 15 of 44
Page 3 of 4
Subject Trauma System Monitoring Policy
Number 332
EMS Agency Local Medical Community
EMS Medical Director Neurosurgeon from Neurosurgical Society)
EMS Director Physician from Rural Area(from Medical Society)
EMS Trauma Coordinator
Each of the agencies listed above shall notify the EMS Medical Director,in writing,of the name
of the person designated to represent the agency and exercise Committee voting privileges.There
will be one vote per facility.
2. Chairperson/Vice Chairperson
The Committee shall elect a Chairman who shall serve a term of one year with new elections each
January.The committee may elect to choose a co-chairperson. The EMS Medical Director will
serve as Vice Chairman in the event of absence of the chairperson(and co-chairperson). Meeting
Minutes will be recorded on topics not related to specific confidential patient care issues.The
EMS Agency will provide staff support for the Regional Trauma Audit Committee.
3. Committee Responsibilities
The Regional Trauma Audit Committee is responsible for reviewing all aspects of the Trauma
Care System and developing recommendations on system operation for the EMS Agency. This
will include system operation,trauma care planning,data analysis,trauma policy development,
hospital assessment and selection and specific patient base reviews.
The Committee's agenda shall include a review and approval of monthly Minutes,case
presentations and specific educational case reviews(e.g.neurologic case review,review of EMS
procedures related to the Trauma Care System). Agenda items may occur on a regular schedule
including monthly(e.g.case presentations)or at the request of the Committee members. Items not
included in the Committee's written agenda may be added at the beginning of the meeting at the
discretion of the Chairman.
The Trauma Centers will present case presentations each month. Non trauma centers may present
problems transfers or problem cases as needed. Criteria for case presentation to the Regional
Trauma Audit Committee are included in Attachment A. Specific educational case reviews may be
presented to illustrate new techniques,patient problems,or system operational issues related to a
medical specialty such as neurosurgery,orthopedics or pediatrics.The EMS Agency will provide
monthly reports to the committee on the regional trauma system.The Committee may provide
feedback on system operation or quality improvement issues directly to the EMS Agency,health
care facility or provider,and other trauma/EMS advisory groups.
D. EMS AGENCY
The local EMS Agency is responsible for monitoring the operation of the Trauma Care System. The EMS
Agency may request an onsite review of any designated trauma hospital with repetitive problems to ensure
the problems are being resolved. Additional agency involvement(e.g. State Department of Health Care
Services)may be requested as appropriate.
Exhibit D
Page 16 of 44
Page 4 of 4
Subject Trauma System Monitoring Policy
Number 332
ATTACHMENT A
CASE PRESENTATION CRITERIA
I. Case Presentations shall occur each month at the regional Trauma Audit Committee.The criteria for case
presentation shall include:
A. Any death classified as unanticipated mortality with opportunity for improvement or anticipated mortality
with opportunity for improvement by the hospital Trauma Review Committee,including:
1. All deaths with initial surgery(required for stabilization)>1 hour after arrival at a trauma hospital.
2. All deaths with a delay in the arrival of the surgeon(>15 minutes).
3. All deaths with unanticipated autopsy findings or autopsy findings inconsistent with the admitting
diagnosis.
4. All deaths with inappropriate prolonged prehospital time including on-scene times greater than 10
minutes without explanation,or a transport time greater than 30 minutes if air transport was available.
5. All deaths where probability of survival(PS)>50%based upon Trauma Score-Injury Severity Score
(TRISS).
B. Major complications which significantly increase inpatient hospital time or lead to premature death.
C. A comatose patient(Glascow Coma Scale of less than 8)going to CT or,leaving the emergency
department before a definitive airway(endotracheal tube or surgical airway)is established.
D. Patients with epidural or subdural brain hematoma receiving craniotomy more than 4 hours from arrival at
emergency department to surgical start time,excluding those performed for intracranial pressure(ICP)
monitoring.
E. Delay to surgery for laparotomy:
1. Surgery start time>1 hour if hypotensive(systolic blood pressure<90mm Hg)
2. Surgery start time>4 hours if stable
F. Problem Transfers-Any trauma patient transfer of greater than 6 hours from original time of arrival time at
the sending hospital.
G. Any trauma team activation with a delay in the arrival of the surgeon of greater than 15 minutes.
H. Any trauma case where the trauma consultant does not respond in the specified time period.
I. Any case which demonstrates system operational problems.
J. Interesting or educational cases.
CENTRAL CALIFORNIA
EMERGENCY MEDICAL SERVICES Exhibit D
A Division of the Fresno County Department of Public Health Page 17 of 44
Manual Policy
Emergency Medical Services Number 333
Administrative Policies and Procedures
Page 1 of 2
Subject Trauma Center Criteria
References California Code of Regulations Effective
Title 22. Social Security 11/08/88
Division 9.Prehospital Emergency Medical Services
Chapter 7.Trauma Care Systems
I. POLICY
A trauma center is a licensed hospital,accredited by the Joint Commission on Accreditation of Healthcare
Organizations,which has been designated as a Level I,II,III,IV,or Pediatric Level I or II trauma center by the
Local EMS Agency. Designated trauma centers for the Central California EMS Region shall adhere to the
minimum standards set forth in the California Code of Regulations,Title 22,Division 9,Chapter 7,Trauma Care
Services and EMS Agency policy and procedure.
II. PROCEDURE
A. Trauma centers shall maintain,at all times,the standards required of its designation as a Level I,II,III,IV,
or Pediatric Level I or II trauma center in accordance the California Code of Regulations,the Central
California EMS Policies and Procedures,and the American College of Surgeons Committee on Trauma
(ACS-COT)once verified
B. All designated trauma centers shall achieve and maintain ACS-COT verification within two(2)years of
their initial designation as a trauma center. Copies of consultative visits or verification visits by the ACS-
COT shall be submitted to the EMS Agency. Designated trauma centers at the time of this policy shall
achieve their ACS-COT verification by January 1,2016.
C. In addition to the requirements listed in the Trauma Center Standards,a designated trauma center for the
CCEMSA EMS Region shall meet and maintain the following additional requirements:
1. Designated trauma centers shall designate a Trauma Program Medical Director,Trauma Nurse
Coordinator/Manager,and an emergency department physician who shall regularly attend the
EMS Agency's Regional Trauma Audit Committee.They each shall attend at least nine(9)of the
Regional Trauma Audit Committee meetings each calendar year. The emergency department
physician representative shall be a board certified in emergency medicine or maintain current
certification in Advanced Trauma Life Support(ATLS)and be a certified base hospital physician.
2. Trauma centers shall be designated Base Hospitals and shall meet all requirements outlined in
EMS Policy and Procedure.
Approved By Revision
EMS Director
05/25/2023
EMS Medical Director
Exhibit D
Page 18 of 44
Page 2 of 2
Subject Trauma Center Criteria Policy
Number 333
3. Trauma centers are expected to provide a full activation of their team resources for patients that
meet the triage criteria for major trauma patients. Patients that are hemodynamically stable,
without major anatomic injury may be considered for a reduced trauma team response.If a trauma
center chooses to implement a tiered trauma team response,a quality assessment and improvement
process must be in place to monitor the effectiveness of the care delivery.A copy of the Trauma
Centers written procedure on trauma team response,including the process to monitor its
effectiveness,must be on file at the EMS Agency.
4. Designated trauma centers shall implement and maintain an EMS Agency approved trauma
registry data collection program and provide registry data to the EMS agency on a monthly basis.
The trauma registry program used in the CCEMSA region is V5 by Digital Innovation
Incorporated.
5. Designated trauma centers shall have a written agreement with the Local EMS Agency
6. Designated trauma centers shall have a written transfer agreement with all affiliated trauma care
hospitals and appropriate specialty care facilities. A copy of the written agreement shall be on file
with the EMS Agency.
D. Immediately Available
Immediately available implies the physical presence of the surgeon in a stated location at the time of need
by the trauma patient within 15 minutes 80%of the time,otherwise upon patient arrival with sufficient
advanced notice.
E. Promptly Available
Promptly available is defined in this policy as the return of a notification call within 20 minutes and
available to the Trauma Center within 30 minutes 80%of the time when requested by the trauma team
leader.
Exhibit D
CCEMSA TRAUMA CENTER STANDARDS Page 19 of 44
SUMMARY OF CALIFORNIA CODE OF REGULATIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
1 II PEDS III IV
E = essential E*= CCEMSA D = desirable
Level Peds** is requirements for Level II Pediatric TC
E# = essential for Level I Pediatric TC in addition to Level II
requirements
Institutions/Organization
The Joint Commission E E E E E
Proof of licensure as a general acute care hospital in the State E E E E E
of California
Basic or comprehensive emergency services with special E E E E* D
permits
Shall have equipment and resources needed for initial E E E E E
stabilization and personnel knowledgeable in the treatment of
adult and pediatric trauma Pediatric TC — pediatric trauma
A trauma center must demonstrate substantial medical, E* E* E* E* E*
administrative, and financial commitment for the level of
designation requested. Commitment must be demonstrated and
include documentation from the hospitals:
Administration
Medical Staff
Nursing
Level I shall have one of the following patient volumes annually; E
A minimum of 1200 trauma program hospital admissions or
A minimum of 240 trauma patients per year whose Injury
Severity Score (ISS) is >15, or
An average of 35 trauma patients (ISS >15) per trauma program
surgeon per year
A trauma research program E E#
An ACGME approved surgical residency program E E#
Requirements for Trauma Centers
Pediatric trauma centers must have qualified pediatric
personnel and pediatric specific resources for all areas
Trauma Program Medical Director E E E E E
Qualifications
Board Certified Surgeon or E E E D
Fellow of ACSE * E* E* E*
Board Certified Pediatric Surgeon for Pediatric Trauma Center E#
A qualified surgical specialist E
A qualified non-surgical specialist E
Responsibilities include but not limited to:
Recommending trauma team physician privileges E E E E E
1
Exhibit D
CCEMSA TRAUMA CENTER STANDARDS Page 20 of 44
SUMMARY OF CALIFORNIA CODE OF REGULATIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
1 II PEDS III IV
E = essential E*= CCEMSA D = desirable
Level Peds** is requirements for Level II Pediatric TC
E# = essential for Level I Pediatric TC in addition to Level II
requirements
Working with nursing & administration to support needs of E E E E E
trauma patients
Developing trauma treatment protocol E E E E E
Determining appropriate equipment and supplies E E E E* E*
Ensuring development of policies/procedures for domestic
violence, elder/child abuse/neglect E E E E* E*
Having authority & accountability for QI peer review process E E E E E
Correct deficiencies in trauma care/exclude team members that E E E E E
don't meet standards
Coordinating pediatric trauma care with other E E E E* E*
hospitals/professional services
Coordinating with local and State EMS agencies E E E E* E*
Assisting with the coordination of budgetary processes for E E E E E
trauma program
Identifying representatives from neurosurgery, orthopedic E E E E* E*
surgery, emergency medicine, pediatrics, and other appropriate
disciplines to assist in identifying physicians from their
disciplines who are qualified to be members of the trauma team
Trauma Nurse Coordinator/Manager E E E E E
Qualifications:
Registered nurse E E E E E
Provide evidence of educational preparation, clinical E E E E E
experience in care of adult and pediatric trauma patients, and
administrative responsibilities
Responsibilities include but not limited to:
organizing services and systems necessary for E E E E E
multidisciplinary care of the injured patient
coordinating day-to-day clinical process & performance E E E E E
improvement of nursing and ancillary personnel
collaborating with trauma program medical director to carry E E E E E
out educational, clinical, research, administrative and
outreach activities of the trauma program
Trauma Service E E E E E
Pediatric TC must provide Pediatric Special ist/Services
Implement requirements of Title 22 and Local policy & E E E E E
coordinate with the EMS agency
2
Exhibit D
CCEMSA TRAUMA CENTER STANDARDS Page 21 of 44
SUMMARY OF CALIFORNIA CODE OF REGULATIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
1 II PEDS III IV
E = essential E*= CCEMSA D = desirable
Level Peds** is requirements for Level II Pediatric TC
E# = essential for Level I Pediatric TC in addition to Level II
requirements
Capable of providing immediate initial resuscitation and E E E
management of the trauma patient
Capable of providing prompt assessment and stabilization of the E E
trauma patient
Ability to provide treatment or arrange for transportation to a E E
hi her level trauma center
Trauma Team E E E E E
A multidisciplinary team responsible for the initial resuscitation E E E E E
and management of the trauma patient.
Pediatric trauma center— the pediatric trauma team leader shall E
be a surgeon with pediatric trauma experience as defined by the
trauma program medical director, and
Remainder of team shall include physician, nursing and support
personnel in sufficient numbers to evaluate, treat, stabilize
pediatric patients
SURGICAL DEPARTMENT (S), DIVISION(S), SERVICE(S),
SECTION(S):
Includes at least the following surgical specialties & staffed
by qualified specialists:
Pediatric TC must provide Pediatric Specialist
General Surgery E E E
Neurologic E E E
May be provided through a written transfer agreement for E
Level III
Obstetric/Gynecologic
May be provided through written transfer agreement for Pediatric E E E
TC
Ophthalmologic E E E
Oral/maxillofacial or head and neck E E E
Orthopedic E E E E
Pediatrics D D E
Plastic E E E
Urolo is E E E
Microsurgery/re-implantation (may be through transfer
agreement with a hospital that has a department, division, E
service that provides this service
3
Exhibit D
CCEMSA TRAUMA CENTER STANDARDS Page 22 of 44
SUMMARY OF CALIFORNIA CODE OF REGULATIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
1 II PEDS III IV
E = essential E*= CCEMSA D = desirable
Level Peds** is requirements for Level II Pediatric TC
E# = essential for Level I Pediatric TC in addition to Level II
requirements
NON-SURGICAL DEPARTMENT (S), DIVISION(S),
SERVICE(S), SECTION(S):
Which includes at least the following non-surgical
specialties & staffed by qualified specialists:
Pediatric TC must provide Pediatric Specialist
Anesthesiology E E E E
Internal Medicine E E
Cardiology E
Critical Care E
Emergency medicine E
Gastroenterology E
General Pediatrics E
Hematology/Oncology Hematology/Oncology E
Infectious Disease E
Neonatology E
Nephrology E
Neurology E
Pathology E E E
Psychiatry E E E
Pulmonology E
Rehabilitation/physical medicine, can be provided by written E E
agreement
Radiology E E E
Emergency Department with qualified specialist in emergency E E E
medicine, immediately available
Emergency Department staffed, trauma patients are assured of E E
immediate and appropriate initial care
QUALIFIED SURGICAL SPECIALIST(S):
Pediatric TC must have Pediatric specialists in all areas
General Surgeon capable of evaluating & treating adult and E E E D
pediatric trauma patients, Board Certified, Immediately available
In-house* at all times for trauma team activation and promptly
available for consultation
4
Exhibit D
CCEMSA TRAUMA CENTER STANDARDS Page 23 of 44
SUMMARY OF CALIFORNIA CODE OF REGULATIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
1 II PEDS III IV
E = essential E*= CCEMSA D = desirable
Level Peds** is requirements for Level II Pediatric TC
E# = essential for Level I Pediatric TC in addition to Level II
requirements
Pediatric TC may be fulfilled by: E
A staff pediatric surgeon with experience in pediatric trauma, or
A staff trauma surgeon with experience in pediatric trauma, or
A senior surgical resident, who has completed 3 clinical years of
surgical residency See resident coverage below
General Surgeon capable of evaluating & treating adult and E
pediatric trauma patients, promptly available at all times
Published on-call schedule E* E* E* E*
Published back up schedule E* E* E* E*
Surgical specialists' requirements may be fulfilled by supervised E E E
senior residents as defined in Section 100245 of Title 22 at the
Level I, 11, or pediatric trauma center.
Residency coverage: (Pediatric TC must have pediatric
specialist)
Senior resident must be capable of assessing emergent
situations in their respective specialty, and
Shall be able to provide overall control and surgical leadership E E E
including surgical care if needed, and
A supervising, staff trauma surgeon/surgeon with experience
in trauma care shall be on-call and promptly available, and
A supervising, staff trauma surgeon shall be advised of all
trauma patient admissions, participate in major
therapeutic decisions, and be present in the ED for all major
resuscitations and in the OR for a all trauma operative
procedures
Qualified Surgical Specialist On-Call and promptly available
Pediatric TC must have Pediatric specialists in all areas
Neurologic, Dedicated to one hospital or back up call * E E E
Level III may be provided through a written transfer agreement E
Obstetric/Gynecologic E E E D
Pediatric TC available by Transfer agreement
Ophthalmologic E E E D
Oral/maxillofacial or head and neck E E E D
Orthopedic, Dedicated to one hospital or back up call * E E E E
Plastic E E E D
5
Exhibit D
CCEMSA TRAUMA CENTER STANDARDS Page 24 of 44
SUMMARY OF CALIFORNIA CODE OF REGULATIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
1 II PEDS III IV
E = essential E*= CCEMSA D = desirable
Level Peds** is requirements for Level II Pediatric TC
E# = essential for Level I Pediatric TC in addition to Level II
requirements
Reimplantation/microsurgery capability. May be provided E E E
through transfer agreement
Urologic E E E D
Cardiothoracic E E# D
Pediatrics E
Pediatric neurologic E#
Pediatric ophthalmologic E#
Pediatric oral or maxillofacial or head and neck E#
Pediatric orthopaedic E#
Surgical service- available for consultation or by transfer
agreements
Burns E E E E
Cardiothoracic E E D
Pediatrics E E
Re-implantation/Microsurgery E E E
Spinal cord injury E E E D
QUALIFIED NON-SURGICAL SPECIALIST(S):
Emergency Medicine
Board Certified, in-house , immediately available at all times E E E E
Emergency medicine physicians, board certified in emergency E E E
medicine shall not be required to complete ATLS.
Current ATLS is required for all emergency medicine physicians E E E D
who are qualified specialist in a specialty other than emergency
medicine
Residency coverage
Maybe be fulfilled by supervised senior residents as defined in E E
Section 100245 or Title 22, in emergency medicine, who are
assigned to ED and serving in the same capacity.
The senior resident shall be capable of assessing emergency E E E
situation in trauma patients and providing initial resuscitation.
Pediatric trauma center:
May be fulfilled by a qualified specialist in pediatric emergency E
medicine; or
A qualified specialist in emergency medicine with pediatric E
experience; or
6
Exhibit D
CCEMSA TRAUMA CENTER STANDARDS Page 25 of 44
SUMMARY OF CALIFORNIA CODE OF REGULATIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
1 II PEDS III IV
E = essential E*= CCEMSA D = desirable
Level Peds** is requirements for Level II Pediatric TC
E# = essential for Level I Pediatric TC in addition to Level II
requirements
A subspecialty resident in pediatric emergency medicine who E
has completed at least one year of subspecialty residency in
pediatric emergency medicine, and
A supervising qualified specialist in pediatric emergency E
medicine, or emergency medicine with pediatric experience shall
be promptly available,
A supervising qualified specialist on-call shall be notified of all E
patients requiring resuscitation, operative surgical intervention or
ICU admission.
Anesthesiology
Immediately available at all times, may be fulfilled by senior E D E# D
residents or CRNAs capable of assessing emergent situations, D
providing treatment, and supervised by staff anesthesiologist.
The staff anesthesiologist on-call shall be promptly available at
all times and present for all operations.
Promptly available and must be in operating room when patient E E D
arrives, may be fulfilled by senior residents or CRNAs capable of
assessing emergent situations, providing treatment, and
supervised by staff anesthesiologist. The staff anesthesiologist
on-call shall be promptly available at all times and present for all
operations.
On-call and promptly available and must be in operating room E
when patient arrives, may be fulfilled by senior residents or
CRNAs capable of assessing emergent situations, providing
treatment, and supervised by staff anesthesiologist.
The staff anesthesiologist on-call shall be promptly available at
all times and present for all operations.
Radiology, promptly available E E E E
Qualified non-surgical specialists available for consultation.
Pediatric trauma centers must have qualified specialists
with pediatric experience; pediatric TC - may be provided
through transfer agreement
Cardiology E E
Gastroenterology E E
Hematology E E D
Infectious Diseases E E D
Exhibit D
CCEMSA TRAUMA CENTER STANDARDS Page 26 of 44
SUMMARY OF CALIFORNIA CODE OF REGULATIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
1 II PEDS III IV
E = essential E*= CCEMSA D = desirable
Level Peds** is requirements for Level II Pediatric TC
E# = essential for Level I Pediatric TC in addition to Level II
requirements
Internal medicine E E D
Nephrology E E D
Neurology E E D
Pathology E E D
Pulmonary Medicine E E D
Adolescent medicine E
Child development E
Genetics/dysmorphology E
Neuroradiology E
Obstetrics E
Pediatric allergy and immunology E
Pediatric dentistry E
Pediatric endocrinology E
Pediatric pulmonology E
Rehabilitation/physical medicine E
Pediatric Critical Care - in-house, immediately available,
fulfilled by:
Qualified specialist in pediatric critical care medicine, or
Qualified specialist in anesthesiology with experience in
pediatric critical care; or
Qualified surgeon with expertise in pediatric critical care, or
A physician who has completed at least 2 years of residency in E
pediatrics.
When a senior resident is responsible for critical patient care,
there shall be a qualified specialist in pediatric critical care or
qualified specialist in pediatric anesthesiology on-call and
promptly available, and,
is advised of all patients requiring admission to the PICU and
participate in all major decisions and interventions.
The qualified pediatric PICU specialist shall be immediately
available, advised of all admitted patients to the PICU, and shall E#
participate in all major therapeutic decisions and interventions
Pediatric trauma centers — qualified specialists with
pediatric experience shall be on hospital staff and available
for consultation, and
Level I Pediatric Trauma Center, qualified pediatric non-
8
Exhibit D
CCEMSA TRAUMA CENTER STANDARDS Page 27 of 44
SUMMARY OF CALIFORNIA CODE OF REGULATIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
1 II PEDS III IV
E = essential E*= CCEMSA D = desirable
Level Peds** is requirements for Level II Pediatric TC
E# = essential for Level I Pediatric TC in addition to Level II
requirements
surgical specialist or specialty availability on call and
promptly available:
General pediatrics E
Mental health E
Neonatology E
Nephrology E
Pathology E
Pediatric anesthesiology E#
Pediatric cardiology E
Pediatric emergency medicine E#
Pediatric gastroenterology E
E#
Pediatric hematology/oncology E
Pediatric infectious disease E
E#
Pediatric nephrology E#
Pediatric neurology E
E#
Pediatric pulmonology E#
Pediatric radiology E
E#
SERVICE CAPABILITIES:
Radiological Service
Radiologist technician immediately available in-house*, capable E E E D
of performing plain film and computed tomography imaging.
Promptly available - angiography and ultrasound E E E
Radiological technician promptly available E E
Clinical laboratory Service
Immediately available at all times, E E E D
Promptly available for Level III and IV, E E
and
Comprehensive blood bank or access to a community central E E E E E
blood bank
Type & cross, coagulation studies, micro-sampling E* E* E*
Surgical Service
Operating suite available for trauma patient or being utilized for E E E E
9
Exhibit D
CCEMSA TRAUMA CENTER STANDARDS Page 28 of 44
SUMMARY OF CALIFORNIA CODE OF REGULATIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
1 II PEDS III IV
E = essential E*= CCEMSA D = desirable
Level Peds** is requirements for Level II Pediatric TC
E# = essential for Level I Pediatric TC in addition to Level II
requirements
trauma patients
Operating staff- with trauma education*, Immediately available E E#
unless operating on trauma patients and backup personnel
promptly available
Operating staff promptly available unless operating on trauma E E
patients and backup staff who are promptly available
Operating staff who are promptly available E
Appropriate surgical equipment/supplies as determined by E E E E
trauma program medical director or EMS Agency for Level III
Cardiopulmonary bypass E E#
Operating microscope E E#
Nursing Services — staffed by qualified licensed nurses with E
education, experience, and demonstrated clinical competence in
the care of critically ill and injured children
Basic Emergency Services per Chapter 1, Division 5 of Title
22: E E E E
Physician in-house, immediately at all times
Designate emergency physician to be member of trauma team, E E E E*
and
Provide emergency medical services to adult and pediatric E E E E
(pediatric patients for Pediatric TCpatients, and
Trauma trained nursing personnel to provide continual E* E* E* E*
monitoring, and
Equipment and supplies appropriate for adult and pediatric E E E E*
patients as approved by the director of emergency medicine in
collaboration with the trauma program director
Emergency department staffed so that trauma patients are E E E E E
assured of immediate and appropriate initial care
Communication with EMS vehicles E E E E E
SUPPLEMENTAL SERVICES
Pediatric trauma centers shall have Pediatric specialists in
all areas
Intensive Care Service, special permit licensing ICU services, E E E
Chapter 1, Division 5, of Title 22
Appropriate equipment and supplies determined by physician E E E
responsible for intensive care service and the trauma program
10
Exhibit D
CCEMSA TRAUMA CENTER STANDARDS Page 29 of 44
SUMMARY OF CALIFORNIA CODE OF REGULATIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
1 II PEDS III IV
E = essential E*= CCEMSA D = desirable
Level Peds** is requirements for Level II Pediatric TC
E# = essential for Level I Pediatric TC in addition to Level II
requirements
medical director
Qualified specialist, in-house, immediately available for trauma E D D
patients in ICU
ICU specialist promptly available E E
Qualified specialist may be a resident with 2 years of training, E E E
supervised by the staff intensivist or attending surgeon who
participates in all critical decision making
The qualified specialist shall be a member of the trauma team E E E
Registered Nurses with trauma education 24/7 E* E* E* E*
Burn Center
In house or through written transfer agreement with a Burn E E E E
Center
Physical Therapy Service
To include personnel trained in physical therapy and equipped E E E
for acute care of the critically inured patient
Rehabilitation Center
Services to include personnel trained in rehabilitation care and E E E E
equipped for acute care of the critically injured patients. May be
provided through a written transfer agreement with rehabilitation
center
Respiratory Care Service
Services to include personnel trained in respiratory therapy and E E E E*
equipped for acute care of the critically inured patient
Acute Hemodialysis Capability E E E
Occupational Therapy Service
To include personnel trained in occupational therapy and E E E
equipped for acute care of the critically injured patient
Speech Therapy Service
To include personnel trained in speech therapy and equipped for E E E
acute care of the critically injured patient
Social Service E E E D
Services or Programs (Special license or permit not
required)
Pediatric Service —Adult TC who provides in-house pediatric
11
Exhibit D
CCEMSA TRAUMA CENTER STANDARDS Page 30 of 44
SUMMARY OF CALIFORNIA CODE OF REGULATIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
1 II PEDS III IV
E = essential E*= CCEMSA D = desirable
Level Peds** is requirements for Level II Pediatric TC
E# = essential for Level I Pediatric TC in addition to Level II
requirements
services, in addition to Chapter 1, Division 5 of Title 22 shall E E
have the following:
Pediatric Intensive Care Unit (PICU), E E E
Shall be approved by California State Department of Health
Services' California Children Services CCS
Adult hospitals without a PICU shall establish written criteria for E E
consultation and transfer of pediatric patients needing ICU care
Have appropriate equipment/supplies approved by the pediatric E
intensive care specialist and pediatric trauma program medical
director
Pediatric intensive care specialist shall be promptly available for E
trauma patients in the PICU
Qualified specialist shall be a member of the trauma team E
Have a multidisciplinary team to manage child abuse and E E
neglect
Pharmacy
In house, 24 hour availability with pharmacist on call E* E* E* D
Shall be in-house within 30 minutes of call E*
Acute Spinal Cord Management Capability E E E
In-house or by transfer agreement
Organ Donor Protocol as described in Div. 7, Chapter 3.5, Cal. E E E E*
HS Code
Outreach Program, to include
Capability to provide both telephone and on-site consultations E E E E
with physicians in the community and outlying areas, and
Trauma prevention to the general public E E E E*
Public education and illness/injury prevention education E* E* E E*
Continuing Education
Continuing education in trauma care shall be provided for: E E E E E
Staff physicians
Staff nurses
Staff allied health personnel
EMS personnel
Community physicians and health care personnel E E E E E
Trauma physicians ( CME, 50% must be extramural) E* E* E* E* E*
General Trauma Surgeon, ATLS completion E* E* E* E*
12
Exhibit D
CCEMSA TRAUMA CENTER STANDARDS Page 31 of 44
SUMMARY OF CALIFORNIA CODE OF REGULATIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
1 II PEDS III IV
E = essential E*= CCEMSA D = desirable
Level Peds** is requirements for Level II Pediatric TC
E# = essential for Level I Pediatric TC in addition to Level II
requirements
Orthopedic Surgeons E* E* E* E*
Neurosurgeons E* E* E* E*
Emergency Medicine E* E* E* E* E*
Pediatric Trauma Centers — In addition to special permit
licensing services shall have:
Outreach and injury prevention programs specifically related to E
pediatric trauma and injury prevention;
A suspected child abuse and neglect team (SCAN) E
An aeromedical transport plan with designated landing site; and E
Child Life program E
Written Interfacility Transfer Agreements E E E
Transfer agreements with referring and specialty hospitals
Written transfer agreements with Level I or II trauma centers, E
Level I or 11 pediatric trauma centers or specialty care centers for
the immediate transfer of those patients whose medical care
need additional resources
Written transfer agreements with Level I, II, or III trauma centers, E
Level I or II pediatric trauma centers or specialty care centers for
the immediate transfer of those patients whose medical care
need additional resources
Trauma Quality Improvement Program
Trauma centers of all levels shall have a quality improvement E E E E E
process to include structure, process, and outcome evaluations,
identify root causes of problems,
intervene to reduce or eliminate root causes and take
appropriate steps to correct the process
Process shall include:
Detailed audit of all trauma-related deaths, major complications, E E E E E
and transfers (including interfacility transfers);
A multidisciplinary trauma peer review committee that includes E E E E E
all members of the trauma team; (CCEMSA* 50% attendance by
reps of Surg, Ortho, Neuro, EM, Anesthesia)
Participate in the trauma system data management system; E E E E E
Participate in the local EMS agency trauma evaluation E E E E E
committee;
13
Exhibit D
CCEMSA TRAUMA CENTER STANDARDS Page 32 of 44
SUMMARY OF CALIFORNIA CODE OF REGULATIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
1 II PEDS III IV
E = essential E*= CCEMSA D = desirable
Level Peds** is requirements for Level II Pediatric TC
E# = essential for Level I Pediatric TC in addition to Level II
requirements
Have a written system in place for patient, parents of minor E E E E E
children who are patients, legal guardian(s) of children who are
patients, and/or primary caretaker(s) of children who are patients
to provide input and feedback to hospital staff regarding the care
provided to the child;
Follow applicable provisions of Evidence Code Section 1157.7 E E E E E
to ensure confidentiality
Appropriately licensed helicopter landing site E* E* E* D
Interfacility Transfer of Trauma Patients
Patients may be transferred between and from trauma centers E E E E E
providing:
Any transfer shall as determined by the trauma center surgeon
of record, be medically prudent;
Be in accordance with local EMS agency interfacility transfer
policies.
Hospitals shall have written transfer agreements with trauma E E E E E
centers and develop written criteria for consultation and transfer
of patients needing a higher level of care.
Hospitals which have repatriated trauma patients from a E E E E E
designated trauma center shall provide the information required
by the system trauma registry, as specified by local EMS agency
policies.
Hospitals receiving trauma patients shall participate in system E E E E E
and trauma center quality improvement activities for those
trauma patients who have been transferred.
14
CENTRAL CALIFORNIA
EMERGENCY MEDICAL SERVICES
A Division of the Fresno County Department of Public Health
Exhibit D
Page 33 of 44
Manual Policy
Emergency Medical Services Number 334
Administrative Policies and Procedures
Page 1 of 3
Subject Trauma Registry Data Collection
References California Code of Regulations,Title 22. Social Security Effective
Division 9.Prehospital Emergency Medical Services
Chapter 7.Trauma Care Systems 12/15/2014
I. POLICY
The EMS Agency is responsible for monitoring the Central California EMS Region's Trauma System. Data
collection and management are critical components to monitoring the system,and essential to performance
improvement and patient safety programs. This policy defines the means of collection of data for Quality
Improvement of the Trauma System.
II. PROCEDURE
A. EMS AGENCY
1. The EMS Agency shall maintain a Trauma Registry and Trauma Information System. The data
submitted by the hospitals shall be utilized for trauma system monitoring,evaluation,and
research.Data will be used for periodic reports to the Regional Trauma Audit Committee.
2. The Trauma Registry will be utilized for quality improvement purposes and will be protected from
disclosure per the California Evidence Code, Section 1157.7. The data base is not subject to the
mandated patient authorization procedures of HIPPA.
3. Data from the Trauma Registry shall be integrated into the State EMS Authority data management
system as required.
B. TRAUMA CENTERS
1. Trauma Centers shall use the Trauma Registry Program approved by the EMS Agency.
2. Trauma Registry Data will be completed by all trauma centers for all patients who meet the
inclusion criteria for the trauma registry as outlined in Attachment A. Trauma Nurse Coordinators
/Managers or Trauma Registrars at the trauma centers will be responsible for completing the
documentation of registry patients.
3. Trauma registries should be concurrent. At a minimum, 80 percent of cases must be entered
within 60 days of discharge.
Approved By Revision
EMS Director
05/25/2023
EMS Medical Director
Exhibit D
Page 34 of 44
Page 2 of 3
Subject Trauma Registry Data Collection Policy
Number 334
4. The completed registry data will be forwarded to the EMS Agency electronically on a monthly
basis. If a trauma registry record is updated at the trauma center,the revised record will be
submitted to the EMS Agency.
C. NON-TRAUMA HOSPITALS
1. Non-trauma hospitals will complete a Non-Trauma Hospital Patient Registry Form (Attachment
B)on the following critical trauma patients who present at a non-trauma hospital:
a. Trauma patients meeting any of the trauma triage criteria/destination criteria to a
designated trauma center.
b. Trauma patients with a final disposition to a Trauma Center.
C. Trauma transfers from other facilities.
d. All traumatic arrests,trauma related deaths in the ED or after hospital admission.
2. Completed registry forms will be emailed to the EMS Agency within 60 days of patient discharge,
transfer or death.
3. The registry form is to be completed by designated personnel from the non-trauma hospital. The
names of designated personnel will be forwarded to the EMS Agency.
D. INSTRUCTIONS FOR COMPLETION OF THE NON-TRAUMA HOSPITAL PATIENT REGISTRY
FORM
1. Section 1 —Identification
a. EMS Number
b. Incident Location: Enter the original location of the incident
C. Hospital: Enter the name of the non-trauma hospital completing the form.
d. Patient: Enter the name of the patient.
e. Date of birth
f. Age: Enter the patient's age.
g. Sex: Check male or female.
2. Section 2—Emergency Department Admission Data
a. Date of Arrival: Enter month,date,year admitted to the ED.
b. Time of Arrival: Enter time of arrival to the ED.
C. Method of Arrival: Check applicable;if"Other",describe.
d. Mechanism of Injury: Check one;if"Other",describe.
Exhibit D
Page 35 of 44
Page 3 of 3
Subject Trauma Registry Data Collection Policy
Number 334
e. Vital Signs Upon Arrival: Enter initial GCS and vital signs taken in the ED.
f. Procedures: Check any applicable procedure and enter time;if"Other",describe.
i. Blood products:Enter time of first unit and the total number of units
given,if any products were given.
g. Injuries: Check applicable.
i. All trauma related hospital admits with at least one injury ICD-10
diagnosis code between S00-S99 with 7th character modifiers of A,B,
or C ONLY. (Injuries to specific body parts-initial encounter).
3. Section 3—Emergency Department Disposition
a. Admitted: Check if applicable,enter time,and specify hospital unit under comments.
b. OR:Check if applicable,enter time,and specify procedure(s)if known under comments.
C. OR Disposition:Check if applicable,enter time,and specify hospital unit under
comments.
d. Discharged: Check if applicable,and enter time.
e. Transfer to a Trauma Center ED: Check if applicable,enter time,and specify destination
under comments.
f. Interfacility Transfer(Patient transferred to inpatient unit): Check if applicable,enter
time,and specify destination under comments.
g. Ground Transport:Check if applicable,and enter time.
h. Air Transport: Check if applicable,and enter time.
i. Other: Check if applicable,enter time,and include explanation under comments.
4. Section 4-Comments:
a. Include anything pertinent,explanatory,or interesting information.
b. Include any transfer questions or problems.
Exhibit D
Page 36 of 44
ATTACHMENT A
TRAUMA REGISTRY—TRAUMA CENTER SELECTION CRITERA
Reference: Current Version of the National Trauma Data Bank(NTDB)Data Dictionary and the State of California
Data Dictionary.
1. All trauma related hospital admits with at least one injury ICD-10 diagnosis code between S00-S99 with
7th character modifiers of A,B,or C ONLY. (Injuries to specific body parts-initial encounter)
A. Fractures(all)
B. Dislocations(all)
C. Intracranial injuries(all—includes concussion)
D. Internal injuries of chest,abdomen,and pelvis
E. Open wounds
F. Injuries to blood vessels
G. Crushing injuries
H. Burns(burn registry)
1. Injuries to optic nerves
J. Spinal cord injuries
K. Certain traumatic complications
1. Air/fat embolism
2. Secondary and recurrent hemorrhage
3. Post traumatic wound infection
4. Traumatic shock
5. Subcutaneous emphysema
L. Excludes:
1. S00(Superficial injuries of the head)
2. S 10(Superficial injuries of the neck)
3. S20(Superficial injuries of the thorax)
4. S30(Superficial injuries of the abdomen,pelvis,lower back and external genitals)
5. S40(Superficial injuries of shoulder and upper arm)
6. S50(Superficial injuries of elbow and forearm)
7. S60(Superficial injuries of wrist,hand and fingers)
8. S70(Superficial injuries of hip and thigh)
9. S80(Superficial injuries of knee and lower leg)
10. S90(Superficial injuries of ankle,foot and toes)
2. All injury-related deaths in ED or after admission
3. All trauma transfers from other facilities
Exhibit D
Page 37 of 44
ATTACHMENT B
CENTRAL CALIFORNIA EMS AGENCY
NON-TRAUMA HOSPITAL PATIENT REGISTRY FORM
1. IDENTIFICATION Iniuries: (ICD-10 S00-S99)
EMS Number Fractures:
Skull O Neck/Spine O Limbs O
Incident Location
Hospital Dislocations O Intracranial Injury O Sprains/Strains O
Patient Open wounds O Burns O Foreign Body O
DOB Internal Injury to: Chest O Abdomen O Pelvis O
Age Male O Female O Injuries involving: Blood Vessels O Crushing O
2. EMERGENCY DEPARTMENT ADMISSION DATA Optic nerves O Spinal Cord O
Date of Arrival
3. EMERGENCY DEPARTMENT DISPOSTION
Time of Arrival Time Time
Method of Arrival: Admit O Transfer to Trauma Center ED O
Walk-in O BLS Ambulance O OR O Interfacility Transfer O
ALS Ambulance O Air Ambulance O OR Disposition: Ground Transport O
Other O If other,describe: Admit O Air Transport O
Mechanism of Iniury: Transfer O Other O
Motor Vehicle Crash O Motorcycle O Bicycle O Discharged Home O
Pedestrian o Assault O Stabbing o Gun Shot o
Please include comments concerning difficulties with the interfacility transfer
Ground Level Fall O Fall from Height O Sports O arrangements,procedures,patient care,etc.
Industrial o Farming o 4. COMMENTS
Other o If other,describe:
Vital SiEns Upon Arrival:
Eyes: Verbal: Motor:
GCS:
HR: RR: BP:
Submitted by:
Procedures:
Time Time
Within 30 days of patient discharge,transfer or death,email the
Intubation O Blood Products O completed form to Mato Parker at mkparkerng,fresnocountyca.gov
#of Units Given
CT Scan o Chest Tube O
Other 0 If other,describe:
CENTRAL CALIFORNIA
EMERGENCY MEDICAL SERVICES Exhibit D
A Division of the Fresno County Department of Public Health Page 38 of 44
Manual: Policy
Emergency Medical Services Number: 703
Administrative Policies and Procedures
Page: 1 of 7
Subject: Continuous Quality Improvement
References: Division 2.5 of the California Health and Safety Code Effective:
Title 22,Division 9 of the California Code of Regulations
Section 1157.7 of Evidence Code 08/07/00
I. POLICY
This policy describes the roles and responsibilities of all Central California EMS System participants in the
provision of Continuous Quality Improvement(CQI).All EMS provider agencies shall meet the requirements of this
policy.
II. PURPOSE
"Continuous Quality Improvement"or"CQI"means methods of evaluation that are composed of structure,process,and
outcome evaluations which focus on improvement efforts to identify root causes of problems, intervene to reduce or
eliminate these causes,and take steps to correct the process.
III. PROCEDURE
The EMS Agency is responsible for the oversight and supervision of the entire CQI process and communicating with all
involved participants.
A. EMS Agency CQI Medical Director/Coordinator responsibilities include:
1. Implement, monitor and evaluate the CQI System, including CQI requirements as described in
Appendix B.
2. Provide oversight of the CQI Committee.
3. Provide regular CQI reports to Medical Control Committee, Base Hospital Committee, EMSOC,
CQI Committee and EMS Staff meetings.
4. Review individual QI Reports and take necessary action.
5. Provide an access point for Intetnal/Extemal Customers as identified in Section III.F.
6. Create an Investigative Review Panel (IRP), as needed, to provide a grievance process for EMS
personnel in accordance with State guidelines and requirements(Refer to Section III.G.).
7. Monitor quality indicators via database analysis as identified in Appendix A.
Approved By: Daniel J.Lynch Revision:
EMS Division Manager (Signature on File at EMS Agency)
Jim Andrews,M.D. 5/25/2023
EMS Medical Director (Signature on File at EMS Agency)
Exhibit D
Page 39 of 44 Page 2 of 7
Subject: Continuous Quality Improvement Policy
Number: 703
8. Review and participate in research generated by the CQI process.
9. Forward CQI Committee recommendations to EMS Training Division.
10. Manage EMS database to assure quality and completeness of databases.
B. CQI Committee responsibilities include:
NOTE: All proceedings are confidential and protected under Section 1157.7 of Evidence Code: "The
prohibition relating to discovery or testimony provided in Section 1157 shall be applicable to proceedings
and records of any committee established by a local governmental agency to monitor, evaluate, and report
on the necessity, quality, and level of specialty health services including, but not limited to trauma care
services, provided by a general acute care hospital which has been designated or organized by that
governmental agency as qualified to render specialty health care services."
1. Review/Monitor Data from EMS System(III.C).
2. Select quality indicators, items for review and monitoring, create action plans, and monitor
performance (i.e.,time,patient satisfaction, workforce satisfaction,protocol compliance, outcome
data). (See Appendix A.)
3. After review by EMS Agency, serve as a forum to discuss issues/concerns brought to the attention of
the EMS Agency by internal and external customers(III.F.).
4. Propose,review,and participate in EMS research.
5. Promote CQI training throughout the EMS System.
6. Policy/Protocol Review—Selected policies reviewed with prenotification sent out to allow participant
feedback. Initial review by CQI Coordinator/Medical Director and proposed revisions discussed at
CQI Committee.
7. Provide recommendations to Training Division,including:
a. Orientation
Paramedic eight-hour introduction to Central California EMS policies,procedures and local
scope of practice.
b. Primary Training
1) Local EMS Paramedic Training Course
2) Local EMT Courses(Fire Department/Schools/Provider Agencies)
3) AED(AED Provider Agencies)
4) Emergency Medical Dispatcher Training
5) Mobile Intensive Care Nursing Training
6) Base Hospital Physician Course
Exhibit D
Page 40 of 44Pa e 3 of 7
Subject: Continuous Quality Improvement Policy
Number: 703
C. Continuing Education
1) Case Review/Tape Review
2) Provider Agency C.E.
3) EMS C.E.—Topics Based on CQI identified deficiencies.
8. CQI Committee Members
a. CQI Medical Director
b. CQI Coordinator
C. Base Hospital Physician(chosen by Medical Control Committee)
d. PLN—(chosen by Base Hospital Committee)
e. PLO—(Three—preferably one from each County)
f. EMS Dispatcher
g. Fire First Responder(chosen by Fire Chiefs Association)
9. CQI Committee Ex-Officio Members
a. EMS Medical Director
b. EMS Division Manager
10. CQI Committee Guests
CQI Medical Director or CQI Coordinator may approve the attendance of guests.
C. Data/System Review
Various databases currently exist which contain data relevant to Continuous Quality Improvement(CQI)in
EMS(see list below). These databases must be searched to:
1. Prospectively identify areas of potential improvement.
2. Answer questions about the EMS System.
3. Monitor changes once improvement plans are implemented.
4. Provide accurate information enabling data driven decisions.
5. Monitor individual performance within the EMS System.
6. Support research that will improve our system and potentially broaden EMS knowledge through
publication.
7. The involved databases include:
a. Dispatch Database
b. First Responder Database
C. PCR Databases
d. Hospital Databases
e. QI Database
f. Trauma Registry
g. County Coroner's Reports
Exhibit D
Page 41 of 44 Page 4 of 7
Subject: Continuous Quality Improvement Policy
Number: 703
D. Individual Quality Improvement Reports
Individual quality improvement reports are generated by anyone in the EMS System and are reviewed at
the Base Hospital Physician level as well as by the EMS Agency.
E. EMS Research
Any parties interested in EMS research may participate. Leadership is expected from EMS Medical
Directors and Senior EMS Specialists with EMS Division Manager and Medical Control Committee
approval.
F. Internal/External Customers
Various entities interact with the EMS System. In order to allow input from these sources,the CQI process
may be accessed via the EMS Agency who will determine if the issue raised will be put on the CQI
Committee Agenda.
1. Internal Customers
Paramedics/EMT-Is/First Responders
MICNs/Flight Nurses
Dispatch Personnel
EMS Students
Ambulance Providers
EMS Committees
Hospitals
State/Regional EMS Personnel
UCSF Residency Personnel
Base Hospital Physicians
2. External Customers
Patients
Patients'Families
Community/Public
Third Party Payors(Insurance Companies,HMOs)
Government Agencies(Public Health Department,Police,etc.)
Nursing Homes
Private Physicians
G. Investigative Review Panel
1. Created on an as needed basis as outlined in Title 22,Division 9.
2. Purpose -An impartial advisory body,the members of which are knowledgeable in the provision
of prehospital emergency medical care and local EMS System policies and procedures,which may
be convened to review allegations against the holder of an EMS prehospital emergency medical
care certificate, assist in establishing facts of the matter, and provide its findings to the EMS
Medical Director.
Exhibit D
Page 42 of 44 Page 5 of 7
Subject: Continuous Quality Improvement Policy
Number: 703
APPENDIX A
Quality Indicators
The following quality indicators are monitored on a routine and continuous basis and reported to the appropriate EMS
committees:
Initial System Review Items: Other Review Items:
1. Trauma Scene Times(<10 minutes) 1. AMA/RAS/RMCT Ratios(at each Base Hospital)
2. Medical Scene Times(<20 minutes) 2. Codes(compliance with times in protocol)
3. Cardiac Arrest Survival Rates 3. Nature of Incident Frequency on QA Reports
4. Trauma Survival Rates 4. Pediatric Survival Rates
5. Percentage of Unrecognized Esophageal Intubation 5. Prehospital Violence
6. 90%Successful IV after Three Attempts
7. 95%Successful ET Placement after Three Attempts
Data to Determine Performance Excellence:
1. Are EMS services timely?
2. Do providers adhere to prescribed protocols?
3. What is the level of patient/stakeholder satisfaction?
4. How does performance compare with similar systems?
5. Are data and information used in planning and operation?
6. Do all workforce members understand and use available data?
7. Have CQI efforts been successful at improving performance?
8. Are changes in one critical performance indicator affecting other areas?
9. Are QI resolutions communicated to all involved parties?
Exhibit D
Page 43 of 44Page 6 of 7
Subject: Continuous Quality Improvement Policy
Number: 703
APPENDIX B
CQI Skills Retainment Requirements
PARAMEDIC
A. Patient Contact Requirement
The Central California EMS Agency maintains a standard of care that provides a high quality,consistent,and dependable
skill level and knowledge base for its Emergency Medical Services personnel.To assure that Paramedics maintain
adequate patient assessment and other ALS skills,the EMS Agency acknowledges the importance of minimum patient
contacts to assure the proficiency of skills,problem recognition,and knowledge.
Each Paramedic accredited in the Central California EMS System shall document an average of at least 20 patient contacts
per month(240 per year)while working on an approved Central California County ALS unit. A written statement from
the employer shall be submitted to the Central California EMS Agency by March 20th of each year.
A patient contact is defined as a patient who is completely assessed by an on-duty Paramedic during the course of an EMS
response and a prehospital care report is completed as a result of the patient assessment. The EMS Agency shall audit
records to verify compliance on a random basis.
In the event that a Paramedic does not achieve the 240 patient contacts(or prorated amount authorized by the Central
California EMS Agency)in the twelve-month period,the individual shall complete five(5)ALS field evaluations within a
sixty(60)day period beginning March 21 st. An EMS Training Officer approved by the Central California EMS Agency
must continuously supervise this field evaluation. An ALS response includes a patient contact involving the use of one or
more ALS skills excluding cardiac monitoring and basic CPR. The EMS Agency,in the event of an unsatisfactory
evaluation,may prescribe additional education or evaluation.
B. Paramedic Field Evaluation Requirement
Document satisfactory field evaluations performed by an approved Central California EMS Training Officer. Paramedics
that have been certified/accredited less than two(2)years within the Central California EMS Region must be evaluated by
a designated EMS Training Officer,each six(6)months(Deadline-September 20th and March 20th).Paramedics that have
been certified/accredited greater than two(2)years within the Central California EMS Region will not be required to do a
field evaluation.
A field evaluation will consist of an EMS Training Officer observing a Paramedic conducting three(3)patient
assessments. The EMS Training Officer will evaluate the Paramedic based upon criteria utilized for field internships as
developed by the Central California EMS Agency. An evaluation is documented utilizing a field evaluation form(as
utilized for field internships)and shall be submitted to the Central California EMS Agency within fifteen days of the
completion of the field evaluation.
The agency's liaison officer and the EMS Agency will review unsatisfactory evaluations with the Paramedic. Possible
actions by the Central California EMS Agency in the case of an unsatisfactory evaluation include reevaluation,additional
training,or initiation of the formal investigation.
C. ACLS Requirement
Within two(2)years of initial accreditation,the Paramedic shall demonstrate proof of current certification and continued
certification as an Advanced Cardiac Life Support(ACLS)provider according to the standards of the American Heart
Association. Fulfillment of this requirement may be utilized for completing a portion of the on-going continuing
education requirements.
Exhibit D
Page 44 of 44 Page 7 of 7
Subject: Continuous Quality Improvement Policy
Number: 703
D. BTLS/PHTLS Requirement
Within two(2)years of initial accreditation,the Paramedic shall demonstrate proof of satisfactory completion of a Basic
Trauma Life Support(BTLS)course according to the standards of the American College of Emergency Physicians,or
Prehospital Trauma Life Support(PHTLS). Fulfillment of this requirement may be utilized for completing a portion of the
on-going continuing education requirements. Refresher training in these courses may be assigned to individuals by the
EMS Medical Director for remedial education as a condition of accreditation.
Exhibit E
Confidentiality and Data Security
1. Definitions
Capitalized terms used in this Exhibit E have the meanings set forth in this section 1.
a. "Authorized Employees" means the Contractor's employees who have access to
Personal Information or Privileged Information.
b. "Authorized Persons" means: (i) any and all Authorized Employees; and (ii) any and all
of the Contractor's subcontractors, representatives, agents, outsourcers, and
consultants, and providers of professional services to the Contractor, who have access
to Personal Information and are bound by law or in writing by confidentiality obligations
sufficient to protect Personal Information in accordance with the terms of this Exhibit E.
c. "Director" means the County's Director Internal Services/Chief Information officer or
their designee.
d. "Disclose" or any derivative of that word means to disclose, release, transfer,
disseminate, or otherwise provide access to or communicate all or any part of any
Personal Information orally, in writing, or by electronic or any other means to any person.
e. "Person" means any natural person, corporation, partnership, limited liability company,
firm, or association.
f. "Personal Information" means any and all information, including any data, provided, or
to which access is provided, to the Contractor by or upon the authorization of the
County, under this Agreement, including but not limited to vital records, that: (i) identifies,
describes, or relates to, or is associated with, or is capable of being used to identify,
describe, or relate to, or associate with, a person (including, without limitation, names,
physical descriptions, signatures, addresses, telephone numbers, e-mail addresses,
education, financial matters, employment history, and other unique identifiers, as well as
statements made by or attributable to the person); (ii) is used or is capable of being used
to authenticate a person (including, without limitation, employee identification numbers,
government-issued identification numbers, passwords or personal identification numbers
(PINs), financial account numbers, credit report information, answers to security
questions, and other personal identifiers); or (iii) is personal information within the
meaning of California Civil Code section 1798.3, subdivision (a), or 1798.80, subdivision
(e). Personal Information does not include publicly available information that is lawfully
made available to the general public from federal, state, or local government records.
g. "Privacy Practices Complaint" means a complaint received by the County relating to
the Contractor's (or any Authorized Person's) privacy practices, or alleging a Security
Breach. Such complaint shall have sufficient detail to enable the Contractor to promptly
investigate and take remedial action under this Exhibit E.
h. "Privileged Information" means any and all information, including any data, provided,
or to which access is provided, to the Contractor by or upon the authorization of the
County or any attorney of the County, under this agreement, including but not limited to
any or all of the following: (i) records pertaining to pending litigation to which the County
is party, or to claims made pursuant to the Government Claims Act (Gov. Code, Tit. 1,
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Exhibit E
Div. 3.6, beginning with section 810), until the pending litigation or claim has been finally
adjudicated or otherwise settled, which are exempt from disclosure under Government
Code section 6254, subdivision (b); (ii) any information that is subject to the attorney-
client privilege, which includes but is not limited to a "confidential communication
between client and lawyer," as that term is defined in Evidence Code section 952, where
the County is the client and any attorney of the County is the lawyer, and the Contractor
may be serving as a representative of the County, as an intermediate representative for
communication between the County and any attorney of the County, or both; or (iii) both
(i) and (ii).
For purposes of a "confidential communication between client and lawyer" under this
Agreement, the Contractor is presumed to be present to further the interest of the
County in its consultation with an attorney of the County, reasonably necessary for the
transmission of the information or the accomplishment of the purpose for which the
attorney of the County is consulted, or both.
The Contractor acknowledges that the attorney-client privilege protecting Privileged
Information belongs to the County and may only be waived by the County's Board of
Supervisors, and may not be waived by any other County official. The Contractor has no
right or authority to waive the attorney-client privilege that belongs to the County.
i. "Security Safeguards" means physical, technical, administrative or organizational
security procedures and practices put in place by the Contractor (or any Authorized
Persons) that relate to the protection of the security, confidentiality, value, or integrity of
Personal Information. Security Safeguards shall satisfy the minimal requirements set
forth in section 3(C) of this Exhibit E.
j. "Security Breach" means (i) any act or omission that compromises either the security,
confidentiality, value, or integrity of any Personal Information or the Security Safeguards,
or(ii) any unauthorized Use, Disclosure, or modification of, or any loss or destruction of,
or any corruption of or damage to, any Personal Information.
k. "Use" or any derivative of that word means to receive, acquire, collect, apply,
manipulate, employ, process, transmit, disseminate, access, store, disclose, or dispose
of Personal Information.
2. Standard of Care
a. The Contractor acknowledges that, in the course of its engagement by the County under
this Agreement, the Contractor, or any Authorized Persons, may Use Personal
Information and Privileged Information only as permitted in this Agreement.
b. The Contractor acknowledges that Personal Information and Privileged Information is
deemed to be confidential information of, or owned by, the County (or persons from
whom the County receives or has received Personal Information) and is not confidential
information of, or owned or by, the Contractor, or any Authorized Persons. The
Contractor further acknowledges that all right, title, and interest in or to the Personal
Information or the Privileged Information remains in the County (or persons from whom
the County receives or has received Personal Information or Privileged Information)
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Exhibit E
regardless of the Contractor's, or any Authorized Person's, Use of that Personal
Information or that Privileged Information.
c. The Contractor agrees and covenants in favor of the Country that the Contractor shall:
i. keep and maintain all Personal Information and all Privileged Information in strict
confidence, using such degree of care under this section 2 as is reasonable and
appropriate to avoid a Security Breach;
ii. Use Personal Information exclusively for the purposes for which the Personal
Information is made accessible to the Contractor pursuant to the terms of this
Exhibit E;
iii. Use Privileged Information exclusively for the purposes for which the Privileged
Information is made accessible to the Contractor pursuant to the terms of this
Exhibit E;
iv. not Use, Disclose, sell, rent, license, or otherwise make available Personal
Information or Privileged Information for the Contractor's own purposes or for the
benefit of anyone other than the County, without the County's express prior
written consent, which the County may give or withhold in its sole and absolute
discretion;
V. not, directly or indirectly, Disclose Personal Information to any person (an
"Unauthorized Third Party") other than Authorized Persons pursuant to this
Agreement, without the express prior written consent the Director; and
vi. not, directly or indirectly, Disclose Privileged Information to any person (an
"Unauthorized Third Party") other than Authorized Persons pursuant to this
Agreement, without the express prior written consent of the County's Board of
Supervisors.
d. Notwithstanding the foregoing paragraph, in any case in which the Contractor believes it,
or any Authorized Person, is required to disclose Personal Information or Privileged
Information to government regulatory authorities, or pursuant to a legal proceeding, or
otherwise as may be required by applicable law, Contractor shall (i) immediately notify
the County of the specific demand for, and legal authority for the disclosure, including
providing County with a copy of any notice, discovery demand, subpoena, or order, as
applicable, received by the Contractor, or any Authorized Person, from any government
regulatory authorities, or in relation to any legal proceeding, and (ii) promptly notify the
County before such Personal Information is offered by the Contractor for such disclosure
so that the County may have sufficient time to obtain a court order or take any other
action the County may deem necessary to protect the Personal Information or the
Privileged Information from such disclosure, and the Contractor shall cooperate with the
County to minimize the scope of such disclosure of such Personal Information or
Privileged Information.
e. The Contractor shall remain liable to the County for the actions and omissions of any
Unauthorized Third Party concerning its Use of such Personal Information or Privileged
Information as if they were the Contractor's own actions and omissions.
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Exhibit E
3. Information Security
a. The Contractor covenants, represents and warrants to the County that the Contractor's
Use of Personal Information and Privileged Information under this Agreement does and
will at all times comply with all applicable federal, state, and local, privacy and data
protection laws, as well as all other applicable regulations and directives, including but
not limited to California Civil Code, Division 3, Part 4, Title 1.81 (beginning with section
1798.80), and the Song-Beverly Credit Card Act of 1971 (California Civil Code, Division
3, Part 4, Title 1.3, beginning with section 1747). If the Contractor Uses credit, debit or
other payment cardholder information, the Contractor shall at all times remain in
compliance with the Payment Card Industry Data Security Standard ("PCI DSS")
requirements, including remaining aware at all times of changes to the PCI DSS and
promptly implementing and maintaining all procedures and practices as may be
necessary to remain in compliance with the PCI DSS, in each case, at the Contractor's
sole cost and expense.
b. The Contractor covenants, represents and warrants to the County that, as of the
effective date of this Agreement, the Contractor has not received notice of any violation
of any privacy or data protection laws, as well as any other applicable regulations or
directives, and is not the subject of any pending legal action or investigation by, any
government regulatory authority regarding same.
c. Without limiting the Contractor's obligations under section 3(A) of this Exhibit E, the
Contractor's (or Authorized Person's) Security Safeguards shall be no less rigorous than
accepted industry practices and, at a minimum, include the following:
i. limiting Use of Personal Information and Privileged Information strictly to the
Contractor's and Authorized Persons' personnel, including technical and
administrative personnel, who are necessary for the Contractor's or Authorized
Persons' Use of the Personal Information or Privileged pursuant to this
Agreement;
ii. ensuring that all of the Contractor's connectivity to County computing systems
will only be through the County's security gateways and firewalls, and only
through security procedures approved upon the express prior written consent of
the Director;
iii. to the extent that they contain or provide access to Personal Information or
Privileged Information, (a) securing business facilities, data centers, paper files,
servers, back-up systems and computing equipment, operating systems, and
software applications, including, but not limited to, all mobile devices and other
equipment, operating systems, and software applications with information
storage capability; (b) employing adequate controls and data security measures,
both internally and externally, to protect (1) the Personal Information and the
Privileged Information from potential loss or misappropriation, or unauthorized
Use, and (2) the County's operations from disruption and abuse; (c) having and
maintaining network, device application, database and platform security; (d)
maintaining authentication and access controls within media, computing
equipment, operating systems, and software applications; and (e) installing and
maintaining in all mobile, wireless, or handheld devices a secure internet
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Exhibit E
connection, having continuously updated anti-virus software protection and a
remote wipe feature always enabled, all of which is subject to express prior
written consent of the Director;
iv. encrypting all Personal Information at advance encryption standards of Advanced
Encryption Standards (AES) of 128 bit or higher when Personal Information is (a)
stored on any mobile devices, including but not limited to hard disks, portable
storage devices, or remote installation, or (b) transmitted over public or wireless
networks (the encrypted Personal Information must be subject to password or
pass phrase, and be stored on a secure server and transferred by means of a
Virtual Private Network (VPN) connection, or another type of secure connection,
all of which is subject to express prior written consent of the Director);
V. strictly segregating Personal Information and Privileged Information from all other
information of the Contractor, including any Authorized Person, or anyone with
whom the Contractor or any Authorized Person deals so that Personal
Information and Privileged Information is not commingled with any other types of
information;
vi. having a patch management process including installation of all operating system
and software vendor security patches;
vii. maintaining appropriate personnel security and integrity procedures and
practices, including, but not limited to, conducting background checks of
Authorized Employees consistent with applicable law; and
viii. providing appropriate privacy and information security training to Authorized
Employees.
d. During the term of each Authorized Employee's employment by the Contractor, the
Contractor shall cause such Authorized Employees to abide strictly by the Contractor's
obligations under this Exhibit E. The Contractor shall maintain a disciplinary process to
address any unauthorized Use of Personal Information or Privileged Information by any
Authorized Employee.
e. The Contractor shall, in a secure manner, backup daily, or more frequently if it is the
Contractor's practice to do so more frequently, Personal Information and Privileged
Information received from the County, and the County shall have immediate, real time
access, at all times, to such backups via a secure, remote access connection provided
by the Contractor, through the Internet.
f. The Contractor shall provide the County with the name and contact information for each
Authorized Employee (including such Authorized Employee's work shift, and at least one
alternate Authorized Employee for each Authorized Employee during such work shift)
who shall serve as the County's primary security contact with the Contractor and shall be
available to assist the County twenty-four (24) hours per day, seven (7) days per week
as a contact in resolving the Contractor's and any Authorized Persons' obligations
associated with a Security Breach or a Privacy Practices Complaint.
g. The Contractor shall not knowingly include or authorize any Trojan Horse, back door,
time bomb, drop dead device, worm, virus, or other code of any kind that may disable,
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Exhibit E
erase, display any unauthorized message within, or otherwise impair any County
computing system, with or without the intent to cause harm.
4. Security Breach Procedures
a. Immediately upon the Contractor's awareness or reasonable belief of a Security Breach,
the Contractor shall (i) notify the Director of the Security Breach, such notice to be given
first by telephone at the following telephone number, followed promptly by email at the
following email address: (559) 600-5900 / incidents@fresnocountyca.gov (which
telephone number and email address the County may update by providing notice to the
Contractor), and (ii) preserve all relevant evidence (and cause any affected Authorized
Person to preserve all relevant evidence) relating to the Security Breach. The notification
shall include, to the extent reasonably possible, the identification of each type and the
extent of Personal Information, Privileged Information, or both, that has been, or is
reasonably believed to have been, breached, including but not limited to, compromised,
or subjected to unauthorized Use, Disclosure, or modification, or any loss or destruction,
corruption, or damage.
b. Immediately following the Contractor's notification to the County of a Security Breach, as
provided pursuant to section 4(A) of this Exhibit E, the Parties shall coordinate with each
other to investigate the Security Breach. The Contractor agrees to fully cooperate with
the County, including, without limitation:
i. assisting the County in conducting any investigation;
ii. providing the County with physical access to the facilities and operations
affected;
iii. facilitating interviews with Authorized Persons and any of the Contractor's other
employees knowledgeable of the matter; and
iv. making available all relevant records, logs, files, data reporting and other
materials required to comply with applicable law, regulation, industry standards,
or as otherwise reasonably required by the County.
To that end, the Contractor shall, with respect to a Security Breach, be solely
responsible, at its cost, for all notifications required by law and regulation, or deemed
reasonably necessary by the County, and the Contractor shall provide a written report of
the investigation and reporting required to the Director within 30 days after the
Contractor's discovery of the Security Breach.
c. County shall promptly notify the Contractor of the Director's knowledge, or reasonable
belief, of any Privacy Practices Complaint, and upon the Contractor's receipt of that
notification, the Contractor shall promptly address such Privacy Practices Complaint,
including taking any corrective action under this Exhibit E, all at the Contractor's sole
expense, in accordance with applicable privacy rights, laws, regulations and standards.
In the event the Contractor discovers a Security Breach, the Contractor shall treat the
Privacy Practices Complaint as a Security Breach. Within 24 hours of the Contractor's
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Exhibit E
receipt of notification of such Privacy Practices Complaint, the Contractor shall notify the
County whether the matter is a Security Breach, or otherwise has been corrected and
the manner of correction, or determined not to require corrective action and the reason
for that determination.
d. The Contractor shall take prompt corrective action to respond to and remedy any
Security Breach and take mitigating actions, including but not limiting to, preventing any
reoccurrence of the Security Breach and correcting any deficiency in Security
Safeguards as a result of such incident, all at the Contractor's sole expense, in
accordance with applicable privacy rights, laws, regulations and standards. The
Contractor shall reimburse the County for all reasonable costs incurred by the County in
responding to, and mitigating damages caused by, any Security Breach, including all
costs of the County incurred relation to any litigation or other action described section
4(E) of this Exhibit E.
e. The Contractor agrees to cooperate, at its sole expense, with the County in any litigation
or other action to protect the County's rights relating to Personal Information, Privileged
Information, or both, including the rights of persons from whom the County receives
Personal Information.
5. Oversight of Security Compliance
a. The Contractor shall have and maintain a written information security policy that
specifies Security Safeguards appropriate to the size and complexity of the Contractor's
operations and the nature and scope of its activities.
b. Upon the County's written request, to confirm the Contractor's compliance with this
Exhibit E, as well as any applicable laws, regulations and industry standards, the
Contractor grants the County or, upon the County's election, a third party on the
County's behalf, permission to perform an assessment, audit, examination or review of
all controls in the Contractor's physical and technical environment in relation to all
Personal Information and Privileged Information that is Used by the Contractor pursuant
to this Agreement. The Contractor shall fully cooperate with such assessment, audit or
examination, as applicable, by providing the County or the third party on the County's
behalf, access to all Authorized Employees and other knowledgeable personnel,
physical premises, documentation, infrastructure and application software that is Used
by the Contractor for Personal Information, Privileged Information, or both, pursuant to
this Agreement. In addition, the Contractor shall provide the County with the results of
any audit by or on behalf of the Contractor that assesses the effectiveness of the
Contractor's information security program as relevant to the security and confidentiality
of Personal Information Used by the Contractor or Authorized Persons during the course
of this Agreement under this Exhibit E.
c. The Contractor shall ensure that all Authorized Persons who Use Personal Information,
Privileged Information, or both, agree to the same restrictions and conditions in this
Exhibit E. that apply to the Contractor with respect to such Personal Information and
Privileged Information by incorporating the relevant provisions of this Exhibit E into a
valid and binding written agreement between the Contractor and such Authorized
Persons, or amending any written agreements to provide same.
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Exhibit E
6. Return or Destruction of Personal Information. Upon the termination of this
Agreement, the Contractor shall, and shall instruct all Authorized Persons to, promptly return to
the County all Personal Information and all Privileged Information, whether in written, electronic
or other form or media, in its possession or the possession of such Authorized Persons, in a
machine readable form used by the County at the time of such return, or upon the express prior
written consent of the Director, securely destroy all such Personal Information and all Privileged
Information, and certify in writing to the County that such Personal Information and Privileged
Information have been returned to the County or disposed of securely, as applicable. If the
Contractor is authorized to dispose of any such Personal Information or Privileged Information,
as provided in this Exhibit E, such certification shall state the date, time, and manner (including
standard) of disposal and by whom, specifying the title of the individual. The Contractor shall
comply with all reasonable directions provided by the Director with respect to the return or
disposal of Personal Information and Privileged Information and copies of Personal Information
and Privileged Information. If return or disposal of such Personal Information or Privileged
Information, or copies of Personal Information or Privileged Information, is not feasible, the
Contractor shall notify the County according, specifying the reason, and continue to extend the
protections of this Exhibit E to all such Personal Information and Privileged Information, and
copies of Personal Information and Privileged Information. The Contractor shall not retain any
copy of any Personal Information or any Privileged Information after returning or disposing of
Personal Information and Privileged Information as required by this section 6. The Contractor's
obligations under this section 6 survive the termination of this Agreement and apply to all
Personal Information and Privileged Information that the Contractor retains if return or disposal
is not feasible and to all Personal Information and Privileged Information that the Contractor
may later discover in its possession or control.
7. Equitable Relief. The Contractor acknowledges that any breach of its covenants or
obligations set forth in this Exhibit E may cause the County irreparable harm for which monetary
damages would not be adequate compensation and agrees that, in the event of such breach or
threatened breach, the County is entitled to seek equitable relief, including a restraining order,
injunctive relief, specific performance and any other relief that may be available from any court,
in addition to any other remedy to which the County may be entitled at law or in equity. Such
remedies shall not be deemed to be exclusive but shall be in addition to all other remedies
available to the County at law or in equity or under this Agreement.
8. Indemnity. The Contractor shall defend, indemnify and hold harmless the County, its
officers, employees, and agents, (each, a "County Indemnitee")from and against any and all
infringement of intellectual property including, but not limited to infringement of copyright,
trademark, and trade dress, invasion of privacy, information theft, and extortion, unauthorized
Use, Disclosure, or modification of, or any loss or destruction of, or any corruption of or damage
to, Personal Information or Privileged Information, Security Breach response and remedy costs,
credit monitoring expenses, forfeitures, losses, damages, liabilities, deficiencies, actions,
judgments, interest, awards, fines and penalties (including regulatory fines and penalties), costs
or expenses of whatever kind, including attorneys' fees and costs, the cost of enforcing any right
to indemnification or defense under this Exhibit E and the cost of pursuing any insurance
providers, arising out of or resulting from any third party claim or action against any County
Indemnitee in relation to the Contractor's, its officers, employees, or agents, or any Authorized
Employee's or Authorized Person's, performance or failure to perform under this Exhibit E or
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Exhibit E
arising out of or resulting from the Contractor's failure to comply with any of its obligations under
this section 8. The provisions of this section 8 do not apply to the sole acts or omissions of the
County. The provisions of this section 8 are cumulative to any other obligation of the Contractor
to, defend, indemnify, or hold harmless any County Indemnitee under this Agreement. The
provisions of this section 8 shall survive the termination of this Agreement.
9. Survival. The respective rights and obligations of the Contractor and the County as
stated in this Exhibit E shall survive the termination of this Agreement.
10. No Third Party Beneficiary. Nothing express or implied in the provisions of in this
Exhibit E is intended to confer, nor shall anything in this Exhibit E confer, upon any person other
than the County or the Contractor and their respective successors or assignees, any rights,
remedies, obligations or liabilities whatsoever.
11. No County Warranty. The County does not make any warranty or representation
whether any Personal Information or Privileged Information in the Contractor's (or any
Authorized Person's) possession or control, or Use by the Contractor (or any Authorized
Person), pursuant to the terms of this Agreement is or will be secure from unauthorized Use, or
a Security Breach or Privacy Practices Complaint.
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