Press Release: District’s 911 System: Reforms Needed to Assure Public Safety
News Release — Office of the DC Auditor
For immediate release
Contact: Diane Shinn
OUC staff requires more supervision, improved call handling, and efficient location identification; recent improvements should continue with enhanced support
October 19, 2021 (WASHINGTON) The D.C. Office of United Communications 911 Operations Division (OUC) has seen inconsistent handling of calls, difficulties with determining the location of emergencies, and does not meet national standards in getting timely help to callers, according to a new report issued by the Office of the D.C. Auditor (ODCA).
The report by public safety communications consulting firm Federal Engineering, Inc. (FE) on contract with ODCA assesses the effectiveness of OUC against national standards including a review of 2019 and 2020 call metrics, a sample of 911 call recordings, an evaluation of OUC culture and training, and a review of OUC’s technological capabilities and internal investigations.
ODCA launched the review after news stories and Advisory Neighborhood Commission complaints detailed OUC failures to handle calls timely and send first responders to the correct locations. The review was also designed to respond to a National Transportation Safety Board call for the OUC to audit its call processing times following the fatal 2015 Metro smoke incident. The audit is a comprehensive evaluation of the OUC
911 Operations Division effectiveness by subject matter experts with decades of experience with police, fire, and public safety call center operations.
“We believe the recommendations, once implemented, will successfully address the issues documented by Federal Engineering,” said D.C. Auditor Kathy Patterson. “While identifying a series of shortcomings, our experts also found that significant reforms are underway at the agency today and that current OUC leadership has pledged to implement most if not all of the report’s recommendations.”
In a written response published with the audit Interim OUC Director Cleo Subido wrote, “improving the accuracy of address locations and quality dispatch are continued areas of focus,” and “we are in the process of developing and rolling out a comprehensive supervisors’ initiative.”
From the thousands of calls received in the audit scope, FE reviewed a sample of recordings and data from 72 calls provided by the Office of the Chief Technology Officer. The appropriate number of units were dispatched in 97% of the calls, and the location validation was performed in 89% of the calls. OCTO also provided the consultants with monthly call counts to compare two metrics – “time to answer” and “answer to notification” for all top priority Fire and Emergency Medical Services calls and found that OUC did not meet national standards for either metric for the majority of the 24 months in 2019 and 2020.
The key underlying performance issues identified by FE include:
A lack of adequate oversight of call-taking and dispatch operations.
FE found OUC policies and procedures are consistent with industry best practices but are not consistently adhered to due to insufficient supervision and a lack of quality assurance follow-up to ensure uniform compliance.
FE also found failure to follow policy is a direct result of minimal operations floor supervision and recommends increasing the total number of OUC shift supervisors from 11 to 38. The report notes that staff autonomy due to lack of supervision “creates independence and stronger skillsets in some, while creating stress, inconsistencies, and habitual errors, in others.”
This lack of consistent and present oversight also has created a culture in which cliques, bullying, and uncorrected inappropriate behaviors exist. Anecdotal information from operations staff indicates that the supervisory staff may participate in and facilitate these behaviors.
- The average time for OUC to answer a 911 call is 5.2 seconds.
- The average talk time for a 911 call is 111.2 seconds.
- The average time to process a 911 call from call answer to queue ready for dispatch:
- Police – 1 minute, 40 seconds
- EMS – 1 minute, 23 seconds
- Fire – 1 minute, 15 seconds
- The busiest day of the week is Friday.
- The busiest hour of the day is 3 p.m.
- The busiest month of the year is July.
—Data reported by OUC
Inconsistent or ineffective use of scripted call handling protocols by call-takers.
An example of how scripted protocols are applied would be for a call where a person is not breathing. In this example a call-taker would use the scripted protocols to guide the caller to perform Cardio-Pulmonary Resuscitation (CPR).
The scripted protocols give step-by-step instructions that the call-taker conveys to the caller. In critical medical emergencies the call-taker must stay on the line with the caller until the medics arrive.
FE found inconsistencies in the application of the protocols in the call-taking processes observed on site, in its review of the 72 sample calls, and in the review of the high priority events. In at least 27 of the 72 sample call reviews FE found evidence of call-takers adlibbing or improvising, and clearly not following the script.
While discretion is allowed by the call-taker on whether to follow the script exactly (for high acuity, low frequency events), or for some of the questions based on what a caller may have already volunteered, it was clear in observations and call reviews that unnecessarily deviating from the script by discretion and improvising are common.
Inconsistent use of technologies used by call-takers to locate callers or confirm location of reported events.
FE found gaps in the administering of training and refresher training of call-takers and dispatchers on the use of technology and oversight of the same. Observations of call-takers found no one using a computerized map to plot the location of a caller but instead relying solely on questioning the caller for a location.
Observations also found that call-takers were routinely erasing the X/Y coordinates and replacing them with the caller’s reported location. It appears that call-takers have been conditioned not to trust the location of cell phone callers. FE found that the equipment configuration does not automatically locate callers using a mobile phone for better accuracy. This has contributed to call-takers mistrust of the map tools. Complications caused by an excessive number of chief complaints call-takers can choose from to select the type of event that callers are describing.
Call-takers must choose among some 500 call/event types, called chief complaints, for both law enforcement and FEMS situations. This has unnecessarily complicated the complaint type assignment process resulting in chief complaint selection errors in the scramble to get calls processed.
The selection of an incorrect chief complaint has a ripple effect on response, including a possible default to a lower priority. Lower priority calls in a high-volume event environment do not receive the level of attention as do calls of a higher priority and may be overlooked by dispatch staff.
FE reviewed the record of four controversial incidents that occurred in 2020 and were featured on the September 2, 2020, Kojo Nnamdi Show on WAMU Radio. At that time then-OUC Director Karima Holmes said each incident had been reviewed and remedial action taken. The Federal Engineering review found that each case was investigated according to policies implemented in 2020, but stated they disagreed with the conclusion in one of the cases and the review was not able to document actions taken in two of the other cases.
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