Community Risk Assessment - Standards of Cover 2021 101
102 Community Risk Assessment - Standards of Cover 2021
Community Risk Assessment - Standards of Cover 2021 103
Resiliency
By looking at resistance, absorption, and restoration, the agency can determine the ability of the system to
reduce the magnitude and/or duration of an incident disruption to the system’s overall capacity and capa-
bilities. Evaluation of system resilience includes analysis of unit utilization and the reliability of a unit in its
district. The analysis of the reliability of units to respond to incidents within their own district is very high
(Figure 85) with unit utilization (Figure 86 & 87) showing that the demand does not adversely impact the
ability of units to answer calls for service.
Figure 85 Station District Reliability
104 Figure 86 Station District Reliability
Community Risk Assessment - Standards of Cover 2021
Figure 87 Unit Utilization by Hour of Day
Resistance
The ability to only deploy the necessary resources to control an incident is achieved by prioritizing incident
types and pre-programming a specific response to each incident type in CAD.
During the quality assurance process of EFD and EMD, telecommunicators are evaluated on the appropri-
ateness of their incident type selection which impacts over response (waste) or under response (risk). This
information is shared back to each telecommunicator and reviewed through their training processes.
During major thunderstorms, operational Battalion Chiefs can request that the agencies move to Storm
Mode. This changes all responses to a single engine response unless it is a confirmed structure fire which
would receive its normal response.
During disasters such as hurricanes, an operational officer is assigned to the 911 center to assist in triaging
and determining response to calls as to not overwhelm the system.
Absorption
The ability to quickly add or duplicate resources is achieved through automatic and mutual aid. Each inci-
dent type in CAD has additional alarms of 2 engines, 1 truck, and 1 Battalion Chief programmed. The agency
also has built out the run order of each zone to include all automatic aid departments. This allows for auto-
matic and quick selection of additional resource needs. Beyond that, resources can be requested as mutual
aid from neighboring counties and then escalated through emergency management to receive statewide
mutual aid.
The agency also moves apparatus to standby locations when multiple units are committed to an incident.
This is done in conjunction with the Wilmington Fire Department and the beach fire departments.
If an incident becomes prolonged, call back of personnel can be initiated. This process uses the agency’s
scheduling software (Telestaff) to contact and notify staff.
Restoration
The ability to return resources to in service status on incidents is managed by the incident commander.
During daily operations, training, maintenance, and special projects are scheduled to minimize out of service
time as well as minimize the time a district is not covered by a unit. To maintain functions after a disaster,
NHCF utilizes the New Hanover County Continuity of Operations Plan to restore essential services.
Community Risk Assessment - Standards of Cover 2021 105
Outcomes
Response time performance and resiliency are only a component of the agency’s total performance. To fully
evaluate the impact of the agency, it is necessary to evaluate outcomes. Outcomes such as flame spread
in structure fires, dollar loss and saved, civilian injuries and fatalities by fire and cardiac arrest outcomes
help focus goals and objectives and performance improvements ensuring the best service for the com-
munity. Flame spread identifies the ability of the agency to effectively mitigate a structure fire and keep it
from further damaging proper-
ty (Figure 88). Another metric
that shows the agency’s ability
to quickly mitigate the incident
and its impact on individuals
is the civilian injuries and fa-
talities that occur during fires.
Low injury and fatality rates
show the effectiveness of the
fire suppression, prevention,
and public education programs
(Figure 89). Dollar loss and
saved identifies the amount of
damage and the amount saved
during a structure fire which
also correlates to the ability to
mitigate the incident (Table 25).
Cardiac arrest survival rates for
2018-2020 are based on Utstein
events which are defined as car-
diac arrest that was witnessed
by a bystander and found in a
shockable rhythm (Figure 90).
All the patients included in these
survival rates were discharged
from the hospital with a Cerebral
Performance Category of 1 (able
to work, might have mild deficit)
or 2 (moderate disability, suffi-
cient function for independent
activities of daily life).
Figure 88 Structure Fire Flame Spread
Table 25 Dollar Loss and Saved for Structure Fires
106 Community Risk Assessment - Standards of Cover 2021
Figure 89 Civilian Injuries and Fatalities by Fire
Figure 90 Utstein (witnessed by bystander and found in shockable rhythm) Cardiac Arrest Survival Rate
Evaluation of Current Deployment and Performance
Performance Evaluation
Methodology
Continuous improvement requires a methodology that ensures that planning occurs, problems are ad-
dressed, outcomes are evaluated, and adjustments are made. The Plan, Do, Check, Act (PDCA) method
provides a problem-solving process for continuous improvement (Figure 91). Utilizing this methodology, a
group shall meet quarterly to evaluate performance. This group shall be comprised of
• Fire Chief
• Deputy Chiefs
• Battalion Chiefs
• Program Managers
• Public Safety Analyst
Figure 91 Continuous Improvement Problem Solving Model 107
Community Risk Assessment - Standards of Cover 2021
This group shall be tasked with performing the following:
• Review strategic plan and progress on key performance indicators and goals
• Evaluate service demand by risk type and planning zone for the previous quarter
• Review program areas and performance data focusing on outcomes
• Evaluate altering conditions, population growth, traffic, development and changing risks
• Discuss industry research findings that are relevant to each program area
• Assess adequacies, consistencies, reliabilities, and opportunities for improvement
• Documenting review process, findings, actions recommended, plans, and efforts to address
performance gaps
Compliance monitoring
Monitoring and reporting of system
performance happens on a month-
ly basis. Monthly, company officers
and battalion chiefs receive the
previous month’s performance and
assess deviations, outliers, and per-
formance. At the monthly battalion
chief meeting, this assessment is
reported out to the Deputy Chief
along with discussion of remedial
actions to maintain performance.
These actions are prioritized and
incorporated into future improve-
ments.
Quarterly the divisions and pro-
gram areas participate in a report
out session outlining and evaluat-
ing the performance over the last
quarter.
Table 26 Performance Gaps by Risk Type Performance Gaps
Response time performance gaps
are summarized in Table 26. Ad-
ditionally, Figure 92 identifies the
geographic areas where units have
historically exceeded a five-minute
travel time for the first due unit.
This analysis shows a significant
hotspot in the Gordon Road and
Gateway area as well as an emerg-
ing spot in the Veteran’s Park
area. The effective response force
performance also shows a hotspot
in the Gordon Road and Gateway
area for exceeding the established
travel time (Figure 93).
108 Community Risk Assessment - Standards of Cover 2021
Figure 92 Heat Map of First Unit Not Meeting 5 Minute Travel Time
Figure 93 Heat Map of the Effective Response Force 109
Not Meeting its Designated Travel Time
Community Risk Assessment - Standards of Cover 2021
Plan for Maintaining and Improving Response Capabilities
Performance Improvement Plan
Strategic Plan Implementation
The NHCFR Strategic Plan uses the balanced scorecard methodology as its foundation. With this methodol-
ogy, there are two major components which are the goals, objectives, tasks, and key performance indicators
for the external focus of the organization and the goals, objectives, and tasks related to the internal focus
of the organization. The key performance indicators (KPIs) for the focus areas of growth and development,
education and outreach, and community response have been identified and have been incorporated into
budget process. Over the next year, the agency will begin the process of collecting data around those KPIs
and adjust as necessary. For the internal focus, owners of the specific tasks will begin working on and com-
pleting those tasks.
Total Response Time Improvements
Alarm Handling Time
NHCFR participates in the Dispatch Review Committee, which is comprised of the fire departments, EMS,
911 quality assurance staff, and select telecommunicators. This committee which meets bimonthly reviews
performance, discusses challenges and problems, and develops action plans for improvement. In conjunc-
tion with the 911 Center, NHCFR has a reporting process (911 Discrepancy Form) from the field to address
discrepancies in the processing and dispatch of incidents. When an item is created, the 911 manager, 911
quality assurance coordinator, 911 public safety analyst, and NHCFR Accreditation Manager are notified.
In October of 2021, the New Hanover County 911 Center implemented automated dispatch for fire incidents
to reduce the time necessary to process an incident. Once the process has had time to operate and be eval-
uated, the plan is to expand the use of automated dispatch to EMS incidents.
The 911 center is currently in the process of implementing Automated Secure Alarm Protocol (ASAP) which
will streamline alarm handling time by eliminating the need for the alarm company to speak with a telecom-
municator.
Future planning includes replacement of the Computer Aided Dispatch (CAD) software within the next five
years and assessing the need for CAD-to-CAD integration with Pender and Brunswick Counties.
Turnout Time
NHCFR has developed a turnout time work group to evaluate performance and establish best practices. This
committee meets periodically and is comprised of operational staff. Monthly, company officers receive their
turnout time performance and update their performance on the performance board in the station.
Additional improvements include upgrades to fire station alerting that integrate with the automated dis-
patch. These upgrades are designed to decrease response times by implementing turnout time clocks,
display of dispatch information, visual cues for the specific company dispatched, and utilizing the network
to simultaneously dispatch units. This system was implemented in Station 17 in October 2021. Station 12
and 16 are slated for installation and implementation in January 2022. Additional stations are planned for
subsequent budgets.
Upgrading apparatus routers and utilizing auto en route/auto arrival are other improvement that are un-
derway. The upgrade of apparatus routers will improve GPS location and reliability of the cellular signal for
the mobile data terminals (MDTs). Auto en route is a feature in the MDT software that automatically time
stamps the apparatus when it is en route. It also automatically time stamps the apparatus when it arrives at
the incident. This feature is currently operating in the background and in conjunction with the regular pro-
cesses for checking en route and arrival while data is collected and technical problems are resolved.
Fire station design is another area that is evaluated for improvement. In the design of the last station, Sta-
tion 16, the impact of design on turnout time was considered. The result is a common corridor with quick
access to the bay area from multiple locations. The impact of station design on turnout times was also con-
110 Community Risk Assessment - Standards of Cover 2021
sidered in the remodel of Station 12 as to not create barriers to responding quickly. This is a consideration
for all future station designs.
Travel Time
NHCFR has developed a relationship with the New Hanover County Planning Department that serves to
identify the impact of the road network on response times. The planning department consults the agency
to determine the impact of development and changes or additions to the road network. This relationship
allows the agency to influence the need for a road network that will not delay response times.
Other improvements include traffic light pre-emption, increasing the Automatic Vehicle Locator (AVL) miles,
and implementing auto en route and auto arrival. In 2017, twenty-five intersections in the City of Wilmington
were installed. In 2022, an additional fifty intersections will be installed with twenty-five in the city and twen-
ty-five in the county as well as the apparatus will receive the equipment to activate the pre-emption. Anoth-
er improvement, increasing the AVL miles, includes changing the deployment model from CAD identifying
the closest unit within a mile of the incident to utilizing the closest unit throughout the county. The technical
aspects of this change have been implemented and the impact on other agencies in the county has been
identified. Currently, the agency is vetting these impacts with the automatic aid departments before pro-
ceeding with implementation. Lastly, the auto en route and auto arrival implementation as described above
will improve the accuracy of response times.
Ten-Year Station Plan
NHCFR has developed a ten-year station plan to outline the capital needs over the next ten years. This
includes adding stations in areas where demand is growing and performance is trending, replacement and
relocation of current stations, and projecting stations for areas of future growth. This plan is monitored and
adjusted periodically to reflect the current environment. The information from this plan directly impacts the
capital improvement plan and future forecasting of budgetary needs.
Staffing Plan
NHCFR has developed a staffing plan to identify future staffing
needs. In FY22, there was an addition of a Zone 3 Captain for
Professional Development. This plan considers response time
performance, demand, reliability, and support staffing needs.
This plan is monitored and adjusted periodically to reflect the
current environment.
Continuous Improvement Strategy
The agency will implement the following process to evaluate
performance and progress toward achieving goals.
• Monitor changing needs and circumstances
• Evaluate performance
• Assess options for maintaining or improving
• Implement improvements
• Evaluate effectiveness of improvements
• Revise plan
Community Risk Assessment - Standards of Cover 2021 111
Correlation of CRA/SOC to Accreditation Model
The following outlines the correlation of the Community Risk Assessment/Standard of Cover with the 10th
edition CPSE Accreditation Model.
CPSE 10th edition Accreditation Model CRA-SOC
pages
Category 1 - Governance and Administration
CC 1A.1 The agency is legally established. 12
CC 1B.2 The administrative structure and allocation of financial, equipment and personnel 10, 12-13
resources reflect the agency's mission, goals, objectives, size and complexity.
Category 2 - Assessment and Planning
2A.1 Service area boundaries for the agency are identified, documented, and legally 12-13
adopted by the authority having jurisdiction.
2A.2 Boundaries for other services responsibility areas, such as automatic aid, mutual 13
aid and contract areas, are identified, documented and appropriately approved by
the authority having jurisdiction.
CC 2A.3 The agency has a documented and adopted methodology for organizing the re- 26-27
sponse area(s) into geographical planning zones.
CC 2A. 4 The agency assesses the community by planning zone and considers the popu- 26
lation density within planning zones and population areas, as applicable, for the
purpose of developing total response time standards.
2A.5 Data that include property, life, injury, environmental, and other associated losses 106-107
as well as the human and physical assets preserved and/or saved, are recorded
for a minimum of three (initial accreditation agencies) to five (currently accredited
agencies) immediately previous years.
2A.6 The agency utilizes its adopted planning zone methodology to identify response 14-18,
area characteristics such as population, transportation systems, area land use, 20-22
topography, geography, physiography, climate, hazards, risk, and service provision
capability demands.
2A.7 Significant socioeconomic and demographic characteristics for the response area 19-20
are identified, such as key employment types and centers, assessed value, blighted
areas, and population earning characteristics.
2A.8 The agency identifies and documents all safety and remediation programs, such as 23-24
fire prevention, public education, injury prevention, public health, and other similar
programs, currently active within the response area.
2A.9 The agency defines and identifies infrastructure that is considered critical within 25
each planning zone.
C. 2B.1 The agency has a documented and adopted methodology for identifying, assessing, 53-56
categorizing, and classifying all risks (fire and non-fire) throughout the community
or area of responsibility.
2B.2 The historical emergency and nonemergency service demands frequency for a min- 29-43,
imum of three immediately previous years and the future probability of emergency 49-52
and nonemergency service demands, by service type, have been identified and
documented by planning zone.
2B.3 Event outputs and outcomes are assessed for three (initial accrediting agencies) to 106-107
five (currently accredited agencies) immediately previous years.
112 Community Risk Assessment - Standards of Cover 2021
CPSE 10th edition Accreditation Model CRA-SOC
pages
CC 2B.4 The agency's risk identification, analysis, and categorization, and classification 66, 68,
methodology has been utilized to determine and document the different catego- 70, 72
ries and classes of risks within each planning zone.
2B.6 The agency assesses critical infrastructure within the planning zones for capabilities 25
and capacities to meet the demands posed by the risks.
2B.7 The agency engages other disciplines or groups within its community to compare 55
and contrast risk assessments in order to identify gaps or future threats and risks.
CC 2C.1 Given the level of risks, area of responsibility, demographics, and socioeconomic 89
factors, the agency has determined, documented and adopted methodology for
the consistent provision of service levels in all service program areas through re-
sponse coverage strategies.
CC 2C.2 The agency has a documented and adopted methodology for monitoring its quality 107-108
of emergency response performance for each service type within each planning
zone and the total response area.
CC 2C.4 A critical task analysis of each risk category and risk class has been conducted to 90-92
determine the first due and effective response force capabilities and a process is in
place to validate and document the results.
CC 2C.5 The agency has identified the total response time components for delivery of ser- 99-103
vices in each service program area and found those services consistent and reliable
within the entire response area.
2C.6 The agency identifies outcomes for its programs and ties them to the community 106-107
risk assessment during updates and adjustments of its programs, as needed.
2C.7 The agency has identified the total response time components for delivery of ser- 29-43
vices in each service program area and assessed those services in each planning
zone.
CC 2C.8 The agency has identified efforts to maintain and improve its performance in the 110-111
delivery of its emergency services for the past three (initial accreditation agencies)
to five (currently accredited agencies) immediately previous years.
2C.9 The agency's resiliency has been assessed through its deployment policies, proce- 104-105
dures, and practices.
CC 2D.1 The agency has a documented and adopted methodology for assessing perfor- 104-105
mance adequacy, consistency, reliability, resiliency and opportunities for improve-
ment for the total response area.
2D.2 The agency continuously monitors, assesses, and internally reports, at least quar- 107-108
terly, on the ability of the existing delivery system to meet expected outcomes and
identifies remedial actions.
CC 2D.3 The performance monitoring methodology identifies, at least annually, future ex- 107-108
ternal influences, altering conditions, growth and development trends, and new or
evolving risks, for purpose of analyzing the balance of service capabilities with new
conditions or demands.
2D. 4 The performance monitoring methodology supports the assessment of efficiency 107-108
and effectiveness of each service program at least annually in relation to industry
research.
2D.5 Impacts of incident mitigation program efforts, such as community risk reduction, 107-108
public education, and community service programs, are considered assessed in the
monitoring process.
Community Risk Assessment - Standards of Cover 2021 113
CPSE 10th edition Accreditation Model CRA-SOC
pages
CC 2D.6 Performance gaps for the total response area, such as inadequacies, inconsisten- 108-109
cies, and negative trends are determined at least annually.
CC 2D.7 The agency has systematically developed a continuous improvement plan that 110-111
details actions to be taken within an identified time frame to address existing gaps
and variations.
2D.10 The agency interacts with external stakeholders and the AHJ at least once every 87-88
three years to determine the stakeholders' and AHJ's expectations for types and
levels of services provided by the agency.
Category 3 - Goals and Objectives
CC 3A.1 The agency has a current and published strategic plan that has been submitted to 88
the authority having jurisdiction.
CC 3B.1 The agency publishes current, general organizational goals and S.M.A.R.T. objec- 88
tives, which use measurable elements of time, quantity and quality. These goals
and objectives directly correlate to the agency's mission, vision, and values and are
stated in the strategic plan.
3B.2 The agency conducts an environmental scan when establishing its goals and objectives. 87-88
CC 3B.3 The agency solicits feedback and direct participation from internal and external 87
stakeholders in the development, implementation, and evaluation of the agency's
goals and objectives.
3B.4 The agency uses internal input to implement and evaluate its goals and objectives 87
and to measure progress in achieving the strategic plan.
3B.6 When developing organizational values, the agency seeks input from its members 11, 87
and is in alignment with its community.
CC 3D.1 The agency reviews its goals and objectives at least annually and modifies as need- 107-108
ed to ensure they are relevant and contemporary.
CC 3D.2 The agency review, at least annually, its overall system performance and identifies 107-108
areas in need of improvement, which should be considered for inclusion on the
organizational goals and objectives.
Category 5 - Community Risk Reduction Program
CC 5B.1 The public education program targets specific risks, behaviors, and audiences iden- 23
tified through incident, demographic and program data analysis and the communi-
ty risk assessment/standard of cover.
5B.3 Programs are in place to identify large loss potential or high-risk audiences (such as 23
low socioeconomic status, age, and cultural/ethnic differences, where appropriate),
forge partnerships with those who serve those constituencies, and enable specified
programs to mitigate fires and other emergency incidents (such as home safety
visits, smoke alarm installations, free bicycles helmet programs, fall prevention
programs, etc.)
CC 5E.1 Given the agency's community risk assessment/standards of cover and emergency 93-94,
performance statements, the agency meets its staffing, response times, station(s), 99-100
pumping capacity, apparatus and equipment deployment objectives for each type
and magnitude of fire suppression incidents.
CC 5F.1 Given the agency's community risk assessment/standards of cover and emergency 94-95,
performance statements, the agency meets its staffing, response times, station(s), 101
apparatus and equipment deployment objectives for each type and magnitude of
emergency medical incident(s).
114 Community Risk Assessment - Standards of Cover 2021
CPSE 10th edition Accreditation Model CRA-SOC
pages
5F.8 The agency has implemented or developed a plan to implement a cardiopulmonary 23-24
resuscitation (CPR) and public access defibrillation program for the community.
CC 5G.1 Given the agency's community risk assessment/standards of cover and emergency 96-97,
performance statements, the agency meets its staffing, response times, station(s), 101,102
apparatus and equipment deployment objectives for each type and level of risk of
a technical rescue incident(s).
CC 5H.1 Given the agency's community risk assessment/standards of cover and emergency 97-98,
performance statements, the agency meets its staffing, response times, station(s), 103
apparatus and equipment deployment objectives for each type and magnitude of
hazardous materials incident(s).
Category 6 - Physical Resources
6A.1 The development, construction or purchase of physical resources is consistent with 111
the agency's goals and strategic plan.
CC 6C.1 Apparatus and vehicle types are appropriate for the functions served (e.g., opera- 46
tion, staff support services, specialized services and administration).
Category 9 - Essential Resources
CC 9A.2 An adequate and reliable water supply is available for firefighting purposes for 59-61
identified risks. The identified water supply sources are adequate in volume and
pressure, based on nationally and/or internationally recognized standards, to con-
trol and extinguish fires.
9A.4 The agency maintains copies of current water supply sources and annually reviews 59
fire hydrant maps for its service area to ensure they are accurate.
9A.5 Fire hydrant adequacy and placement are based on nationally and/or international- 59
ly recognized standards and reflect the hazards of the response area.
9B.7 The agency has established time-based performance objectives for alarm handling. 89, 110
These objectives are formally communicated to communications center managers
through direct report, contracts, service level agreements and/or memorandums of
agreement and are reviewed at least annually to ensure time-based performance
objectives are met.
9B.10 The dispatch process utilizes a formal and recognized emergency medical dispatch 89
(EMD) system that allows for pre-arrival instructions and adequate triaging of med-
ical calls for service.
9B.11 The agency has a documented and tested system in place for the notification and 105
recall of off-duty agency personnel and telecommunicators for unplanned, large-
scale incidents.
CC 9C.1 The administrative support services are appropriate for the agency’s size, function, 48
complexity, and mission, and are adequately managed.
Category 10 - External System Relationships
CC 10A.1 The agency develops and maintains external relationships that support its mission, 13, 89
operations, and/or cost-effectiveness.
10A.2 The agency’s strategic plan identifies relationships with external agencies/systems 87-88
and outlines a process to identify any impact or benefit to the agency's mission,
operations or cost-effectiveness.
Community Risk Assessment - Standards of Cover 2021 115