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National ‘Learning Opportunity’

Regular Reviews Could Prevent DC Dispatching Issues, Say 911 Experts

Auditing Washington, D.C.’s 911 center will uncover any systemic dispatching issues, and more regular reviews could go a long way toward preventing future problems, said experts in interviews. While it's concerning to read reports of the D.C. Office of Unified Communications sending responders to wrong addresses, closer review is needed, and some possible causes, including training and retention, are national problems, they said.

The Office of D.C. Auditor is seeking responses by Friday to its request for proposals to write an OUC report by mid-May (see 2009240066). OUC is confident in its performance and welcomes an audit, said Director Karima Holmes, echoing previous comments in a Tuesday statement. Holmes previously warned not to read too much into unsubstantiated reports and noted that callers sometimes give incorrect addresses (see 2009030048). ODCA declined to comment Tuesday.

The audit should first focus on whether reports are individual failures or if patterns show a “much more systemic issue” in Washington, advised Glenn Marin, a 911 expert witness. “My instinct is, given the number, it’s probably a systemic problem. I would be surprised if that many individual dispatchers flubbed up that many times.” The average center doesn’t have as many problems, and attributing mistakes to the caller giving bad information is “victim blaming,” said Marin. “It’s not the citizen’s job to know how to do the 911 operator’s job.” Many local stakeholders say similar. Our Freedom of Information Act request for information on when such errors are caused by callers versus dispatchers is pending.

Consider the office’s organizational structure, training program and how it reviews calls, Marin said. With the right management structure, the problem could have been addressed sooner, he said: OUC should have an operations management group where firefighters, police and paramedics can meet to discuss any problems that arise. “You stay ahead of the problems by dealing with these issues on a monthly basis.” Training and retention are critical, said Marin. “They’re a routinely underappreciated group of people” who often don’t get enough pay because their positions are regarded as clerical, he said.

Nobody wants to send emergency responders to the wrong address, and reports about OUC issues may only “show part of the story,” cautioned ThemisPro 911 consultant Heather Hunt. The number of incidents must be examined against the context that OUC is "a busy center" with "tremendous" call volume, and callers may give the wrong address in some cases, she said. “Anytime you have human beings doing a job, human error is going to occur.” Staffing is a global 911 problem, she said. “It's a very difficult and stressful job that requires a lot of training,” and stress can lead to errors, she said.

Incorrect addresses should be a rare occurrence,” so an audit is a good idea, said Hunt. "It's hard to form any firm opinions when you don't have all the data in front of you,” and getting that information in an easily understandable format “is going to go a long way to help all stakeholders understand what's really going on.” The D.C. auditor asked many good questions in its RFP, she said.

Wider Lessons

911 centers should have a “robust quality assurance program” in which they “review a certain percentage of work on a regular basis,” Hunt said. Technology like RapidSOS can improve location accuracy, and training and skills of call takers still matter, she said. “Just because you have all the bells and whistles, it doesn't mean magically nobody's going to make a mistake.” Protocol systems that provide scripts for call takers can increase accuracy by making sure the right questions are asked, though one criticism of such systems is that they may provide less flexibility, she said. Errors could occur when the call taker inputs data into computer-aided dispatch systems; for example, systems sometimes display a drop-down menu of addresses as the user types, and the call taker might inadvertently select an address in an incorrect quadrant of the city, she said.

What we’re seeing in D.C. is not atypical of what we’ve seen in many other places,” said University of Chicago Health Lab Executive Director Rebecca Neusteter, author of a Vera Institute of Justice report this month on 911 call handling issues. The 911 system is an underfunded “black box,” despite being a “gateway not just to the criminal justice but to social services writ large,” she said. More funding is needed to upgrade technology and increase pay, benefits and training for personnel, she said. “There are [911] calls that are incredibly difficult to understand what’s going on for a whole host of reasons,” but that’s “all the more reason to ... invest in the technology and the workforce in order to minimize and prevent the compounding of any” call issues.

Audits should be “part of regular practice” for OUC and can be a “learning opportunity” that becomes a model for other locations, Neusteter said. Auditors should listen to the actual audio of 911 calls and compare it with what is entered into CAD systems to check if something is getting lost in transcription or if any patterns emerge, she said. They should compare the office’s training, policies and procedures with best practices, she said.

This is no time for the city to get defensive, said Neusteter. The District's 911 office is “a leader in a lot of ways, particularly when it comes to professionalizing their workforce” and “formalizing call taking and scripts,” she said. “I hope that the audit will actually contribute further to that.”

Although the 911 call system has been in use for 50 years, there is a lack of information on many of its core features, including how calls are processed; how call-takers, dispatchers, and other personnel are trained; and where opportunities for alternative responses exist and can be expanded," Vera Institute reported. About 80% of 911 calls were wireless in 2016, it said. “One of E911’s greatest limitations is that it did not anticipate the widespread use of cell phones, which results in complications for call-takers and dispatchers.” Wireless calls may be transmitted to call centers closest to the tower rather than the caller, which can be problematic when a call is made near a jurisdictional border, Vera said. "The call center is not always in the same department or precinct that the person is calling from, and when this happens, the call-taker must transfer the caller to the correct area before they can receive assistance, which takes longer and is a drain on resources in both departments." Providers don't necessarily release exact location data, and mobile callers may not know their specific location when asked, it said.

Editor's note: This is part of an ongoing series of articles about D.C. 911 dispatching problems. To read previous top news stories on this, see here, here, here, here and here.