Citygate completed an expansive review of the organizational and operational components of the EMS program at the Los Angeles County Fire Department. A comprehensive strategic plan was also developed to guide the next three to six years of improvement in the Department’s EMS programs and allied support structures. This study and strategic plan addressed deployment, use of resources, best practices in pre-hospital medicine, organizational and personnel practices, and the use of information technology. Despite challenges faced, the Department is managing and implementing the delivery of successful programs and changes recommended in Citygate’s reports. Among those achievements, the Department hired a permanent Medical Director, improved relations with the EMS agency, implemented electronic patient care records, revamped the quality improvement program, completed back-logged EMS report scanning, and became the first Fire Department to go live with the implementation of the Safety Intelligence Risk Management Software tool.