Southern Tier Regional EMS Council


QUALITY IMPROVEMENT
MANUAL

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TABLEOF CONTENTS
Introduction
     Summary of Legislation
Guidelines for Prehospital Provider Services
Guidelines for Hospital Emergency Departments and Services
Guidelines for Reporting Process and Information Flow
Hospital-based Area QI Coordinator
Service QI Reviewer
Regional Quality Improvement Committee
Area Quality Improvement Committee
EMD QI Procedure
EMD Certification Requirement and Continuing Education
Quality Improvement Flow Chart(PDF Format)
Glossary, Bibliography, On-line Resources
Sample QI Forms(PDF format)
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Introduction

The primary goal of an EMS System is to reduce death and disability from injuries and/or illnesses. As research continues into the impact that prehospital care has on the ultimate outcome of patients, the need to evaluate the quality of the care that we as individuals and organizations provide becomes paramount. However, because we don't exist in isolation we must evaluate our care as it relates to the EMS System in which we practice and, ultimately, to the rest of New York State.
Health care is a dynamic field constantly in a state of change. New discoveries and new technologies are constantly on the horizon. This is especially true in the field of EMS. In order to ensure that our patients are receiving the best care that we can provide, we must routinely evaluate our standards of care and identify areas of strengths and weaknesses. Then we must be willing to share our strengths and correct our weaknesses.
Quality Improvement (QI) is a program of systematic evaluation to ensure excellence. Instead of asking "Who caused this to happen?", QI asks "What is wrong with the process that caused this to happen?" It is ajudgmentlinked to mechanisms or a system to effect positive change. That judgment is based on acceptable standards of care provided by written protocols and on-line medical control.
A quality improvement program has several components. These are case review, evaluation of indicators, tracking and evaluation of repeating problems, incidents and complaints and scanning monitors.
Quality improvement activity is a means to guarantee continuous quality of care to our patients, educational programs for our providers and a means for identifying areas of concern before they become problems. It requires the cooperation of all EMS players from first responder to the New York State Medical Advisory Committee (SEMAC). It must recognize common needs for education, structured feedback, professionalism, mutual respect and, above all,confidentialityof all quality improvement activities.
Confidentiality: Notwithstanding any other provision of law, none of the records or documentation or committee actions or records required pursuant to Section 3001.6 of Article 30 shall be subject to disclosure under Article 6 of the Public Officers Law or Article 31 of the Civil Practice Law and Rules, except as provided in any other provision of law. No person in attendance of an Area Quality Improvement Committee shall be required to testify as to what transpired thereat. The prohibition related to disclosure of testimony shall not apply to the statements made by any person in attendance at such a meeting who is a party to an action or proceeding, the subject of which was reviewed at the meeting. Prohibition of disclosure of information from the prehospital reporting system shall not apply to information which does not identify the ambulance service or individual. Any person in good faith and without malice provides information to further the purpose of this section or who, in good faith and without malice participates on the Regional Quality Improvement Committee, or on the Area Quality Improvement Committee, shall not be subject to any action, civil damages or other relief as a result of such activity.
New York State Department of Health Code and Federal regulations give hospitals a responsibility for prehospital quality improvement activity. This recognizes that EMS patients are hospital patients in the field and that prehospital care is an extension of emergency physician care. Written regional protocols are developed by off-line medical control physicians to direct real-time care. With this mechanism in place and hospital involvement identified, we can measure the system as a whole against established standards. Following are the pieces of legislation that impact the QI process.

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Summary of Legislation:

1. Article 30, Section 3006:
  Establishes that every ambulance service and advanced life support first response service shall:
  i) establish and participate in a quality improvement program, which shall be an ongoing system to monitor and evaluate the quality and appropriateness of medical care provided by the ambulance service or advanced life support first response service
  ii) pursue opportunities to improve patient care and resolve identified problems.
2. Part 800.29
  The EMS service shall implement and maintain a quality improvement program on its own in conjunction with other organization(s). It shall include a planned and systemic process for monitoring and enhancing the quality and appropriateness of patient care, clinical performance, and administrative coordination support activities of the service on an ongoing basis and seek to solve causes of identified deficiencies.
3. 405.19 Regulations:
  a. require a review of emergency services at least four times a year as part of a hospital's overall QI program (Article 28).
  b. require review of Medical Control and Medical Oversight of the system for prehospital emergency medical services.
  c. require review of on-scene triage procedures and protocols for those patients in need of specialized care at designated hospitals (i.e., trauma center, burn center, etc.).
  d. require review of protocols and emergency care provided for patients. This must include prehospital care providers, emergency services personnel, and appropriate physicians.
4. Part 80 - Rules and Regulations on Controlled Substances: Federal Regulations
  Documents administrative rules and regulations pertinent to the handling of controlled substances. Also requires a Quality assurance plan and lists pertinent responsibilities of the Medical Director.
5. Federal Regulations:
  Consolidated Omnibus Budget Reconciliation Act (COBRA): Mandates requirements for interfacility transfers, and holds the individual practitioner liable for violations.

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I.  Guidelinesfor Prehospital Provider Services

Service specific quality improvement activity should be conducted by the most capable person(s) available within each service. The development of the QI process begins with the identification of the service's Reviewer.
The Service Reviewer has available resources such as:
  1. Existing protocols and standards
  2. The EMS QI Coordinator at your primary receiving hospital
  3. Your service and/or system Medical Director
  4. Prehospital Care Reports (PCRs)
  5. Service specific data available from the State PCR System
  6. Field supervision by experienced personnel
  7. Education curricula
  8. OSHA Regulations, Worker's Compensation, etc.
  9. Cobra
  10. Article 30
  11. 405.19 regulations
  12. Part 800
  13. Part 80
  14. Title 10, Part 708
A basic tool for any prehospital QI program is PCR review. This is called retrospective review and is the easiest to implement.
To begin, the QI Reviewer should select specific indicators that will be reviewed on a regular basis. These indicators will cause certain PCRs to "fall out".
The basic list of indicators that trigger review will be established by the Regional QI Committee in cooperation with STREMAC. Some examples of review indicators are:
  1. *All pediatric transports age 6 and under
  2. Medical control/service request
  3. *Cardiac arrest
  4. *Multiple trauma
  5. Shock of any origin
  6. Unconscious/unknown cause
  7. Heart rate less than 60 or greater than 120
  8. BP greater that 160/90 or less than 90 systolic
  9. Respirations greater than 28 or less than 12
  10. Service/provider/patient/family/hospital complaint
  11. Protocol deviation
  12. *GCS <13
  13. Any other issue of concern
*These are the minimum identifiers as established by Regional QI and STREMAC.. The frequency of review is determined by the Area QI Committee, with approval of the Regional QI Committee, and can be based on frequency of runs, types of runs, number of personnel, etc. However, formal interaction between the base hospital and the service should occur on at least a quarterly basis.
Once the PCRs are identified to be reviewed from your list of indicators, the QI Reviewer will be assessing such things as:
  1. Appropriateness of care: the degree to which the correct care is provided given the current state of the art. Are written protocols current? Was there any deviation from written protocol?
  2. Continuity of care: the degree to which the care needed by patients is coordinated among providers and across organizations and time. Was medical control contacted appropriately?
  3. Timeliness of care: the degree to which care is provided to patients when it is needed. Was on-scene time less than 20 minutes?
As the service QI Reviewers begin to ask questions about the system and identify areas of concern, they can turn to the many resources described above. In particular, the primary receiving hospital can provide data, education and expertise in problem solving.
QI is an ongoing activity, including regular periodic review. The process described above will help each service document its care, provide constructive feedback, identify deficiencies and improve performance through appropriate inservice programs. From a medical-legal perspective, such a program will reduce risk by reinforcing the delivery of appropriate care. More importantly, from the patient perspective, your efforts will contribute to the overall goal of EMS: reducing death and disability.
In addition to regular review of the service list of indicators, periodic review of such things as all patients with chest pain, all pedestrian injuries or diabetic problems might be selected for a focused study (see form #4 for a tool). Follow the steps listed below for the review process, use approved review forms and proceed from there.
The basic steps for review are:
  1. Selecting a subject for study, which includes an operational definition of the condition or procedure under study and a definition of patients to be included.
  2. Developing criteria and standards, defining acceptable levels of quality.
  3. Collecting data.
  4. Comparing data to criteria and standards in order to identify areas of excellence and deficiencies.
  5. Determining causes of deficiencies and taking corrective action, including:
    6. Tags design Ideas Garden. 1. determining who or what is expected to change
    2. determining who is responsible for implementing action
    3. determining what action is appropriate , and
    4. determining when it is expected to occur.
  6. Evaluating the study.
Focused studies are done as a need arises, not on a regular basis. For example, perhaps there is a concern over cardiac patients not being given O2 as per protocol You might pull all PCRs on cardiac patients for a 3 month period. Look to see if O2 was administered in all cases. If not, what percentage did not receive O2. If your acceptable level of practice as determined beforehand is 100% and compliance in your study is only 80%, then you must inservice your personnel, send out a memo, post notices, contact service medical director, etc. Then, after a preestablished period of time, you must complete a similar review to see if compliance has improved. Quality Improvement is a way of looking at improving care, not finding problems for punitive action. Proposals for any focused study should be approved by the Area and Regional QI Committees to identify opportunities for Region-wide focused studies and to avoid duplication.

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II.  Guidelinesfor Hospital Emergency Departments and Services

The hospital plays a vital and pivotal role in the EMS system. A hospital-based Area QI Coordinator, drawing on data from a variety of sources, has a bird's eye view of the system and is in a position to effect positive change.
Many elements are required to hold the EMS system together: vehicles, equipment, trained personnel, communications and dispatch, to mention a few. We now know that an additional, essential component must be included: medical direction or "external quality control", which should be completely independent from provider control. The hospital-based Area QI Coordinator should provide this direction, in collaboration with the physician representative to the Area QI Committee.
The hospital should:
  1. Identify an Area QI Coordinator.
  2. Review all ED deaths and DOAs.
  3. Review selected prehospital cases as identified by Service reviewer.
  4. Provide for clinical training and continuing education for prehospital providers. (Agreements should be made with local agencies to address this).
  5. With Service Reviewer, monitor PCR completeness and compliance with existing protocols.
  6. Give and receive feedback with local Service Reviewer regarding PCR completeness, protocol compliance, prehospital diagnosis versus ED diagnosis, patient outcome.
  7. Maintain the ED log and include therein the PCR#, ED diagnosis, prehospital service and level of care (ALS or BLS) in addition to the patient identification data. Completion of On-Line Medical Control form (form # 501) must be done and appropriate copies sent to STREMS.
  8. Evaluate transfers. (Were provider qualifications and equipment/supplies in transport appropriate for the patient's condition?)
  9. Incorporate the PCR into the permanent hospital record.
  10. Participate in regional medical control, including audits and protocol revision.
  11. Monitor on-line medical control. (Was it in compliance with regional protocols?)

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III.  Guidelinesfor Reporting Process and Information Flow

1. Service QI Reviewers will review PCRs based on indicators established by the Regional QI Committee and STREMAC using the PCR audit tool. If the PCR does not meet established Area QI and Regional QI standards it is referred on to the Area QI Coordinator for review. The Area QI Coordinator will determine whether the particular PCR will go to the Area QI committee or be handled individually.
2. The service QI Reviewer will prepare a monthly report, using the General Audit Summary Form, for the Area QI Committee. If totals do not meet the established completion standard, the Area QI Committee will determine what corrective action to take, based on problem areas identified. Is it protocol deviation, illegibility, vital signs not taken, etc.?
3. If areas of excellence are identified, the service or the provider will be notified of a job well done.
4. The Area QI Committee will meet at least quarterly and will review the monthly General Audit Summaries from the various services in their catchment area, problems identified by the QI Coordinator or issues related to quality improvement.
5. The Area QI Committee will provide a quarterly summary in writing of all QI activity to the Regional QI Committee.
6. The Regional QI Committee will provide summary reports to STREMAC and STREMS.

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Hospital-basedArea QICoordinator

Definition: The Hospital-based Area QI Coordinator will assume the responsibilities of data gathering from each service reviewer for service performance.
Goal: The goal of this position will be the gathering of information to provide feedback and to determine what is and is not positively affecting patient outcomes. The data will be utilized to assure competence of all personnel in each skill area for which they are responsible.

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Duties and responsibilities

c.
I. Review all PCRs or those identified based on system indicators
  a. Review times - response time, response to urgent and life-threatening calls, on-scene time and destination times.
  b. Quality and appropriateness of documentation
    1. All areas of PCR completed
    2. Appropriate sets of vital signs
    3. Legibility
    4. Orderly flow of narrative
  Adherence to protocols: Review for appropriateness of treatment based on chief complaint history, assessment and treatment.
  d. Documentation of flow of information and follow-up of the review process. Maintain documentation in a confidential environment.
  e. articipate as a member of the Regional QI Committee.
II. Identify problems or potential problems as either training or counseling needs and document appropriately.
  a. Time requirement difficulties may require counseling and/or training. Refer to service management for resolution and follow-up with documentation in personnel file.
  b. Difficulties with quality and/or quantity of work will initially require retraining and counseling by the QI coordinator or designee with follow-up and documentation completed by QI Coordinator and service management.
  c. Difficulty with adherence to medical protocols will initially require retraining by QI Coordinator or designee. If problem continues, counseling by the service medical director. Resolution will be completed by QI Coordinator, service management and service medical director with appropriate documentation in the personnel file.
  d. Reports of any conflicts will be documented and reviewed by QI process.
III. Resolution of identified problem will be thoroughly documented. Procedures utilized will be outlined and a follow-up evaluation upon resolution will be carried out and documented.

ServiceQI Reviewer

Definition: The Service QI Reviewer will identify all PCRs that meet the Regional QI criteria. Using the appropriate forms and documentation, each service QI reviewer will report their findings to the Area QI Coordinator The Area QI Coordinator will review reports and report findings to the Area QI Committee.
Goal: The goal of this position will be data gathering and maintaining patient confidentiality at the hospital level.
Duties and Responsibilities
  1. Identify PCRs that meet the regional QI criteria.
  2. Participate on the Area QI Committee and report back to service membership through their monthly meetings.
  3. Provide leadership to other service members in improving prehospital care.
  4. Maintain own skills and knowledge base.t


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RegionalQuality Improvement Committee

Membership shall number at least five and include at least:
1 chairperson, a member of the Southern Tier Regional EMS Council
1 vice-chairperson, a member of the Southern Tier Regional EMS Council
1 physician, 1 nurse, 3 prehospital providers, STREMAC Chair, All Area QI Coordinators
Responsibilities:
  1. Present quality improvement data to the regional emergency medical advisory committee.
  2. Receive and review data from the Area Quality Improvement Committee and to recommend to the Council changes in administrative policies and procedures.
  3. Notify the Council of significant issues related to the provision of quality prehospital care.
  4. Receive and review from the Area Quality Improvement Committee reports on provider credentialing and performance.
  5. Receive and review reports from the Area Quality Improvement Committee on:
     a. Quality of care
     b. Compliance with standard of care procedures and protocols.
  6. Establish and/or provide continuing education programs to address areas in which compliance with procedures and protocols need to be improved.
  7. Periodically evaluate system's Quality Improvement Program.
Meetings shall be held at least quarterly, or as needed to fulfill the committee's responsibilities. Written minutes of all meetings will be taken and distributed to all committee members, STREMSC, and others as designated by the committee.

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AreaQuality Improvement Committee

Membership: based on the requirements of Article 30, this committee must consist of at least five members, one of which must be a physician, three who do not provide direct care to any given service, and other health care providers as appropriate. An identified QI Coordinator named by each hospital will chair the Area QI Committee. Each participating service's service QI reviewer shall be a member of a given Area QI Committee.
 
Responsibilities:
  1. Review care rendered by those services that care for patients transported to the Area QI Committees identified hospital.
  2. Notify Regional Quality Improvement Committee of significant issues related to the provision of quality prehospital care.
  3. Quarterly review:
    a. Quality of care
    b. Compliance with standards of care procedures and protocols.
    Grievances filed with services by patients or their families.
    d. The occurrence of incidents injurious or potentially injurious to patients. Report these findings to the Regional Quality Improvement Committee.
  4. Suggest continuing education programs to address areas of compliance with procedures and protocols that need to be improved and recommend to the Regional Quality Improvement Committee regional continuing educational programs and/or topics.
  5. Participate in the system wide evaluation of the quality improvement program
Meetings will be held at least quarterly or as needed to fulfill the committee's responsibilities. Minutes will be maintained in a secure area and marked, "Confidential, for QI purposes only."

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EMD QI Procedure

The purpose of this policy is to ensure that the Emergency Medical Dispatch portion of Prehospital Emergency care is monitored for quality so as to deliver the best possible care to each patient from the Southern Tier from entry into the system to delivery at the hospital.
Procedures
  1. Reviews will be done a least on a quarterly basis.
  2. Reviews will be conducted by STREMS, Inc. or a representative designated by STREMS, Inc.
  3. A minimum of 25 calls will be reviewed from random PCRs within the respective county.
  4. The EMD Center will prepare the recordings for review and provide them to the STREMS, Inc. EMD QI reviewer(s).
  5. The STREMS, Inc. EMD QI reviewer will prepare a report and provide a copy of it to the Regional QI Committee as well as to the respective EMD Center.
  6. The Center will complete a EMS/EMD QI Fallout Disposition sheet where indicated and return it to STREMS, Inc. prior to the next Committee
meeting.
See related EMDFormsbelow and requirements.

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EMDCertificationRequirement and Continuing Education

Emergency Medical Dispatchers shall be compliant with applicable State and Local law's and regulations. In addition the EMD dispatchers will have the following certifications and utilize the following requirement for Continuing Education.
Initial Certification:Attend a certified Public Safety Dispatching course consisting of at least 40 hours of training. This course should be nationally recognized and uniformly used throughout the region.
Obtain CPR certification utilizing Nationally recognized standards and instruction.
Continuing Education
Attend updates and inservices of the regionally approved dispatch protocols when necessary.
Complete 24 CE (Continuing Education) credits within a 24 month period. These credits should be from, but are not limited to the following sources:
  1. Study Topics with quiz, obtained from the Regional EMD Protocols.
  2. Study Topics with quiz, obtained from Nationally recognized dispatch training service.
  3. Study Topics with quiz, obtained from Nationally recognized dispatch trade journals.
  4. Study Topics with quiz, Obtained from Regionally supplied study materials.
Maintain current CPR certification utilizing Nationally recognized standards and instruction.
Attend inservices when necessary provided by their employer on the following topics:
  1. Hazardous Materials - guide book utilization
  2. Internal Policies and Procedures.
  3. Any other topics as deemed necessary.

QualityImprovementFlow Chart

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Glossary

Continuous Quality Improvement: The sum of activities undertaken by the service to provide confidence to its patients and maintain a standard of excellence. It is a dynamic process based on multiple activities to maintain the ultimate goal of the Emergency Medical Service System: the provision of timely, efficient and effective prehospital care to all those who need it.
Indicators:Any of a group of predetermined values that are of high risk to the provider or service that should be periodically reviewed to reduce risk. They can be either high or low volume.
Concurrent Review:Real time review of processes through on-line medical control, ED observation, field observation, etc.
Prospective Review:Measuring future evens against predetermined standards. This is accomplished through standardized protocols, establishment of time standards, etc.
Retrospective Review:Review of system processes after they occur. This is accomplished through PCR review, critique sessions, patient complaints, etc.
Structural Evaluation:Deals with the presence of mandated resources and includes standard setting for non-personnel issues. This includes evaluating physical facilities, equipment stocking and control procedures, etc.
Process Evaluation:Deals with the use of resources and appropriateness of such utilization. This deals with patient processing, triage, utilization of available resources, etc.
Outcome Evaluation:Deals with the results of care provided. This deals with stabilization and survival through to recovery and hospital discharge.
Bibliography
  1. New York State EMS Quality Assurance Manual and attendant bibliography.
  2. Resource Document: Nursing Care of the Trauma Patient, Trauma Nursing Coalition, 992.
  3. Joint Commission Primer on Indicator Development and Application, Measuring Quality in Health Care, 1990, Chapter 2.
  4. Polaky, A. Axott, M.D., Continuous Quality Improvement in EMS, ACEP, 1992
  5. Swor, Robert A., M.D., Quality Management in Prehospital Care, NAEMS Physicians, Mosby, 1993.
On-line Resources
EMS Field Guideswww.emsguides.com
A Leadership Guide to Quality Improvement for Emergency Medical Services Systems
     http://www.nhtsa.dot.gov/people/injury/ems/leaderguide/
Continuous Quality Improvement (CQI)http://www.health.state.ny.us/nysdoh/ems/srgcqi.pdf.
NAEMSQP (EMS Quality Professionals)http://www.mhf.net/emscompass/

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SampleForms

Audit Tool
PCR Audit
EMD QI Audit
EMS/EMD QI Disposition
Case Review Evaluation
Agency Report to Area QI Committee
Area QI Committee Report to Regional QI Committee