Quality Improvement Programs
Old Requirements / New Directions
New York State Emergency Medical Services Council
State Emergency Medical Advisory Committee
Department of Health - Bureau of Emergency Medical Services
7/11/2017
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SEMSCO/SEMAC DOH BEMS
Evaluation / QI Committee charged with re-writing
the NY State QI Manual
Provide Guidance to Services, Program Agencies,
REMSCOs and REMACs on developing and
maintaining QI Programs based on well established
principles and new processes
Create a paradigm shift in the way we approach
the QI process here in NY State
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Table of Contents

Introduction
– The Paradigm Shift in the QI Process in NY State
– Glossary of Key Terms

Chapter 1
– How to Establish a QI Committee / “The Nuts & Bolts of the
Organization.”

Chapter 2
– EMS / “At the Crossroads of Public Safety, Public Health, and the
Community Health Care System.”

Chapter 3
– Steps for Monitoring, Evaluating & Improving Organizational
Efficiency / “From Data Collection to Performance
Enhancements.”
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Table of Contents

Chapter 4
– Customer Service / “For It is The Customer, That We
Exist.”

Appendices
– Article 30, Section 3006
– Part 800.21 (q) (r)
– QI Process Flow Charts
– Sample Audit Tools
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CQI - It’s Not the Blame Game!!!
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PCR Audits
Organizational Efficiency
Technician – specific Behavior
Customer Service
Benchmarking
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EMS
The “S” in EMS stands for the word SERVICE
 Service
(sur-vis)
supplying services rather than a product or goods;
The organized activities of apparatus, appliances and
employees for supplying some accommodation
required by the public;
The performance of any duties or work for another
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“... service people are the most important
ones in the organization. Without them
there is no product, no sale, and no
profit. Indeed, they are the product.”
J.W. Marriott, Jr.
Chairman of the Board and President
Marriott Corporation
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“Everyone in a service oriented
organization has a service
role, even those who never
see the customers.”
Researchers Karl Albrecht and Ron Zemke
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EMS System Goals
 The
overall goal of an EMS System is to reduce
death and disability from injuries and medical
emergencies.
 The
basic assumption in health care is that the
system of care and the individuals within it can
improve and aspire to a higher standard of
care.
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SYSTEM is the operative word
A complex unity formed of many
often diverse parts subject to a
common plan or serving a
common purpose.
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The Birth and Development of an
EMS SYSTEM

1966 “Accidental Death & Disability: The Neglected Disease
of Modern Society.”
National Highway Safety Act
1972 Robert Wood Johnson Grant Funding
1973 EMS Systems Act
1998 NY State EMS Plan
2006 ACEP Report Card on the State of Emergency
Medicine in the U.S.
2006 Institute Of Medicine – The Future of Emergency
Care in the U.S. HealthCare System
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15 Components of an EMS System








Manpower
Training
Communications
Transportation
Hospitals
Critical/Specialty Care
Public Safety Agencies
Consumer Participation







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Access to Emergency Care
Patient Transfer
Standardized
Recordkeeping
Public Information &
Education
System Review &
Evaluation
Disaster Management
Mutual Aid
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Benchmarking 101
On-going and systematic process for measuring
and comparing the work process of one
organization to those of another, by bringing an
external focus to internal activities functions or
operations.
The goal is to provide policy makers with a
standard for measuring the quality and cost of
internal activities and to help identify where
opportunities for improvement may reside.
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Benchmarking 101
How well are we doing compared to others?
 How good do we want to be?
 Who is doing it the best?
 How do they do it?
 How can we adapt what they do in our organization?
 How can we be better than the best?

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Who are the Customers ?
 The Patient
 The Patient’s Family
 Taxpayers
 Managed Care Organizations/Insurance Companies
 Physicians, Nurses, Hospitals
 Health Care Organizations
REMSCO, REMAC, SEMSCO, SEMAC, TRAUMA
TRAUMA COUNCIL’S, ETC
 City Council, Town Board
 Police/Fire, Public Health Personnel
 Others ?????
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Agency Leadership & Management Test





Authority
Command
Yeah..I got a Chief’s car!
I am in Charge
People will have to listen
to me now
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Responsibility
 Accountability

– To the patients
– To the members
– To the taxpayers
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Dangerous Attitudes……
“We’re only volunteers, we do the best we can.”
“We are 911! Who else you going to call.”
“It’s my district, and I am in charge, and we are
the only game in town.”
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Is This Your Service?
Over 100 years
of tradition….
….not impeded
by a single
day’s progress!
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Words not to live by….

“We’ve always done it like that….”

“That’ll never work here…..”

“’Cause I’m the boss - that’s why….”
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Or…Is This?
teem-work: the
joint action by a
group of people, in
which individual
interests are
subordinate to the
group’s unity and
efficiency
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Management 101:
Accentuating the Positive

Compliment your employees whenever possible and appropriate
– Although it’s easier to focus on the negative – don’t do it!
– Frequent small acknowledgments outweigh rare large ones
– Praise in public - discipline in private
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CQI & The Strategic Planning Process
Leaders & Managers must be effective strategists if
the organization is to fulfill its mission,
meet its mandates, and
satisfy its constituents in the years ahead
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Strategic Planning

Development of effective strategies to cope with
changing circumstances

Set of concepts, procedures and tools designed to assist
leaders & managers with a variety of tasks

Disciplined effort to produce fundamental decisions and
actions that guide what an organization is, what it does,
and how it does it
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Data Collection / Analysis And The
Strategy Change Cycle
 Setting
the organization’s direction
 Formulating broad policies
 Making internal/external assessments
 Pay attention to needs of key stakeholders
 Identify key issues
 Develop strategies to deal with each issue
 Implement procedures
 Continually monitor and assess results
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From Philosophical to Operational
in 5 Easy Steps
1.
2.
3.
4.
5.
What are practical alternatives, dreams and visions
you might pursue?
What are the barriers to realizing those alternatives,
dreams and visions?
What proposals might you pursue to overcome
those barriers?
What steps are needed to implement those
proposals?
Who is responsible to implement these proposals?
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Plan-Do-Check-Act
This is a continuous process without end.
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What is Continuous
Quality Improvement?
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What Is Quality Improvement?
 QI
is a program of systemic evaluation to
ensure excellence.

QI is a judgment as to what is deficient
and linked to a system to effect positive
change.
 QI
is identification of positive actions by
EMS Providers and organizations.
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It’s also the LAW………
Most states have a component of their EMS statute
or code that mandates at least some form of QI
program
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QI Laws and Regulations
 Article
30 requirement (Section 3006) PHL
 Rules and Regulations of NYS Part 800
 Article 28 PHL - Part 405.19 (hospital regs.)
 Part 80 - Controlled Substances
 JCAHO
 Federal Regulations - HIPAA
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QI is a Continuous Activity
From a Service Perspective
Reinforces excellence
 Helps the service document its care
 Provides constructive feedback to stakeholders
 Identifies deficiencies
 Improves performance through education

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QI is a Continuous Activity
From a Medical-Legal Perspective
 Reduces
risk by reinforcing the delivery of
appropriate care
From a Patient Perspective
 Reduces
death and disability
 Ensures appropriate EMS action for the
community’s safety and well being
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Traditional Approach
Retrospective analysis – Review of agency’s
processes after they occur
 React to problems after they occur

Weak but also most well known
PCR audits
Medical debriefings
Incident reports
React to red flag incidents
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Modern View
 Concurrent
Methods - Review of activities that
are on-site and on-going
On-line (direct) medical control
Comparison of EMS findings and E.D. diagnosis
Field observation of EMS personnel by
M.D.s, senior instructors, clinical preceptors,
etc.
All aspects of organizational efficiency
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Modern View
 Prospective
Methods - measuring future events
against predetermined standards. Accomplished
through:
Development & use of protocols
Establishment of time standards
Minimal levels of primary training
Requirements for continuing education
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QI Guidelines for EMS
Services Providing
Prehospital Care
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Select a QI Coordinator
 The
service Medical Director
 Hospital’s EMS QI Coordinator
 The system Medical Director
 E.D. physician
 Senior prehospital provider
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Duties of a QI Coordinator
 Build
a QI Team
 Communicate with hospital EMS Coordinator
 Interface with Medical Director & field
supervisors
 Review PCRs
 Review existing protocols & standards
 Develop CME curricula
 Review consumer communications
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Resources for QI Coordinator
 Existing
protocols and standards
 Agency specific data from PCRs
 Feedback from hospitals
 Field supervision observations by experienced
providers
 Educational curricula
 Consumer satisfaction surveys
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Objective of an Audit
 To
compare actual performance with desired
performance
 Mechanism:
Identify and monitor preselected key indicators
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QI Criteria/Indicators Should Be
 Explicit
- concisely written & understood
 Critical - highly correlated with good care
 Directly related to study objective
 Comprised of a few (4-8) key elements
 Objective - not prone to individual
interpretation
 Realistic & achievable
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Types of Audits
1. Structural Evaluation
Presence of mandated resources (non-personnel issues)
Evaluates
Physical facilities and equipment
Stocking & control procedures
Staffing patterns & backup
Qualifications, credentialing and recordkeeping
requirements
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Types of Audits
2. Process Evaluation
Use of resources & appropriateness of such use
Specific complaint case/patient management
Proper patient processing
adequate hx & physical exam
appropriate assessment & treatment procedures
mechanics/flow - registration & triage procedures
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Types of Audits
3. Outcome Evaluation
Results of patient care provided
Selected outcome
Could be: stabilization & recovery of a critical
patient; resolution of an episode of an illness;
socially/medically recognized “recovery”
Audit of patient outcome by disease category
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Methods of Evaluation
1. Prospective Methods
Measuring future events against predetermined
standards
Development & use of protocols
Establishment of time standards
Minimal levels of primary training
Requirements for CME
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Methods of Evaluation
2. Concurrent Methods
Review of activities that are on-site and on-going
On-line (direct) medical control
Comparison of EMS findings and E.D. diagnosis
Field observation of EMS personnel by:
M.D.s, senior instructors, clinical preceptors
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Methods of Evaluation
3. Retrospective Methods
Recognition of past deficiencies, trends & patterns
Medical debriefings
Critique sessions
Audits
Practice profile/credentialing
Incident reports
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Some Thoughts On What To Review
 Accuracy
and completeness of documentation
 Response Time
 On-scene Time
 Accuracy of patient assessment
 Accuracy of prehospital intervention
 Patient outcome
 Adherence to Protocol or SOP
 Appropriateness of destination hospital
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Some Thoughts on What to Review
 Diagnosis
specific
 Population specific
 Patient satisfaction or complaints
 RMAs
 Intubations
 Educational Programs
Didactic Understanding
Skills Performance
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Some Thoughts on What to Review
 Sentinel
events
Standard of Care deviation
 Incident
reports
Unusual occurrences
 Equipment
downtimes
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failures/defects and ambulance
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Advantages of a QI Program
ID Areas of Excellence
ID areas needing improvement
Monitor and improve care provided
Establish evaluation criteria
Basis for CME
Reduce exposure to liability
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Advantages of a QI Program
 Improve
patient (customer) relations
 ID administrative problems
 ID Obstructions to patient care delivery
 Assesses:
• Staff and System Performance
• Equipment Performance
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Successful QI Requires

Willing cooperation of all providers in the EMS system

Recognition of a common need for:
• Education
• Structured feedback
• Professionalism
• Mutual respect
CONFIDENTIALITY
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Predetermined Paths of Action
 Key
QI personnel should have clearly
identified roles understood by all
 Ultimate
responsibility for areas of
improvement lies with the service’s Governing
Authority
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General Process for QI
 Assign
responsibility
 Delineate scope of care
 ID problems (potential, perceived, real)
 Establish standard criteria for patient care
 Compare the quality of care given to preestablished standards
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General Process for QI
 Collect
and organize data
 Identify areas of excellence
 Identify deficiencies
 Define the magnitude and scope of problem
 Evaluate care/service provided
 Develop a plan for corrective action
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General Process for QI
Provide feedback
 Implement the corrective action
 Reevaluate after specified period of time
 Communicate relevant information and trends to
responsible persons
 Retrain as needed
 Re-visit in future
 Share information with REMAC QI

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Steps in a QI Program
 Select
a subject of study that includes an
operational definition of the condition or
procedure under study
 Define patients to be included in the study
 Develop criteria and standards
 Collect data
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Steps in a QI Program
 Compare
data to standards to ID excellence
or deficiencies
 Determine cause and take appropriate action
 Pass along findings to all interested parties
 Repeat review to evaluate effect of changes
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Sample Review
 Select
a prehospital impression for review
– Respiratory Difficulty secondary to Asthma
 I.D.
patient population and length of study
– All patients with hx of asthma and dyspnea for
month of July
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Sample Review
Select standard based criteria i.e., regional
or NY State protocol
NY State Bronchospasm Protocol
Review PCRs, collect and collate data
Did patient who fit criteria receive medication
If yes, appropriate by protocol?
If no, why not?
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Sample Review

Provide Structured Feedback
Excellence
Weakness
Publicize results to all concerned (reinforces positive
behavior)
Targeted Remedial Activity as indicated
Re-visit
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Sample Review
 Select
a prehospital SOP for review
– Patients with s/s indicative of stroke/CVA
transported to a designated Stroke Center
 I.D.
patient population and length of study
– All patients with presenting problem of
stroke/CVA for months January - June
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Sample Review
 Select standard based criteria i.e., regional protocol,
NY State Policy
 98-15 Emergency Patient Destinations
 Review PCRs, collect and collate data
Documentation include time onset of s/s, use of CPHSS?
Were patients who fit criteria transported to a designated
stroke center?
Is documentation of essential information present?
If yes, receiving hospital appropriate by protocol and policy?
If no, why not?
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Sample Review

Provide Structured Feedback
Excellence
Weakness
Publicize results to all concerned (reinforces positive
behavior)
Targeted Remedial Activity as indicated
Re-visit
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Is this you?
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Organizational QI Plan
 Developed
 Focus
should be supportive & educational
 Should
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prior to any case review
not revolve around crisis management
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Effective QI Programs
 Should
be monitored continuously
 Consistently improve or maintain quality of
patient care
– ID & analyze QI program strengths & weaknesses
– ID possible options for remediation
– Choose an appropriate & consistent course of action
– Reevaluate effects of corrective action
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Writing a QI Plan
An effective QI Plan should include:

A Vision Statement- declares where the organization wishes to
be in the future

A Mission Statement- describes the fundamental reasons for the
existence of the plan

A Basis in Reality-Be prepared to Do once you’ve completed your
Plan

References to State Legislation and Regional Guidelines and
Policies as the basis of your document
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Writing a QI Plan
An effective QI Plan should include:

Address issues of Confidentiality per Article 30, Policy
Statement 02-05 and HIPAA
– Be linked to agency PCR Policy to identify “PCR Pathways”

Call Review Criteria and Parameters

Events that require Mandatory Call Review

The frequency of QI Committee meetings

QI Reporting Procedure
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HIPAA – It’s OK to share PHI !

The use of PHI is an essential component of QI

Acceptable under the law for sharing in this capacity

Agencies and providers are responsible to ensure
confidentiality and limit use to bona fide QI operations
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HIPAA – It’s OK to share PHI !

45CFR 164.512
“ A covered entity may disclose PHI to a health
oversight agency for said oversight activity
authorized by law including; audits; civil
administrative or criminal investigations;
inspections; licensure or disciplinary actions; or
other activities necessary for appropriate
oversight in the health care system.”
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QI Guidelines for Hospital
Emergency Departments
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Hospital Responsibilities
 Appoint
EMS liaison
 Provide Patient Outcome Information
 Quarterly review of selected prehospital
cases
 Provide for clinical training and CME
 Monitor PCRs
 Provide and receive constructive feedback
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Hospital Responsibilities
 Evaluate
transfers (COBRA/EMTALA)
 Ensure PCR is part of permanent hospital record
 Participate in regional medical oversight
 Monitor on-line and direct medical control
 Provide clinical feedback on patients
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QI Guidelines for
Regional and State
Organizations
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REMACs
 Evaluate
compliance with standards
 Facilitate QI activity between hospitals
and services
 Review and revise BLS (SEMAC) & ALS
(REMAC) protocols periodically
 Establish equipment & supply standards
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REMACs
 Establish
QI procedures ensure compliance
by services
 Establish
standards for on-line medical
control facilities
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REMSCOs and/or Program Agencies
 Organize
and disperse PCR data to services
 Monitor
PCR utilization and completeness by
services’ providers
 Monitor
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for and report trends
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Department of Health – Bureau of EMS
 Provide
 Input
the Patient Care Report (PCR) forms
PCR data and send reports to regions
 Review
data from statewide perspective
 Establish
other standards necessary to foster
quality patient care (SEMAC)
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ANY QUESTIONS?
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Let’s Be Careful Out There!
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A Special Thanks!
Robert Delagi, MA, NREMT-P
Chairman, SEMSCO QI and
Evaluation Subcommittee
Bradley Kaufman, MD
Co-Chairman SEMSCO
QI and Evaluation Subcommittee
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