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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 SEMSCO/SEMAC DOH BEMS

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quality improvement programs old requirements new directions

Quality Improvement ProgramsOld Requirements / New Directions

New York State Emergency Medical Services Council

State Emergency Medical Advisory Committee

Department of Health - Bureau of Emergency Medical Services

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

table of contents
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.”
table of contents5
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

Organizational Efficiency

Customer Service


PCR Audits

Technician – specific Behavior


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
“... 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 PresidentMarriott Corporation
“Everyone in a service oriented organization has a service role, even those who never see the customers.”Researchers Karl Albrecht and Ron Zemke
ems system goals
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.
system is the operative word
SYSTEM is the operative word

A complex unity formed of many often diverse parts subject to a common plan or serving a common purpose.

the birth and development of an ems system
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
15 components of an ems system





Critical/Specialty Care

Public Safety Agencies

Consumer Participation

Access to Emergency Care

Patient Transfer

Standardized Recordkeeping

Public Information & Education

System Review & Evaluation

Disaster Management

Mutual Aid

15 Components of an EMS System
benchmarking 101
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.

benchmarking 10116
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?
who are the customers
Who are the Customers ?
  • The Patient
  • The Patient’s Family
  • Taxpayers
  • Managed Care Organizations/Insurance Companies
  • Physicians, Nurses, Hospitals
  • Health Care Organizations


  • City Council, Town Board
  • Police/Fire, Public Health Personnel
  • Others ?????
agency leadership management test


Yeah..I got a Chief’s car!

I am in Charge

People will have to listen to me now



To the patients

To the members

To the taxpayers

Agency Leadership & Management Test
dangerous attitudes
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.”

is this your service
Is This Your Service?

Over 100 years of tradition….

….not impeded by a single day’s progress!

words not to live by
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….”
or is this
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

management 101 accentuating the positive
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
cqi the strategic planning process
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

strategic planning
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
data collection analysis and the strategy change cycle
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
from philosophical to operational in 5 easy steps
From Philosophical to Operational in 5 Easy Steps
  • 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?
plan do check act

This is a continuous process without end.

what is quality improvement
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.
it s also the law
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

qi laws and regulations
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
  • Federal Regulations - HIPAA
qi is a continuous activity
QI is a ContinuousActivity

From a Service Perspective

  • Reinforces excellence
  • Helps the service document its care
  • Provides constructive feedback to stakeholders
  • Identifies deficiencies
  • Improves performance through education
qi is a continuous activity34
QI is a ContinuousActivity

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
traditional approach
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

Quality Assurance (QA)

Total Quality Management (TQM)

Continuous Quality Improvement

The Baldridge System

Six Sigma

modern view
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
modern view38
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
select a qi coordinator
Select a QI Coordinator
  • The service Medical Director
  • Hospital’s EMS QI Coordinator
  • The system Medical Director
  • E.D. physician
  • Senior prehospital provider
duties of a qi coordinator
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
resources for qi coordinator
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
objective of an audit
Objective of an Audit
  • To compare actual performance with desired performance
  • Mechanism: Identify and monitor pre-selected key indicators
qi criteria indicators should be
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
types of audits
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
types of audits46
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
types of audits47
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
methods of evaluation
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
methods of evaluation49
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

methods of evaluation50
Methods of Evaluation

3. Retrospective Methods

Recognition of past deficiencies, trends & patterns

  • Medical debriefings
  • Critique sessions
  • Audits
  • Practice profile/credentialing
  • Incident reports
some thoughts on what to review
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
some thoughts on what to review52
Some Thoughts on What to Review
  • Diagnosis specific
  • Population specific
  • Patient satisfaction or complaints
  • RMAs
  • Intubations
  • Educational Programs
    • Didactic Understanding
    • Skills Performance
some thoughts on what to review53
Some Thoughts on What to Review
  • Sentinel events
    • Standard of Care deviation
  • Incident reports
    • Unusual occurrences
  • Equipment failures/defects and ambulance downtimes
advantages of a qi program
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
advantages of a qi program55
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

successful qi requires
Successful QI Requires
  • Willing cooperation of all providers in the EMS system
  • Recognition of a common need for:

• Education • Structured feedback

• Professionalism • Mutual respect


predetermined paths of action
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
general process for qi
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 pre-established standards
general process for qi59
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
general process for qi60
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
steps in a qi program
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
steps in a qi program62
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
sample review
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
sample review64
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?

sample review65
Sample Review
  • Provide Structured Feedback
    • Excellence
    • Weakness
    • Publicize results to all concerned (reinforces positive behavior)
    • Targeted Remedial Activity as indicated
    • Re-visit
sample review66
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
sample review67
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?

sample review68
Sample Review
  • Provide Structured Feedback
    • Excellence
    • Weakness
    • Publicize results to all concerned (reinforces positive behavior)
    • Targeted Remedial Activity as indicated
    • Re-visit
organizational qi plan
Organizational QI Plan
  • Developed prior to any case review
  • Focus should be supportive & educational
  • Should not revolve around crisis management
effective qi programs
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
writing a qi plan
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
writing a qi plan73
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
hipaa it s ok to share phi
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
hipaa it s ok to share phi75
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.”

QI Guidelines for Hospital

Emergency Departments

hospital responsibilities
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
hospital responsibilities78
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
QI Guidelines for

Regional and State


  • Evaluate compliance with standards
  • Facilitate QI activity between hospitals and services
  • Review and revise BLS (SEMAC) & ALS (REMAC) protocols periodically
  • Establish equipment & supply standards
  • Establish QI procedures ensure compliance by services
  • Establish standards for on-line medical control facilities
remscos and or program agencies
REMSCOs and/or Program Agencies
  • Organize and disperse PCR data to services
  • Monitor PCR utilization and completeness by services’ providers
  • Monitor for and report trends
department of health bureau of ems
Department of Health – Bureau of EMS
  • Provide the Patient Care Report (PCR) forms
  • Input PCR data and send reports to regions
  • Review data from statewide perspective
  • Establish other standards necessary to foster quality patient care (SEMAC)
a special thanks
A Special Thanks!

Robert Delagi, MA, NREMT-P

Chairman, SEMSCO QI and

Evaluation Subcommittee

Bradley Kaufman, MD

Co-Chairman SEMSCO

QI and Evaluation Subcommittee