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Quality Improvement Programs Old Requirements / New Directions

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Title: Quality Improvement Programs Old Requirements / New Directions


1
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

2
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

3
(No Transcript)
4
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.

5
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

6
CQI - Its Not the Blame Game!!!
7
Organizational Efficiency Customer
Service Benchmarking
PCR Audits Technician specific Behavior
8
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

9
  • ... 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

10
  • Everyone in a service oriented organization has
    a service role, even those who never see the
    customers.Researchers Karl Albrecht and Ron
    Zemke

11
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.

12
SYSTEM is the operative word
  • A complex unity formed of many often diverse
    parts subject to a common plan or serving a
    common purpose.

13
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

14
15 Components of an EMS System
  • Access to Emergency Care
  • Patient Transfer
  • Standardized Recordkeeping
  • Public Information Education
  • System Review Evaluation
  • Disaster Management
  • Mutual Aid
  • Manpower
  • Training
  • Communications
  • Transportation
  • Hospitals
  • Critical/Specialty Care
  • Public Safety Agencies
  • Consumer Participation

15
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.

16
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?

17
Who are the Customers ?
  • The Patient
  • The Patients Family
  • Taxpayers
  • Managed Care Organizations/Insurance Companies
  • Physicians, Nurses, Hospitals
  • Health Care Organizations
  • REMSCO, REMAC, SEMSCO, SEMAC, TRAUMA TRAUMA
    COUNCILS, ETC
  • City Council, Town Board
  • Police/Fire, Public Health Personnel
  • Others ?????

18
Agency Leadership Management Test
  • Authority
  • Command
  • Yeah..I got a Chiefs car!
  • I am in Charge
  • People will have to listen to me now
  • Responsibility
  • Accountability
  • To the patients
  • To the members
  • To the taxpayers

19
Dangerous Attitudes
  • Were only volunteers, we do the best we can.
  • We are 911! Who else you going to call.
  • Its my district, and I am in charge, and we
    are the only game in town.

20
Is This Your Service?
  • Over 100 years of tradition.
  • .not impeded by a single days progress!

21
Words not to live by.
  • Weve always done it like that.
  • Thatll never work here..
  • Cause Im the boss - thats why.

22
OrIs This?
  • teem-work the joint action by a group of
    people, in which individual interests are
    subordinate to the groups unity and efficiency

23
Management 101Accentuating the Positive
  • Compliment your employees whenever possible - and
    appropriate
  • Although its easier to focus on the negative
    dont do it!
  • Frequent small acknowledgments outweigh rare
    large ones
  • Praise in public - discipline in private

24
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

25
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

26
Data Collection / Analysis And The Strategy
Change Cycle
  • Setting the organizations 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

27
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?

28
Plan-Do-Check-Act
  • This is a continuous process without end.

29
What is Continuous Quality Improvement?
30
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.

31
Its also the LAW
  • Most states have a component of their EMS statute
    or code that mandates at least some form of QI
    program

32
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

33
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

34
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
    communitys safety and well being

35
Traditional Approach
  • Retrospective analysis Review of agencys
    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

36
Quality Assurance (QA)
Total Quality Management (TQM)
Continuous Quality Improvement
The Baldridge System
Six Sigma
37
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

38
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

39
QI Guidelines for EMS Services Providing
Prehospital Care
40
Select a QI Coordinator
  • The service Medical Director
  • Hospitals EMS QI Coordinator
  • The system Medical Director
  • E.D. physician
  • Senior prehospital provider

41
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

42
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

43
Objective of an Audit
  • To compare actual performance with desired
    performance
  • Mechanism Identify and monitor pre-selected key
    indicators

44
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

45
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

46
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

47
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

48
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

49
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

50
Methods of Evaluation
  • 3. Retrospective Methods
  • Recognition of past deficiencies, trends
    patterns
  • Medical debriefings
  • Critique sessions
  • Audits
  • Practice profile/credentialing
  • Incident reports

51
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

52
Some Thoughts on What to Review
  • Diagnosis specific
  • Population specific
  • Patient satisfaction or complaints
  • RMAs
  • Intubations
  • Educational Programs
  • Didactic Understanding
  • Skills Performance

53
Some Thoughts on What to Review
  • Sentinel events
  • Standard of Care deviation
  • Incident reports
  • Unusual occurrences
  • Equipment failures/defects and ambulance downtimes

54
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

55
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

56
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

57
Predetermined Paths of Action
  • Key QI personnel should have clearly identified
    roles understood by all
  • Ultimate responsibility for areas of improvement
    lies with the services Governing Authority

58
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

59
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

60
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

61
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

62
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

63
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

64
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?

65
Sample Review
  • Provide Structured Feedback
  • Excellence
  • Weakness
  • Publicize results to all concerned (reinforces
    positive behavior)
  • Targeted Remedial Activity as indicated
  • Re-visit

66
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

67
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?

68
Sample Review
  • Provide Structured Feedback
  • Excellence
  • Weakness
  • Publicize results to all concerned (reinforces
    positive behavior)
  • Targeted Remedial Activity as indicated
  • Re-visit

69
Is this you?
70
Organizational QI Plan
  • Developed prior to any case review
  • Focus should be supportive educational
  • Should not revolve around crisis management

71
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

72
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 youve
    completed your Plan
  • References to State Legislation and Regional
    Guidelines and Policies as the basis of your
    document

73
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

74
HIPAA Its 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

75
HIPAA Its 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.

76
  • QI Guidelines for Hospital
  • Emergency Departments

77
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

78
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

79
  • QI Guidelines for
  • Regional and State
  • Organizations

80
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

81
REMACs
  • Establish QI procedures ensure compliance by
    services
  • Establish standards for on-line medical control
    facilities

82
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

83
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)

84
ANY QUESTIONS?
85
Lets Be Careful Out There!
86
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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