Quality Improvement Programs Old Requirements / New Directions

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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

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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 - Its Not the Blame Game!!!
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Organizational Efficiency Customer
Service Benchmarking
PCR Audits Technician specific Behavior
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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 PresidentMarriott 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

• 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

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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 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 ?????

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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

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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.

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Is This Your Service?

• Over 100 years of tradition.
• .not impeded by a single days progress!

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Words not to live by.

• Weve always done it like that.
• Thatll never work here..
• Cause Im the boss - thats why.

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OrIs This?

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

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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

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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 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

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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?

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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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Its 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
  communitys safety and well being

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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

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Quality Assurance (QA)
Total Quality Management (TQM)
Continuous Quality Improvement
The Baldridge System
Six Sigma
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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
• Hospitals 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 pre-selected 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 failures/defects and ambulance downtimes

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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 services 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
  pre-established 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 prior to any case review
• Focus should be supportive educational
• Should 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 youve
  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 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

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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.

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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 for and report trends

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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)

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ANY QUESTIONS?
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Lets 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