HomeMy WebLinkAboutSOG 203.03 REVISED 7-2017_QA & QI203.03 — Medical Services Quality Assurance & Improvement
Effective. 2/1/2008
Revised: 7/5/2017
Replaces: UOG 203.01 B
I. Guiding Philosophy
As emergency medical services providers, we are charged with providing quality care
that is based on medical direction, mandated standards, legal requirements, City, and fire
department policies. To ensure that our services are delivered consistently, meet quality
standards, and that our response capabilities are improved whenever and wherever we can, we
routinely review calls for service to measure, assess and improve upon our performance.
II. Purpose
The purpose of this policy is to describe the emergency medical quality assurance and
improvement process that will be utilized by Beaumont Fire -Rescue Services.
III. Goals
The goals of this policy are to:
A. Discuss the mission and objectives of the Emergency Medical Response Program.
B. Communicate confidentiality concerns and consequences regarding unauthorized
disclosure of medical information.
C. Assign implementation responsibilities relative to the overall QA/QI process.
D. Detail the QA/QI standards-based peer review process to be implemented.
IV. Definitions
A. Benchmark — A procedure or process established as a minimum standard for
assessing relative performance.
B. BFR Emergency Medical Program Manager — District Chief who is tasked
with day-to-day supervision, quality management, appropriate follow up, growth
and improvement of the fire department's Emergency Medical First Responder
Programs (BLS and ALS levels), and who serves as facilitator of the Medical
Services Advisory Group (MSAG).
C. BFR Medical & Officer Development Branch Director — Deputy Chief who is
tasked with executive management and leadership of the emergency medical,
health and wellness, and officer development programs.
D. Initiating Action/Intervention Time — Time -stamped interval from arrival time
to patient contact time.
E. MSAG — Medical Services Advisory Group, a standing BFRS committee.
F. NFPA 1710 —National Fire Protection Association Standard for the Organization
and Deployment o Fire Suppression Operation, Emer enc Medical Operations
and Special Operations to the Public by Career Fire Departments.
G. Protocols — Approved off-line medical direction that outlines the acceptable
method of providing patient care in a particular situation.
H. Quality Assurance (QA) — A formal methodology designed to assess the quality
of services provided, including formal review/evaluation of actions taken and
care, problem identification, corrective actions to remedy any deficiencies.
I. Quality Improvement (QD — A continuous process that identifies relative
effectiveness and efficiencies in service delivery, examines solutions to the issues
identified, and regularly monitors and evaluates the solutions to assess results.
J. Standard Firehouse Report Form (SFRF) — Electronic form used to document
medical service delivery.
K. Total Response Time — Time stamped interval from dispatch time to arrival time.
L. Travel Time — Time stamped interval from enroute time to arrival time.
M. Turnout Time — Time stamped interval from dispatch time to enroute time.
N. Patient Transfer Report — Paper-based form used to document patient
information necessary for a transfer of care.
V. Mission and Objectives of the BFR Emergency Medical Response Program
A. The mission of the department's Emergency Medical Response Program is to
provide prompt, patient -centered medical assessment and/or treatment to people
requesting our assistance.
B. To achieve this mission, we strive to provide care that is:
SAFE — Preventing injury, accident or exposure to patients, responders or
bystanders.
SOG 203.03 — Medical Services Quality Assurance & Improvement Process Page 2 of 12
2. EFFECTIVE — Providing patient -centered, science -based emergency
medical services to those who would benefit, and refraining from
providing these services to those who are not likely to benefit.
TIMELY — Striving to reduce avoidable delays.
4. EFFICIENT — Avoiding waste, including care and management of
equipment, supplies, effort.
C. To meet these objectives, emergency medical calls for service will be
systematically reviewed in an ongoing Quality Assurance/Quality Improvement
(QA/QI) Program.
The QA/QI Program demonstrates the department's commitment to
ensuring and advancing the quality of care delivered.
2. The QA/QI Program outlines strategies for ensuring patient and
responder safety, delivering quality care, and achieving high patient
satisfaction.
The QA/QI Program focuses on direct delivery of patient care and
support processes that promote optimal patient outcomes and fiscal
responsibility.
4. Since the fire department's Emergency Medical Response Services do
not exist in isolation, patient care must also be evaluated as it relates to
the broader healthcare system within the community.
VI. Confidentiality
A. Unlike treatment situations where a patient's entire record is shared with other
health care providers, QA/QI activities normally apply a "minimum necessary"
standard relative to the information needed to accomplish the task.
B. Strict protection of peer review material will be adhered to in accordance with the
following provisions:
No member, consultant, advisor or person supplying information to the
MSAG or sub-group(s) shall disclose patient information concerning
matters submitted to, considered by, or issuing from the QA/QI process of
the MSAG or sub-group(s).
2. No disclosure of any interview materials, reports, records, statements,
memoranda, proceedings, findings or data shall be made without the
authorization of the Medical Director or his/her designee.
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C. Unauthorized disclosure will be grounds for disciplinary action, up to and
including indefinite suspension. For information on handling patient health
information refer to iliWR '10AWlK ilii"11(W1'1WTUll) 113WlL'I' l IN17011.I "hiliO
VII. Implementation Responsibilities
A. The Medical Services Advisory Group (MSAG) will perform routine the QA/QI
review process monthly.
B. The BFR Emergency Medical Program Manager (District Chief) will:
Facilitate and manage monthly MSAG and QA/QI meetings
a. Set the monthly meeting dates, times and locations
b. Notify group members of meetings in a timely manner to
maximize participation in the program development and review
processes.
c. Insure that all identified Standardized Firehouse Run Forms
(SFRFs) will be reviewed according to the process outlined in this
policy, established protocols and benchmarks, and in a timely
manner.
d. Insure that meeting minutes, status, exception, completion,
monthly and other reports, and overtime hours are accurately
reported to his/her assigned and Medical Branch chain of
command in a timely manner.
2. Attend periodic meetings with the Medical Director or other community
healthcare practitioners.
3. Forward a Quarterly QA/QI Summary Report of year-to-date
recommendations made and their current status to the Management Team.
4. Insure that recommendations reviewed by the Management Team and/or
action items and are followed up on in a timely manner.
C. The Emergency Medical Training Coordinator (Captain) will:
1. Serve as the QA/QI Coordinator.
2. Compile, reproduce, and distribute patient reporting packets to MSAG
members for the purposes of monthly QA/QI review.
3. Insure original review checklists and supplementary reports and/or
documentation is filed in Laserfiche.
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4. Insure that patient reporting packets are properly disposed of after the
monthly review per 11&11102.041K
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5. Insure timely follow up and proper documentation of individual, group
and/or departmental training needs that are identified during the QA/QI
review process or during benchmark evaluations.
6. Coordinate logistical needs of medical training classes, to include but
not limited to:
a. Instructor and classroom scheduling and set up
b. Development of curriculum, classes and benchmarks
c. Delivery/pick up of training aids, materials and classes.
7. Provide status, exception and completion reports for all action items.
8. Communicate emergency medical training program activities,
achievements, progress and QA/QI and benchmark evaluation lessons
learned in the monthly report.
9. Coordinate with the Logistics Section chain of command (Logistics
Section Chief, Support & Services Branch Directors) to insure:
a. Emergency medical training needs are addressed when discovered,
and that remedial training activities are properly documented.
b. Scheduled and/or random medical benchmark evaluations are
conducted each month to insure minimum performance standards
are met or exceeded.
c. Coordination/scheduling of members being credentialed in the
ALS First Responder Program.
d. Certifications are maintained per Texas Department of State Health
Services (TDSHS) requirements.
D. The Support Branch Director (District Chief) will:
1. Insure the responsibilities of the Emergency Medical Training
Coordinator (Captain) outlined above are being completed in an
appropriate and timely manner, providing his/her assistance and support
when required.
2. Insure all training activities and programs are documented appropriately
and in a timely manner.
3. Coordinate with the Services Branch Director on all training aspects of
the Emergency Medical Program to insure the medical training program
meets or exceeds minimum competency and regulatory standards at both
the BLS and ALS levels.
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4. Routinely audit training curriculum, classes, and benchmark evaluations
to insure program integrity and competency standards are achieved.
5. Insure medical supplies are efficiently maintained and distributed to
support safe and effective emergency medical response operations.
6. Follow up on deficiencies in any of the responsibilities listed above
professionally and in a timely manner.
7. Coordinate with members of the Management Team related to
recommendations, issues, questions or concerns.
E. The Logistics Section Chief (Deputy Chief) will:
Insure leadership and effective management of all logistical aspects of
the emergency medical response program, to include but not limited to
the following:
a. Support Branch — supply and ground support, equipment
maintenance, purchasing, certification and training.
b. Services Branch — communications and technology, medical and/or
food unit activations.
2. Coordinate with members of the Management Team related to
recommendations, issues, questions or concerns.
F. The Medical & Officer Development Branch Director (Deputy Chief) will:
Insure leadership and effective management of all operational aspects of
the emergency medical response program to include but not limited to
the following activities:
a. Medical field operations meet or exceed competency, regulatory
and quality standards.
b. Track local, state and national medical response trends to insure
the program and services adapt to meet changing needs
c. Monitor NFPA 1710 compliance.
d. Work together with Operations Deputies and Logistics Section
personnel to support seamless integration of logistical and
operational requirements.
2. Coordinate with members of the Management Team related to
recommendations, issues, questions or concerns.
G. The Operations Section Chief (Assistant Chiefs and Fire Chief, in conjunction
with the Management Team, will work together and with external stakeholders to
support safe, effective, efficient medical response operations.
H. Based on the outcome of a review, the MSAG may recommend remedial or other
corrective actions. If a review or situation reveals conduct that may lead to
SOG 203.03 — Medical Services Quality Assurance & Improvement Process Page 6 of 12
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V111. QA/Ql Standards-based Peer Review Process
A. Any peer review will require a minimum of three MSAG members, with at least
one being a certified EMT -Paramedic.
B. Group members MAY NOT review forms for incidents in which they were
involved.
C. As a minimum, the review will include an evaluation of
1. Run times
2. Form completeness
3. Readability
4. Use of proper terminology
5. Interpretive findings (diagnostic skills)
6. Adherence to operational policies
7. Adherence to treatment protocols
D. If specific medical standards are not available, the Medical Director will provide
needed guidance and make decisions regarding the standard of care.
E. The following calls for service will be pulled for review:
1. All runs where medications were administered.
2. All cardiac arrest events.
3. Every tenth medical run.
4. Any call where there have been scene issues or complaints.
F. Inquiry or investigation related to any serious issues should begin within twenty-
four (24) hours of notification of the issue, and adhere to S06 702.02
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SOG 203.03 — Medical Services Quality Assurance & Improvement Process Page 7 of 12
G. Beaumont Fire -Rescue Services will comply with its obligation to report serious
incidents to the Texas Department of State Health Services (TDSHS). Such
reportable incidents include, but are not limited to:
1. Medication errors resulting in serious injury.
2. Failure to provide treatment in accordance with treatment protocols
resulting in serious injury.
3. Major medical communications device failure, or other equipment failure
or user error resulting in serious injury or delay in response or treatment.
IX. Overview of Quality Assurance/Quality Improvement
A. Although the terms quality assurance and quality improvement are often used
interchangeably, they each have a distinct meaning. QUALITY ASSURANCE
focuses on services that were provided, while QUALITY IMPROVEMENT focuses on
improvement of services. The department's medical program management uses a
cyclic process.
An organization should PLAN to improve
quality of services. They should then DO it by rPLAN ao
putting the plan in action, CHECK to see how
well it worked, and then ACT to make any AC7 CHECK
changes necessary to achieve the desired
results.
2. Standards, laws, ordinances, department policies, recommendations,
surveys, and industry best practices are used to identify areas for
analysis and common benchmarks in the QA/QI process. Sources used
to identify areas for analysis and common benchmarks for comparison
include:
a. Texas Department of State Health Services (TDSHS)
b. National Institute of Health (NIH)
c. National Fire Protection Association (NFPA)
d. U. S. Fire Administration (USFA),
e. International Association of Fire Chiefs (IAFC)
f International Association of Firefighters (IAFF)
g. International City/County Management Association (ICMA).
B. Response Times
According to NIH and the 2016 edition of the NFPA 1710 standard, the
response time benchmark for first medical responder to arrive at the
scene of a cardiac arrest event should be five minutes or less from the
time of dispatch. This standard should be met 90% of the time.
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2. Total response time data will be calculated using a fractile method of
measurement. The following will be evaluated:
a. Turnout time shall be 60 seconds or less
b. Travel time shall be 240 seconds or less
c. Initiating action/intervention time (Patient Contact) shall be 60
seconds or less
C. Completeness and Accuracy of Required Documentation
The National Fire Incident Reporting System (NFIRS) is a result of
Public Law 93-498, which mandates the collection of response data. As
such, response data entered into the Firehouse database must be accurate
and complete to assist in this process.
2. Responsibilities for entering and quality checking of response
information are outlined in S041 106.03,--
D.
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D. Achieving Effective Communications in Documentation
Seven Golden Rules for Document Writing
a. Use short, simple, familiar words
b. Avoid j argon
c. Use culture and gender neutral language
d. Use correct grammar, punctuation, and spelling
e. Use simple sentences, active voice, and present tense
f. Begin instructions in the imperative mode by starting sentences
with an action verb
g. Use simple graphic elements such as bulleted lists and
numbered steps to make information visually accessible
2. Using Proper Terminology
a. USE COMMON TERMINOLOGY— Avoid the use of "10 codes." It
is easier and more effective to use common terminology, and
this helps to avoid confusion.
b. ABBREVIATIONS MAY HAVE MORE THAN ONE MEANING—
Abbreviations must makes sense within the context of the
report and you must be able to recall its meaning in the future.
EXAMPLE:
IN°ppm "Assessment revealed no left BS."
ORRECI'a "Assessment revealed absent left bowel sounds."
................................................
NOTE:
No left "BS" could be misinterpreted as no left breath sounds.
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c. DO NOT MAKE UP ABBREVIATIONS—Proper medical
abbreviations that are used every day and are universally
understood are appropriate. It is inappropriate to "substitute"
an abbreviation to cover a lack of understanding or spelling
error. Google it!
E. Interpretive Findings (Diagnostic Skills)
1. During patient assessment, interpretive findings are the analysis,
presentation, and implementation of findings.
2. Once a determination of the patients' complaint is made, the appropriate
protocol/procedure should be initiated to begin treatment.
Documentation of interpretive findings verifies that the proper treatment
has been provided, and also documents any positive or negative
outcomes.
F. Adhering to Rules, Regulations, Policies & Treatment Protocols
1. Violations of department rules, regulations or guidelines will be noted in
the QA/QI review.
2. Deviations from SOG will be
noted in the QA/QI review.
3. Recommendations will be made and evaluated in accordance with
Section VII of this policy.
G. Confidentiality of Reports
The patient report contains the patient's private demographic and
personal medical information. INFORMATION CONTAINED IN A PATIENT
REPORT IS THE PATIENT'S PROPERTY.
2. Although HIPAA legislation is broad in scope, its Privacy Rule has
immense importance for emergency responders. UPON ARRIVAL AT THE
SCENE, THE MEDICAL RESPONDER BECOMES A LEGAL CUSTODIAN OF
THIS INFORMATION AND IS ACCOUNTABLE FOR ITS PROPER HANDLING.
Use the Patient Care Transfer Report to document as the scene/patient
presents.
4. Keep patient information secure, and be aware of who is watching. If
your report is left on the clipboard, it can be easily viewed by others.
5. When providing a copy of the report, always give it to the medical
personnel accepting transfer of patient care.
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6. The Patient Care Transfer Report is used only from the scene to the station,
once information is entered into Firehouse, shred the form per 1W[t
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H. Minimum Data required for the SFRF (Patient Information)
1. Basic Tab
a. Name, address, phone numbers
b. Date of birth
c. Gender
d. Race, Ethnicity
e. Patient Disposition
2. Response Tab
a. Verify times
b. Transfer of care
c. Lights and sirens to scene
d. Primary role of the unit
3. Scene Tab
a. Initial observed condition
b. Past medical history and alerts
c. Aid given prior to arrival
4. Clinical Tab
a. Complaint Tab
i. Chief Complaint
ii. Signs and Symptoms
b. Provider Tab
i. EMS provider level (Fire Department Only)
ii. Provider Impression
iii. Protocols
iv. Patient/Staff Exposures
v. Exposure Precautions Taken
c. Cardiac Arrest and CPR Tab
i. Only used if incident was a cardiac/respiratory arrest
5. Assessments & Treatments Tab
a. Add Vitals
b. Add Procedures
c. Add Medications
6. Patient Narrative
a. Auto Generate
b. Add Information
SOG 203.03 — Medical Services Quality Assurance & Improvement Process Page 1 1 of 12
Related Criteria & Forms:
• SFRF Review Checklist
• SFRF Review Checklist Criteria
• Dispatch Review Checklist
• Dispatch Review Checklist Criteria
• FH Report Review Checklist
• FH Report Review Checklist Criteria
• Patient Care Transfer Report
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