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HomeMy WebLinkAboutSOG 203.03 (02)203.03 — 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. SOG 203.03 — Medical Services Quality Assurance & Improvement Process Page 3 of 12 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. SOG 203.03 — Medical Services Quality Assurance & Improvement Process Page 4 of 12 4. Insure that patient reporting packets are properly disposed of after the monthly review per 11&11102.041K JFOIIIAT1COflffi1fl1[`1111A1.______________ 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. SOG 203.03 — Medical Services Quality Assurance & Improvement Process Page 5 of 12 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 disciplinary action, adhere to S06 702.02-- 4"'CWNLjXJN'Y ]NOIJ1111' ------------------------------------------ 2 --------- = ------- ll� ili�t iliili lilt l�t �ili 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 ­ ------------------ ("'OHINLAINirl' ]NOIJ1111' ISCJINLJNI� ---------------------- 11 --------------- -- ------------------------------------------------------- ------------- 11111W'111�ssl.. 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. SOG 203.03 — Medical Services Quality Assurance & Improvement Process Page 8 of 12 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. 10i1.03°- 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. SOG 203.03 — Medical Services Quality Assurance & Improvement Process Page 9 of 12 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. SOG 203.03 — Medical Services Quality Assurance & Improvement Process Page 10 of 12 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 102.0419, �I �I� ilu �l�� Irl ----------1-----U--1--,1-1--1---N-l�l� II 1-01-1------A-----1-4- H!�"� 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 SOG 203.03 — Medical Services Quality Assurance & Improvement Process Page 12 of 12