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QAQI - Policy On QAP

QAQI polities on quality Assurance Program

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Fret Ramirez Coronia RN
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159 views5 pages

QAQI - Policy On QAP

QAQI polities on quality Assurance Program

Uploaded by

Fret Ramirez Coronia RN
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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BestCare Ambulance Services, Inc.

35 Bedford Avenue
Gilford, NH 03249-2204
603/527-9119 Transfers
603/527-3553 Business

Quality Assurance Policy Plan and Procedure

Effective Date: 12/1999

Reviewed: 3/2000
9/2000
Monday, April, 1 2002
Friday, October 3, 2003
Wednesday, September 22, 2004

Revised: Monday, April, 1 2002


Friday, October 3, 2003
Wednesday, September 22, 2004

I. PURPOSE
To provide a consistent, systematic approach for the regular review of the quality and
appropriateness of interfacility care; to provide compliance with the Quality Assurance Plan and
Advanced Life Support Provider Standards.

Quality Assurance (QA) means an organized method of auditing and evaluating care provided
within EMS systems.” Contrary to popular belief, the primary focus of QA is on improving the
Quality of the EMS system. However, as with all medical services, questions arise as to the
appropriateness of care provided to an individual patient and the policies controlling the
provision of medical care. This plan provides both a forum for continuous system improvement
and a means to review significant incidents. A medical review process must consider the facts
concerning individual incidents, adjudicate allegations in a fashion which is consistent, provide
due process to all parties, and ensures quality patient care.

II. POLICY
BestCare shall monitor aspects of interfacility care provided by their company and report
monthly on the important aspects of the program, to include but not be limited to the following:

A. Concurrent and Retrospective Monitoring of interfacility Care

1. Supervisor field observation

2. Indicators for Prehospital Care Record (PCR) Review: (monthly 100% PCR audit)

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A. cardiac arrest
B. advanced paramedic protocol use
C. patient condition deteriorates while enroute
D. pediatric ALS care
E. all intubations
F. scene delay of > 20 minutes for a trauma patient
G. random focused audit
H. patient complaints

Medical Incident Review Responsibilities:


a) To review written or oral allegations that an EMS provider failed to act in accordance
with applicable law or protocols or that pre hospital care was below the applicable
standard of care

b) To identify protocol variations.


i) Identify variation
ii) Identify root cause
iii) Address root cause – lack of knowledge or skills, limitation of resources, poor
communications, conduct issue, etc.
c) To provide remedial action to resolve patient care issues
i) Remedial actions may include retraining, counseling, disciplinary action.
Disciplinary action is not normally considered unless the incident review
demonstrates that a conduct (behavior) problem occurred or that a pattern of similar
patient care issues exists with the provider.
ii) Establish format to document such actions
d) To notify the referring facility if deemed appropriate:
i) Extraordinary Care Protocol - 24 hours notification to EMS medical director and
required
ii) Protocol variances, other care issues – preliminary report 2 days

2) Using Quality Assurance / System Review For Quality Improvement:


a) To review patient care data in order to identify trends and sentinel events
i) Data sources may include PCR, Additional Narratives,
ii) Analyze sentinel events to determine if protocol change, equipment / resource change
or remedial action is necessary
b) To analyze trends and develop recommendations for appropriate action
i) Determine specific indicators to track in determining compliance
ii) May select a percentage of forms for random review
iii) May track specific jurisdictional indicators such as:
(1) Customer service / satisfaction

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(2) Response time
iv) Review all incidents involving a specific patient condition or procedure such as:
(1) High volume patients i.e. Asthma
(2) High risk patients i.e. Cardiac arrest
(3) Optional or new protocols i.e. RSI
(4) Opportunity to improve care i.e. Service issues with nursing homes
v) Work with Referring facility to review Managing for Results Indicators

c) Recommendations might include changes in protocol, operational procedures or


equipment
d) Plan should identify a type of review
e) Trends tracked to identify:
i) System issues
ii) Opportunities for improvement
iii) Disposition tracking

Method/Plan

BestCare will review all Patient Care Records for predefined criteria.

BestCare Ambulance will use a data collection sheet.

This sheet will ask approximately 10 questions in a yes or no format.

This sheet will have short term identifiable numbers, which protect the patient’s identity and
confidentiality.

The data from this sheet will be entered into a computer program for numerical calculation

The results of this data shall be collated, organized and printed out monthly.

Data collection and data entry sheet may be kept for a limited amount of time, however, there
disposal should occur within one year, and be in a manner consistent with the destruction of any
medical record.

Data bits may be changed as deemed desirable.

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I. GLOSSARY

II.
Compliance in quality improvement terms means are we doing what we said we would do. In
EMS terms this generally means are we following protocols.

Credentialling: the process by which the Jurisdictional Medical Director evaluates the
qualifications of an EMS provider and approves them to practice at a specific level

Data in quality assurance terms refers to readily available sets of information about a process,
treatment, etc and includes such things as runsheets, patient care reports, surveys, demographics
etc.

Discipline is a punitive action (such as written reprimand, fine, suspension or revocation of


certification or license, termination) taken by a jurisdictional operation program or EMS Board
in response to a medical incident or prohibitive conduct issue

Incident means a significant occurrence or event involving emergency response or care, a


variance from the standard of care.

Indicator means a specific thing that is tracked for evaluation purposes. In EMS it could be a
treatment, medication usage, assessment category etc.

Medical practice is the approval to practice at a specific level within a jurisdiction or state. The
jurisdictional or state medical director may suspend or limit medical practice at any time if they
feel that the provider poses a threat to health and welfare of patients.

Patient Care Incident is an incident in which patient care is not within the normal parameters.
Investigation may lead to retraining of providers involved, a change in protocol or operations or
acquisition of new or different patient care equipment. For example a patient care incident in
which in a child under the recommended age guideline was successfully resuscitated using an
AED led to a change in Maryland protocols.

Practice Review Process is a State peer review process, which recommends whether or not a
pre hospital provider’s certification or licensure needs to be suspended or revoked by the
appropriate State Board.

Privileges are benefits associated with employment or membership in an EMS program

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Protocol variation is any act or failure to act in practice or judgment, involving patient care that
is not consistent with established protocol, whether or not it results in any change in the patient’s
status or condition.

Quality Assurance (QA) means an organized method of auditing and evaluating patient care
within EMS systems. This is a broad definition that includes both tracking of “sentinel events i.e.
specific patient care incidents ” and systemwide performance.

Quality Assurance Occurrence means a patient care incident in which a protocol variation
occurs, an Extraordinary Care Procedure occurs, providers are unable to carry out physician
orders or some other sentinel event impacts patient care negatively.

Quality Control is the comparison of outcome to specifications.

Quality Improvement is also known as Continuous Quality Improvement, Total Quality


Management, Total Quality Systems, Quality Systems Improvement, Total Quality, and Quality
Management. All of these terms apply to a systematic, organization wide approach for
continuously improving all processes to deliver quality products or services. It includes four
basic ideas:
Involve employees
Focus on the customer
Use data and team knowledge to improve decision-making
Continuously improve processes

Re education provides for review of didactic information and /or skills from course materials.

Remediation process is a means of improving competence, remedying or correcting faulty


habits

Root Cause is the basic, underlying reason for variance from standard of care or sentinel event.
If root cause is identified, improvement strategies should target the root cause to reach the
desired outcome i.e. a long lasting improvement.

Sentinel Event means a rare incident or occurrence that has significant impact on patient
outcome or system function.

Return to Index

© BestCare Ambulance Services, Inc. 2000-2005. All rights reserved.

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