QI_Manual maine.pdf - Maine EMS Quality Improvement Program January 2012 Maine EMS Quality Improvement Program January 2012 INTRODUCTION 3

QI_Manual maine.pdf - Maine EMS Quality Improvement Program...

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Maine EMS Quality Improvement Program January 2012
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Maine EMS Quality Improvement Program January 2012 2 INTRODUCTION ..................................................................................................................................................................... 3 A CKNOWLEDGEMENTS ................................................................................................................................................................................... 4 CHAPTER 1; ESTABLISHING AN EMS QUALITY IMPROVEMENT PROGRAM ........................................................ 5 S ECTION 1: L EGAL C ONSIDERATIONS .................................................................................................................................................. 5 S ECTION 2: O RGANIZATIONAL C OMMITMENT ................................................................................................................................... 5 S ECTION 3: Q UALITY I MPROVEMENT C OORDINATOR ...................................................................................................................... 5 S ECTION 4: Q UALITY I MPROVEMENT C OMMITTEE ........................................................................................................................... 5 S ECTION 5: W RITTEN P LAN ................................................................................................................................................................. 6 S ECTION 6: T WO WAY C OMMUNICATION .......................................................................................................................................... 7 S ECTION 7: C ONFIDENTIALITY AND P ROTECTED H EALTH I NFORMATION ................................................................................... 8 CHAPTER 2: BEGINNING THE PROCESS .......................................................................................................................... 9 S ECTION 1: G ETTING S TARTED ............................................................................................................................................................ 9 S ECTION 2: C ONVERTING I NFORMATION TO P OSITIVE A CTIONS ................................................................................................. 10 CHAPTER 3: NEXT STEPS IN QUALITY IMPROVEMENT ......................................................................................... 11 S ECTION 1: A GENCY S ELF ‐A SSESSMENT : T HE S TARTING P OINT ................................................................................................. 11 S ECTION 2: A DVERSE E VENT AND N EAR ‐M ISS R EPORTING S YSTEMS ........................................................................................ 12 S ECTION 3: C USTOMER S ERVICE ........................................................................................................................................................ 13 CHAPTER 4; ADDITIONAL RESOURCES FOR SERVICE OR SUB ­ REGIONAL QI COMMITTEES ...................... 18 S ECTION 1: R EGIONAL EMS O FFICES ............................................................................................................................................... 18 S ECTION 2: S TATE EMS O FFICE ........................................................................................................................................................ 18 A PPENDICES ................................................................................................................................................................................................... 19 Appendix A ­ Glossary of Key Terms ................................................................................................................................................. 19 Appendix B ­ QI Committee Topics ................................................................................................................................................... 21 Appendix C ­ Medical Director Job Description ........................................................................................................................... 22 Appendix D ­ Sample QI Service Plan .............................................................................................................................................. 24 Appendix E ­ Evaluating Performance in Your Organization .............................................................................................. 24 Appendix F ­ QI Audit Examples ­ XYZ EMS .................................................................................................................................. 27 XYZ EMS ‐ Airway QI Audit .......................................................................................................................................................................... 29 XYZ EMS ‐ Patient Refusal Audit ................................................................................................................................................................ 30 Appendix G ­ HIPAA .................................................................................................................................................................................. 32 Appendix H ­ Strategic Planning ....................................................................................................................................................... 33 Appendix I ­ 12 Lead Model QI Programs, Quality Markers/Targets and Resources ................................................ 34 Appendix J ­ Maine EMS Run Reporting System ......................................................................................................................... 40
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