Bernalillo County Fire & Rescue EMS Report Quality Assurance and Quality Improvement (QA/QI) Policy PDF

**PURPOSE** The purpose of this policy is to outline how the QA/QI team is selected and clarify the duties, responsibilities, and benefits of being on the team, establishing the criteria in which reports are reviewed, explain how reports will be assigned and reviewed by team members, address how co...

**PURPOSE** The purpose of this policy is to outline how the QA/QI team is selected and clarify the duties, responsibilities, and benefits of being on the team, establishing the criteria in which reports are reviewed, explain how reports will be assigned and reviewed by team members, address how corrective action and remediation will be handled, and identify the need for records management. **POLICY** It is the policy of the Bernalillo County Fire and Rescue to establish a continuous Quality Assurance Program to review every EMS report generated at least once. Some of the highest acuity calls will be reviewed more than once. The reference resource for this task in Bernalillo County is the applicable revision release of the adopted protocols. Emergency Medical Services (EMS) Quality Assurance is mandated by the New Mexico Department of Health (NM DOH) EMS Bureau for Medical Rescue Services in 7.27.10 NMAC. **PROCEDURE** - Quality Assurance (QA) -- the retrospective review or inspection of EMS incident records to determine if appropriate care was provided as defined in 7.27.10.7 NMAC Section VV. - Quality Improvement (QI) -- the application of preventive or corrective measures to ensure that deficiencies (continued non-compliance and/or departure from EMS protocols, policies & procedures and any pertinent memoranda) are addressed and quality care is provided on all EMS reports. - **Company Officers/Paramedics** -- Incident reports are first reviewed by the station officer/Paramedic to assure that the incident report and all associated documents are complete, clerically correct, and referred (as applicable) for QA/QI. It is required that the company officer/Paramedics close all reports by the end of the shift. - **Field Personnel** -- Are to complete all EMS reports as per the EMS Report Writing Manual and policy and procedure. When the report meets predetermined criteria, notification will be sent to the EMS Division for review. If for any reason, there is a circumstance where a QA/QI is desired outside of the criteria, field personnel should indicate this by checking the box labeled "EMS Review Requested for this Patient". - **EMS Division** - It is the duty of the EMS Division to: - Assign a member of the EMS Division as the QA/QI Officer; this will be done by the EMS Division Chief. - Notify the QA/QI team member, via e-mail, of each scheduled meeting date, time and place with at least ten-day advanced notice. - Take attendance at the QA/QI meetings. - Take minutes at the QA/QI meeting. - Issue Continuing Education (CE) credit for attendance at QA/QI meetings. - Archive the minutes and attendance rosters in the appropriate repository.. - Bring issues of deep concern and/or willful departure from protocol to the attention of the EMS Division Chief. - Develop training based on information gathered from QA/QI issues. I. **QA/QI TEAM SELECTION, COMPENSATION, AND PRIVILEGES** The EMS QA/QI team shall review EMS reports and make recommendations to the personnel under the authority of the Division Chief of EMS. A. When vacancies occur on the QA/QI team, a memo will be sent out by the Division Chief of EMS requesting letters of interest. 1. This team is made up of field personnel who hold an EMT Paramedic license. 2. Selection will be made by the Division Chief of EMS based on the recommendation of the QA/QI officer and existing team members. B. Upon selection and acceptance, the QA/QI team member shall complete a "Commitment to EMS Quality Assurance Team" form provided by the EMS Division. 3. As a member of the team, this form is to be submitted annually. C. QA/QI team members are offered up to five (5) hours of "Additional Time" paid monthly for their review of EMS incidents, timely forwarding of QA/QI forms, or completion of special assignment relating to Quality Assurance as assigned by the medical director. 4. If the member of the QA/QI team does not submit the completed assignment prior to the scheduled QA/QI meeting, no pay will be given for that month of QA/QI. 5. If after two (2) occurrences of inattention to their QA/QI commitment, the member may be removed from the QA/QI team at the discretion of the Division Chief of EMS. D. QA/QI team members are given up to a total of five (5) hours of continuing education credit per licensing period by the EMS Division for attendance at the monthly QA/QI meeting. E. The QA/QI team members shall be afforded permission and authority to the electronic reporting system, such that they may gain access to reports for the purposes of audit, review, and statistical investigation. This level of authority is only provided while serving on the QA/QI team. F. When a QA/QI team member no longer wishes to be part of the QA/QI team, they must submit a letter to the Division Chief of EMS stating they would like to be removed from the team. II. **CRITERIA FOR REPORTS TO AUTOMATICALLY BE REVIEWED** A. The following list are areas that have been identified by the Medical Director as criteria for automatic QA/QI review (Medical Director has the authority to add criteria to the list below at any time). - *Patient died in EMS care after EMS contact.* - *Patient transported any distance by BCFR.* - *The patient received synchronized cardioversion.* - *The patient received transcutaneous pacing.* - *Needle decompression of the patient's chest was attempted or performed.* - *The patient received an advanced airway.* - *Use of tourniquet.* III. **ASSIGNING REPORTS TO BE EVALUATED** A. Fifteen percent (15%) of the EMS call volume will be evaluated by the QA/QI team monthly. ***"G. Quality assurance review.** An EMS agency shall implement a quality assurance program, which shall be planned, developed and implemented by the EMS agency's medical director in a manner consistent with 7.27.3 NMAC ("Medical Direction for Emergency Medical Services"). The quality assurance program shall include review of documentation of patient care in a pre-determined set of circumstances to ensure a feedback and training loop for the EMS providers. 7.27.10 NMAC"* B. The following types of reports will be reviewed for errors, inadequate documentation, and protocol deviations. 1. All incident types identified in Section II above. 2. Any report that is not identified in Section II above, but a request is made to have the report reviewed, shall be assigned for review. 3. Any report that is deemed necessary to be reviewed by the EMS Division or a team member. C. The reports will be dispersed equally among QA/QI team members for review. IV. **INCIDENT REVIEW BY THE QA/QI TEAM MEMBER** A. The monthly QA/QI team meeting will be held as scheduled by the QA/QI Officer.. 1. The meeting place is determined monthly. B. All information is to be considered confidential patient information. The following applies: C. Once a set of reports are assigned, the team member will receive an email with a document (form) that must be filled out for each issue. 2. It is the responsibility of the team member to review the incident report(s) on the electronic patient reporting system. 3. The team member will have to indicate on the form if the incident did or did not meet the requirements of the Guidelines. a. The form is to be filled out in its entirety, documenting in detail all deficiencies and/or violations, then returned to the EMS Division by the due date. 4. Team members shall present any findings to the QA/QI Team at the next meeting. D. For reports having issues, the QA/QI team will contact the individuals who have had their reports reviewed and discuss any problems, errors, or recognition for exceptional care. 5. The QA/QI officer will then review the report and will determine if corrective action and remediation is necessary. E. QA/QI team members shall not review their own EMS Reports. 6. V. **CORRECTIVE ACTION AND REMEDIATION** A. If due to the QA/QI process an employee is found to have a deficiency in the provision of care at their licensure level, the Department will make an effort to remediate the employee via a Personal Improvement Plan (PIP). 1. A PIP may be developed based on the results of a written test and/or skills evaluation to determine the focus areas. b. The chosen means of evaluation will be over medical knowledge as it pertains to BCFR EMS guidelines, policies & procedures, and any pertinent department memoranda and be commensurate to their level of licensure. 2. Implementation of the PIP may be done in the field, or by the individual being brought in on Special Assignment, as determined by provisions of the PIP. a. The PIP will be overseen by the EMS Division Chief or their designee. b. Consideration for Special Assignment must be cleared through the Fire Chief prior to the issuance of the PIP. 3. After the PIP has been completed, a final evaluation will be administered by the EMS Division and in conjunction with the department Medical Director as needed. a. This evaluation will consist of a written test and/or skills evaluation to ensure that the employee has been adequately remediated. VI. **RECORDS MANAGEMENT** A. Emergency Medical Service agencies are required to retain written records of their Quality Assurance undertakings for a period of seven years as per 7.27.10 NMAC. B. The EMS Division will maintain a record of the resolutions determined from the discussions held with field providers regarding the care rendered in the commission of their duties. **REVIEWED/REVISED** - **1/02/2023** - Change references from BCFD to BCFR - Added Paramedics to scope of duties and responsibilities - Removed "consecutive" under I.(C.)2. - Added Medical Director authority to add to criteria for review as needed under II.A. - Removed spinal immobilization under II.A - Removed guidelines for time and place of QA QI meetings. - Removed redundant language in IV. (E.) and (F.) - 4/03/2018 - Rewrite