[CSEMSmail] Regional Performance Improvement

[Matt Lawler]

Date:    September 18, 2008

To:       Regional EMS Agencies

            Regional Hospitals

From:   Asher Brand, M.D., Regional Operational Medical Director

Re:       Regional Performance Improvement

 

Since the beginning of the year, two subcommittees of the Medical
Control Review Committee (MCRC), the General Performance Improvement and
the Trauma Performance Improvement (PI) committees, have been working to
develop regional performance improvement plans, one for trauma and the
other for general performance improvement.

 

The goals of these committees are to assure and improve the quality of
pre-hospital medical care within CSEMS region and to monitor compliance
with the region's Trauma Triage Plan.  The objectives of the committees
are to conduct regional quality assurance and encourage local agency
medical incident reviews as required by state regulation; collect
patient care statistics to evaluate system effectiveness and identify
trends; and provide constructive feedback on medical quality improvement
to all hospital and out-of-hospital EMS professionals within the CSEMS
Council region.

 

Virginia regulation 12 VAC 5-31-600, Quality Management Reporting,
mandates EMS agencies have an ongoing Quality Management (QM) Program
designed to objectively, systematically and continuously monitor, assess
and improve the quality and appropriateness of patient care provided by
the agency.  The PI committees have developed a template for regional
EMS agencies to use, if needed, when setting up or maintaining a quality
management reporting program.

 

The PI committees will be collecting data from EMS agencies on certain
topics.  The data will be used by the PI committees and the MCRC to
evaluate system effectiveness and identify trends in patient care and
measure regional system effectiveness.  The committees will then be able
to identify the educational needs of EMS providers in the region and
identify methods that will be used to resolve issues identified through
the PI process.

 

The following data will be collected starting October 1, 2008.

 

*         King LT airway insertion.

*         Administration of aspirin for chest pain.

*         12-lead ECG acquisition

*         Application of trauma triage guidelines

 

There are a variety of ways to submit the data to the committees.

 

1.      Agencies may collect data through agency-based quality
management programs and submit to the CSEMS Council.  A spreadsheet can
be downloaded from the Council's website.  Submission of the data is
requested within 30 days of the end of each quarter.

2.      Record data on a case-by-case basis on the PI Form and deposit
the form in a drop box at any hospital emergency department in the
region.  Submit data on a case-by-case basis using the PI Report Form on
the PI page of the CSEMS Council website.  This is a backup option for
cases where the provider was unable to report the data in an ED drop
box.

3.      Permit the Committee access to the agency's electronic patient
data collection software through QA/QI administrative access.

 

A host of information concerning the performance improvement projects
can be found on the CSEMS Council website at www.csems.vaems.org/pi.
The following documents can be found on the website.

 

*         General Performance Improvement Plan.

*         Trauma Performance Improvement Plan.

*         General PI Committee Meeting Minutes.

*         Trauma PI Committee Meeting Minutes.

*         Regional Performance Improvement Template.

*         Links to report a PI review topic or an incident for medical
review.

*         Excel spreadsheet for quarterly submission of data.

 

We are excited about these new performance improvement initiatives.  We
feel the process will have a significant impact on the care we provide
to the citizens of our community.  In fact, the committees have already
identified an issue with the King LT airways through review of the data
being submitted.  This issue is being addressed is providing valuable
information for our King airway instructors so that they may better
provide King airway education to the providers of the region.

 

If you have any questions, please contact me or Matt Lawler, chair of
the performance improvement committees.

 

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