Quality Improvement Programs Old Requirements / New Directions

1. Quality Improvement ProgramsOld Requirements / New Directions New York State Emergency Medical Services Council State Emergency Medical Advisory Committee Department of Health - Bureau of Emergency Medical Services

2. SEMSCO/SEMAC DOH BEMS Evaluation / QI Committee charged with re-writing the NY State QI Manual Provide Guidance to Services, Program Agencies, REMSCOs and REMACs on developing and maintaining QI Programs based on well established principles and new processes Create a paradigm shift in the way we approach the QI process here in NY State

4. Table of Contents • Introduction • The Paradigm Shift in the QI Process in NY State • Glossary of Key Terms • Chapter 1 • How to Establish a QI Committee / “The Nuts & Bolts of the Organization.” • Chapter 2 • EMS / “At the Crossroads of Public Safety, Public Health, and the Community Health Care System.” • Chapter 3 • Steps for Monitoring, Evaluating & Improving Organizational Efficiency / “From Data Collection to Performance Enhancements.”

5. Table of Contents • Chapter 4 • Customer Service / “For It is The Customer, That We Exist.” • Appendices • Article 30, Section 3006 • Part 800.21 (q) (r) • QI Process Flow Charts • Sample Audit Tools

6. CQI - It’s Not the Blame Game!!!

7. Organizational Efficiency Customer Service Benchmarking PCR Audits Technician – specific Behavior

8. EMS The “S” in EMS stands for the word SERVICE • Service (sur-vis) • supplying services rather than a product or goods; • The organized activities of apparatus, appliances and employees for supplying some accommodation required by the public; • The performance of any duties or work for another

9. “... service people are the most important ones in the organization. Without them there is no product, no sale, and no profit. Indeed, they are the product.”J.W. Marriott, Jr.Chairman of the Board and PresidentMarriott Corporation

10. “Everyone in a service oriented organization has a service role, even those who never see the customers.”Researchers Karl Albrecht and Ron Zemke

11. EMS System Goals • The overall goal of an EMS System is to reduce death and disability from injuries and medical emergencies. • The basic assumption in health care is that the system of care and the individuals within it can improve and aspire to a higher standard of care.

12. SYSTEM is the operative word A complex unity formed of many often diverse parts subject to a common plan or serving a common purpose.

13. The Birth and Development of an EMS SYSTEM • 1966 “Accidental Death & Disability: The Neglected Disease of Modern Society.” • National Highway Safety Act • 1972 Robert Wood Johnson Grant Funding • 1973 EMS Systems Act • 1998 NY State EMS Plan • 2006 ACEP Report Card on the State of Emergency Medicine in the U.S. • 2006 Institute Of Medicine – The Future of Emergency Care in the U.S. HealthCare System

14. Manpower Training Communications Transportation Hospitals Critical/Specialty Care Public Safety Agencies Consumer Participation Access to Emergency Care Patient Transfer Standardized Recordkeeping Public Information & Education System Review & Evaluation Disaster Management Mutual Aid 15 Components of an EMS System

15. Benchmarking 101 On-going and systematic process for measuring and comparing the work process of one organization to those of another, by bringing an external focus to internal activities functions or operations. The goal is to provide policy makers with a standard for measuring the quality and cost of internal activities and to help identify where opportunities for improvement may reside.

16. Benchmarking 101 • How well are we doing compared to others? • How good do we want to be? • Who is doing it the best? • How do they do it? • How can we adapt what they do in our organization? • How can we be better than the best?

17. Who are the Customers ? • The Patient • The Patient’s Family • Taxpayers • Managed Care Organizations/Insurance Companies • Physicians, Nurses, Hospitals • Health Care Organizations REMSCO, REMAC, SEMSCO, SEMAC, TRAUMA TRAUMA COUNCIL’S, ETC • City Council, Town Board • Police/Fire, Public Health Personnel • Others ?????

18. Authority Command Yeah..I got a Chief’s car! I am in Charge People will have to listen to me now Responsibility Accountability To the patients To the members To the taxpayers Agency Leadership & Management Test

19. Dangerous Attitudes…… “We’re only volunteers, we do the best we can.” “We are 911! Who else you going to call.” “It’s my district, and I am in charge, and we are the only game in town.”

20. Is This Your Service? Over 100 years of tradition…. ….not impeded by a single day’s progress!

21. Words not to live by…. • “We’ve always done it like that….” • “That’ll never work here…..” • “’Cause I’m the boss - that’s why….”

22. Or…Is This? teem-work: the joint action by a group of people, in which individual interests are subordinate to the group’s unity and efficiency

23. Management 101:Accentuating the Positive • Compliment your employees whenever possible - and appropriate • Although it’s easier to focus on the negative – don’t do it! • Frequent small acknowledgments outweigh rare large ones • Praise in public - discipline in private

24. CQI & The Strategic Planning Process Leaders & Managers must be effective strategists if the organization is to fulfill its mission, meet its mandates, and satisfy its constituents in the years ahead

25. Strategic Planning • Development of effective strategies to cope with changing circumstances • Set of concepts, procedures and tools designed to assist leaders & managers with a variety of tasks • Disciplined effort to produce fundamental decisions and actions that guide what an organization is, what it does, and how it does it

26. Data Collection / Analysis And The Strategy Change Cycle • Setting the organization’s direction • Formulating broad policies • Making internal/external assessments • Pay attention to needs of key stakeholders • Identify key issues • Develop strategies to deal with each issue • Implement procedures • Continually monitor and assess results

27. From Philosophical to Operational in 5 Easy Steps • What are practical alternatives, dreams and visions you might pursue? • What are the barriers to realizing those alternatives, dreams and visions? • What proposals might you pursue to overcome those barriers? • What steps are needed to implement those proposals? • Who is responsible to implement these proposals?

28. Plan-Do-Check-Act This is a continuous process without end.

29. What is Continuous Quality Improvement?

30. What Is Quality Improvement? • QI is a program of systemic evaluation to ensure excellence. • QI is a judgment as to what is deficient and linked to a system to effect positive change. • QI is identification of positive actions by EMS Providers and organizations.

31. It’s also the LAW……… Most states have a component of their EMS statute or code that mandates at least some form of QI program

32. QI Laws and Regulations • Article 30 requirement (Section 3006) PHL • Rules and Regulations of NYS Part 800 • Article 28 PHL - Part 405.19 (hospital regs.) • Part 80 - Controlled Substances • JCAHO • Federal Regulations - HIPAA

33. QI is a ContinuousActivity From a Service Perspective • Reinforces excellence • Helps the service document its care • Provides constructive feedback to stakeholders • Identifies deficiencies • Improves performance through education

34. QI is a ContinuousActivity From a Medical-Legal Perspective • Reduces risk by reinforcing the delivery of appropriate care From a Patient Perspective • Reduces death and disability • Ensures appropriate EMS action for the community’s safety and well being

35. Traditional Approach • Retrospective analysis – Review of agency’s processes after they occur • React to problems after they occur • Weak but also most well known • PCR audits • Medical debriefings • Incident reports • React to red flag incidents

36. Quality Assurance (QA) Total Quality Management (TQM) Continuous Quality Improvement The Baldridge System Six Sigma

37. Modern View • Concurrent Methods - Review of activities that are on-site and on-going • On-line (direct) medical control • Comparison of EMS findings and E.D. diagnosis • Field observation of EMS personnel by • M.D.s, senior instructors, clinical preceptors, etc. • All aspects of organizational efficiency

38. Modern View • Prospective Methods - measuring future events against predetermined standards. Accomplished through: • Development & use of protocols • Establishment of time standards • Minimal levels of primary training • Requirements for continuing education

39. QI Guidelines for EMS Services Providing Prehospital Care

40. Select a QI Coordinator • The service Medical Director • Hospital’s EMS QI Coordinator • The system Medical Director • E.D. physician • Senior prehospital provider

41. Duties of a QI Coordinator • Build a QI Team • Communicate with hospital EMS Coordinator • Interface with Medical Director & field supervisors • Review PCRs • Review existing protocols & standards • Develop CME curricula • Review consumer communications

42. Resources for QI Coordinator • Existing protocols and standards • Agency specific data from PCRs • Feedback from hospitals • Field supervision observations by experienced providers • Educational curricula • Consumer satisfaction surveys

43. Objective of an Audit • To compare actual performance with desired performance • Mechanism: Identify and monitor pre-selected key indicators

44. QI Criteria/Indicators Should Be • Explicit - concisely written & understood • Critical - highly correlated with good care • Directly related to study objective • Comprised of a few (4-8) key elements • Objective - not prone to individual interpretation • Realistic & achievable

45. Types of Audits 1. Structural Evaluation Presence of mandated resources (non-personnel issues) • Evaluates • Physical facilities and equipment • Stocking & control procedures • Staffing patterns & backup • Qualifications, credentialing and recordkeeping requirements

46. Types of Audits 2.Process Evaluation Use of resources & appropriateness of such use • Specific complaint case/patient management • Proper patient processing • adequate hx & physical exam • appropriate assessment & treatment procedures • mechanics/flow - registration & triage procedures

47. Types of Audits 3. Outcome Evaluation Results of patient care provided • Selected outcome • Could be: stabilization & recovery of a critical patient; resolution of an episode of an illness; socially/medically recognized “recovery” • Audit of patient outcome by disease category

48. Methods of Evaluation 1. Prospective Methods Measuring future events against predetermined standards • Development & use of protocols • Establishment of time standards • Minimal levels of primary training • Requirements for CME

49. Methods of Evaluation 2. Concurrent Methods Review of activities that are on-site and on-going • On-line (direct) medical control • Comparison of EMS findings and E.D. diagnosis • Field observation of EMS personnel by: M.D.s, senior instructors, clinical preceptors

50. Methods of Evaluation 3. Retrospective Methods Recognition of past deficiencies, trends & patterns • Medical debriefings • Critique sessions • Audits • Practice profile/credentialing • Incident reports