What does QA/QI look like at your department/service?

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FiremanMike

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I'm curious what QA/QI looks like at your department/service. If you guys wouldn't mind sharing, I think this is something that could help the community.

Briefly describe your department's/service's EMS delivery model (FD, Third Service, Private, etc):

What is your approximate run volume?

Who does QA/QI at your department/service?

Describe what QA/QI looks like at your department:
 
I'll start..

Briefly describe your department's EMS delivery model - We are a fire department that provides full ALS care and transport. In order to even apply for initial appointment, one must have already obtained their firefighter 2 and paramedic certifications and everyone rotates equally between the medics and fire truck.

What is your approximate run volume? - We run 2 ALS ambulances and 1 fire truck. We take ~6500 EMS runs per year and ~1000 fire runs per year.

Who does QA/QI at your department? - I current do the QA/QI. I have been moved off company into a 40hr M-F job, although I don't hold rank beyond "EMS Coordinator"

Describe what QA/QI looks like at your department - QA/QI comes in many forms but I take an educator approach to the entire process.

Some of my primary tasks related to QI;
1. Read/sign-off on ALL PCRs for content. I look beyond proper documentation to see whether or not treatment pathways and critical thinking made sense
2. Take runs. It is very important to me to stay connected to the streets. I have a staff car with lights/sirens that I use to respond to whatever runs I feel like. In addition, I am allowed to work 1 24 hour shift per month where I spend the first 12 hours taking ALL EMS runs in the city, the second 12 hours I ride in charge of one of the medics
3. Actual QI with the crews takes many forms and is tailored to each individual. There are frustrations with working in a small department, but one of the advantages is that I have a pretty good idea how to communicate with most of the personalities there. Some runs need to be broken down with a formal debrief, where I bring the crew into my office and discuss what they saw, what they did, and what they could have done differently. Some runs just need a tailboard discussion to say "hey, did you think about...?" And sadly, some runs result in administrative level discipline.
4. Schedule and/or conduct training - I base this around deficiencies I am seeing collectively through my run review and first hand experiences there
 
Delivery model: Wilderness and rescue medicine at the BLS level supported by specially trained EMS ALS. Most of our EMT and above providers have other healthcare jobs. Our agency ALS providers can give ALS under EMS, same medical director, even if they aren't EMS employees.

Run Volume: Probably 100

QA/QI: I started a QA/QI committee, but it is defunct. It is done by our medical director and their liaison (medic) who are both beyond excellent.

I think we have 100% run review. Improvement is accomplished through individual discussion, targeted training, and in-services.
 
Summit said:
Delivery model: Wilderness and rescue medicine at the BLS level supported by specially trained EMS ALS. Most of our EMT and above providers have other healthcare jobs. Our agency ALS providers can give ALS under EMS, same medical director, even if they aren't EMS employees.

Run Volume: Probably 100

QA/QI: I started a QA/QI committee, but it is defunct. It is done by our medical director and their liaison (medic) who are both beyond excellent.

I think we have 100% run review. Improvement is accomplished through individual discussion, targeted training, and in-services.
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When they identify an issue, how do they address it with the crew/provider?
 
Briefly describe your department's/service's EMS delivery model (FD, Third Service, Private, etc): Hybrid staffed (paid/volunteer combination) third-service (nominally under PD direction)

)What is your approximate run volume? ~3,000 calls per year

Who does QA/QI at your department/service? One Paramedic reviews charts (paid staff member)

Describe what QA/QI looks like at your department: Pretty limited for BLS providers (both paid & volunteer), usually comes in the form of a "Hey, double check your chart." The hospital does some QA/QI that I'm not briefed on. Hospital follow-ups are decidedly *not* encouraged by the service or the hospital.

Summit said:
Our agency ALS providers can give ALS under EMS, same medical director, even if they aren't EMS employees.
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Are these non-EMS trained ALS providers (RNs, etc.)?
 
EpiEMS said:
Are these non-EMS trained ALS providers (RNs, etc.)?
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Right now just medics who are otherwise employed as medics. We have discussed and might utilize our working RNs, especially for parenteral analgesia/antiemetic, but nobody is in a rush at the moment.

FiremanMike said:
When they identify an issue, how do they address it with the crew/provider?
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Minor issues may addressed one-on-one with the liaison-educator. Major issues are a meeting with the med director. Repeat minor issues or a single major incidents usually generate organizational memos or training which usually are taught by me, the liaison, and even the med director. Repeat serious issues can get more involved, but that is above my pay grade these days.
 
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Summit said:
Right now just medics who are otherwise employed as medics. We have discussed and might utilize our working RNs, especially for parenteral analgesia/antiemetic, but nobody is in a rush at the moment.
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Interesting - thanks!
 
Briefly describe your department's/service's EMS delivery model (FD, Third Service, Private, etc): Hospital-based/3rd service

What is your approximate run volume? 125,000 last year

Who does QA/QI at your department/service? We have a captain and lieutenant who do QA full-time. We also have 3 paramedics who do half-time QA and half-time ambulance. The medical director, 2 associate medical directors, and EMS fellows are also involved, but not as regularly.

Describe what QA/QI looks like at your department:

There's a few things that are 100% QA- surgical crichs, ketamine administration, pediatric refusals, and a few others I don't remember off the top of my head. A random selection of refusals get audited monthly. They also randomly audit a selection of other calls. For example- they focused on chest pain calls for a quarter, abdominal/flank pain calls for a quarter, etc. We get a grade Exceptional, sufficient, insufficient, hypothetically within a week of the audit. Our average QA score is a big part of our annual review/raise.
 
Briefly describe your department's/service's EMS delivery model (FD, Third Service, Private, etc): We operate as a third service supported by tax revenue collected from properties within the district, which covers part of four counties that range from lightly suburban to frontier.

What is your approximate run volume? 2700 calls split between 2-3 ambulances per day.

Who does QA/QI at your department/service? One of our paramedics is the lead QA person and he is supported by two others who also read charts. They review 100% of charts. If issues are found, they are passed up to that provider's shift captain. If it is a part time person one captain just gets told to deal with it. In theory the shift captain who takes care of education is supposed to be involved in the remediation portion. Additionally, the health network that provides our medical direction also provides QA. They do not do 100% chart review but rather have a monthly "target run type." These charts are reviewed by paramedics, some of whom are full time EMS staff for the health network and some who are active providers in the system and do run review part time. Finally, our medical director reviews all waivered skill use (RSI and joint reduction). Ketamine is waivered but reviewed by the health network folks and not him. Surgical crics are no longer waivered.

Describe what QA/QI looks like at your department: I have never had much of QA experience in the last year as a medic or the previous three as an EMT. As above, if some sort of error is found by the QA medics, he might have an informal conversation with out to see if something was documented unclearly. If a greater error is found, it's passed up to a captain. After that, there is no procedure. Sometimes you get a lighthearted "probably shouldn't have done that but I get it." Sometimes there is yelling. Rarely an incident report is drafted. Never is an improvement plan documented. Sometimes suspensions happen. If the health network finds an error, they send it to the training captain, and the above is followed. They also rate your chart on a scale of one (poor) to four (excellent). Allegedly they have an average score, nothing is done with that really. If the medical director finds something, I have no idea what happens.
 
FiremanMike said:
I'm curious what QA/QI looks like at your department/service. If you guys wouldn't mind sharing, I think this is something that could help the community. Briefly describe your department's/service's EMS delivery model (FD, Third Service, Private, etc):
Click to expand...

Private agency with a board of directors comprised of 1 elected person from each of the 5 volunteer squads that cover. We recive some logistical support from the township, ie fuel, dispatching service, property maintenance, light automotive maintenance. 15ish Employees operating 2 BLS (EMT/EMT) units M-F 0500 - 1800

What is your approximate run volume?
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2k a year

Who does QA/QI at your department/service?
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EMS Administrator, Me

Describe what QA/QI looks like at your department:
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I review every chart, looking for errors in both clinical and billing areas. Initial concerns will be addressed by a native messaging system within the charting software for minor issues regarding documentation, consistency, logic errors, ect. greater and obvious clinical errors will be both documented in the messaging as well as face to face conversations with the staff. I am in the same building as the staff so its normal for a hot wash after the "hot jobs" like arrests, anything we fly, traumas, ect. Theoretically more serious clinical issues would be discussed with the employee and our MD, but that hasnt occurred yet.
 
Bullets said:
Private agency with a board of directors comprised of 1 elected person from each of the 5 volunteer squads that cover.
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Volunteers cover from 1801-0459?
 
EpiEMS said:
Volunteers cover from 1801-0459?
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for now.....We went in service a year ago with one truck 5-5 and the volunteers would "totally back us up"

4 months later, a second paid truck was added 10-6, a month later, that was 8-6, now its 6-6, In December we will also cover them on holiday nights. Death by 1000 cuts
 
EpiEMS said:
That's the modern world for you.
Who does the volley QA/QI?
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Depends on the squad, one has an MD who still rides, others i assume do no QA as they still do paper charts
 
We are hospital-based EMS running about 9,000 calls per year in four counties.

QI is done monthly with a meeting with medical director and a liasion from all agencies from 911 to fire dept to ER. We look at critical calls like RSI with an intention of making sure the crew has all the tools and resources to be successful.

QA is done as peer review of documentation and clinical decision making. All our field training officers are trained to do quality reviews and utilize a standard form that makes its way to the manager and then the provider after completion to close the loop.
 
1,200 paid and 2,000 volunteer officers; approx 500,000 patients p.a.

Single national electronic PRF

Some types of cases automatically audited e.g. RSI and something like 5 or 10% of others randomly audited by peer reviewers. Of these a portion of audits are themselves audited.

Audits can either be closed, or you can be asked for more information and given some feedback, or in the worst case scenario a very small number of personnel can be formally reviewed including having their authority to practice reviewed. This latter step is only for severe departures from what is expected.

When registration comes in the latter will also trigger a notification to the regulatory authority and can result in your practising certificate being subject to investigation, variance or cancellation.

There is a much greater shift now towards individual clinical responsibility and accountability, particularly externally as registration is coming very soon. Some are uncomfortable with this and well, frankly, they need to either change or leave.
 
I work for a private with 6 municipal contracts and an estimated 3.7 million facilities and private patients. All indicators point towards us breaking 300k run numbers issued this year. Not calls mind you, as there are several inefficiencies causing extra numbers to be issued, but I would say 200k calls where patient contact was made and a proper report "should" be filled.

All that to say our qa dept (nominally one man wearing several other hats) can't possibly even pretend to read them all. I can't say exactly what reports automatically trigger an audit beyond the calls associated with our field trials, but if we're actively reviewing more than 10% of our calls(for clinical deficiencies), I'll give back half my overtime next week....
 
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