Guideline 1-800 - Quality Improvement

CMH EMS & MIH Protocols

Scope:

LicenseVolunteerCareerCMH
EMDNAYesNA
EMRYesYesNA
EMTYesYesYes
AEMTYesYesYes
RNYesYesYes
MedicYesYesYes
CPYesYesYes

Guideline:

Documentation and clinical documentation shall be reviewed to ensure quality patient care.

Purpose:

Guidelines for documentation review is to ensure exceptional and compassionate care is being provided and documented.

Procedure:

Ongoing in-house quality improvement must include review of documentation by management staff to ensure clinical competence, protocol compliance, appropriate patient care, and liability reduction.

These reviews must be shared in a timely manner with the individuals reviewed for future improvements.

Refer to Guideline 1-800-33 - Clinical Reviewer Reference Sheet.

In the event, clinical issues or concerns are found, refer to Guideline 1-800-66 - Employee Remediation.

Refer to specific licensure levels for minimum review rates.

EMD Monthly, each agency must review reports by EMDs:
  • The first ten (10) reports by newly hired or newly certified EMDs should be reviewed for documentation and clinical correctness.
  • 10% documentation review.
  • 50% clinical review.
EMR
Monthly, each agency must review reports by EMRs:
  • The first ten (10) reports by newly hired or newly certified EMRs should be reviewed for documentation and clinical correctness.
  • At least 0% documentation review of a random sampling.
  • At least 10% clinical review of a random sampling.
EMT Monthly, each agency must review reports by EMTs:
  • The first ten (10) reports by newly hired or newly licensed EMTs should be reviewed for documentation and clinical correctness.
  • Monthly, each agency must review reports by volunteer EMTs:
    • At least 25% documentation review of a random sampling.
    • At least 10% clinical review of a random sampling.
  • Monthly, each agency must review reports by career EMTs:
    • At least 50% documentation review of a random sampling.
    • Select the lowest scoring documenters and clinicians from previous months for 100% clinical review. Select as many individuals as needed to get total clinical review to at least 10% of all requests for service.
AEMT Monthly, each agency must review reports by AEMTs:
  • Ensure completion of applicable EMT items above.
  • The first 15 reports by newly hired or newly licensed AEMTs should be reviewed for documentation and clinical correctness.
  • Monthly, each agency must review reports by AEMTs:
    • At least 75% documentation review of a random sampling.
    • Refer to EMT section above for individual selection to meet 10% review rate.
RN
Monthly, each agency must review reports by RNs:
  • The first 20 reports by newly hired or newly licensed RNs should be reviewed for documentation and clinical correctness.
  • Monthly, each agency must review reports by RNs:
    • At least 100% documentation review.
    • At least 50% clinical review of calls where the patient was transported lights and siren and/or transported by air ambulance.
    • At least 50% clinical review of the following diagnoses:
    • At least 75% clinical review of the following treatments:
      • Cardioversion, defibrillation, or pacing.
      • Intubation (attempted or successful) or cases where RSI should have been used but was not (i.e., GCS less than eight with BVM for prolonged periods).
    • At least 100% clinical review of the following treatments:
    • Refer to EMT section above for individual selection to meet 10% review rate.
Medic Monthly, each agency must review reports by Paramedics:
  • The first 20 reports by newly hired or newly licensed Paramedics should be reviewed for documentation and clinical correctness.
  • Monthly, each agency must review reports by Paramedics:
    • At least 100% documentation review.
    • At least 50% clinical review of calls where the patient was transported lights and siren and/or transported by air ambulance.
    • At least 50% clinical review of the following diagnoses:
    • At least 75% clinical review of the following treatments:
      • Cardioversion, defibrillation, or pacing.
      • Intubation (attempted or successful) or cases where RSI should have been used but was not (i.e., GCS less than eight with BVM for prolonged periods).
    • At least 100% clinical review of the following treatments:
    • Refer to EMT section above for individual selection to meet 10% review rate.
CP
Monthly, each agency must review reports by CPs:
  • The first 20 reports by newly hired or newly licensed CPs should be reviewed for documentation and clinical correctness.
  • Monthly, each agency must review reports by CPs:
    • At least 10% documentation review.
    • At least 10% clinical review of all client encounters.

Citations:

Change Log:

DateLink to
previous
version		Description of change
12/29/14Added placeholder for this protocol.
03/31/15Created content for this protocol with similar requirements to Section 6-030 - Competencies and Education.
09/16/15pdfRemoved requirements for quality meetings to be held in each county. Added indications for calls to be reviewed that meet RSI requirements. Also added that crew and responders will be invited.
02/03/16pdfAdded EMD section with dispatch center requirements.
08/24/17pdfRemoved quality review triggers for Ketamine, Vecuronium, and Succinylcholine.
09/22/17Added CPR as a quality reivew trigger.
11/11/17pdfRemoved data presentation details. Added at least one representative to all the meeting requirements.
11/19/17Changed percentage of quality reviews from 10% to 15%. and made adjustments to no longer having monthly meetings in each county.
10/15/18pdfAdded clarification of percent of meetings are required by each agency.
07/23/19pdfModifiedclarified requirements for agencies to attend quality meetings. Added links to performance graphs.
04/04/20pdfAdded content from old Section 6-105 - Quality Improvement. Major changes to requirments as monthly quality meetings are no longer being held. Agency minimum chart review rates were established. The minimums are currently only draft pending discussions with medical directorsagency heads.
04/27/20Made some changes to reflect improved clinical review process.
06/08/20At the request of Dr. Nicholes, added reviewing trauma charts where a c-collar was indicated.
07/09/20Added reference to employee remediation guideline. Added requirement to review Ketamine use at the request of Dr. Nicholes.
10/07/20Renamed all policies to guidelines.
06/06/21pdfMoved to emsprotocols.online
12/01/21Updated link to Vecuronium.
02/25/22pdfAdded recommendation for new hire and newly certified or licensed staff to have additional chart reviews.
02/28/22Updated link for Succs.
02/28/22Updated link for Rocuronium.
03/20/23Changed link for Ketamine.
04/27/23pdfAdded CP reviews.

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