CQIP CONTINUOUS QUALITY IMPROVEMENT PLAN
CQIPCONTINUOUS QUALITYIMPROVEMENT PLAN2019
CQIP CONTI NUOUS Q UAL ITY IMPROVEMENT PLAN - 2019CONTENTSAbout Riverside County EMS Agency (REMSA) . .3Introduction .4Reporting relationships between Providers/Base Hospitals, REMSA, and EMSA .5Organization and Structure. .6REMSA Organizational Chart .8EMS Personnel & Regulation .9Skills Maintenance & Competency. 10Equipment & Supplies . 10Transportation & Facilities . 11Public Education & Prevention . 11Risk Management 12Documentation . 12Inter-Agency Communication Systems . 14Stakeholder Communication & Relationships . 16CQI for Clinical Care & Patient Outcomes .18EMS CQI Team . .20EMS CQI Leadership Team (CQILT) .21CQI Data Unit . .22CQI Data Collection & Analyses. . . .22Page 1 of 46
Standard Data Collection Method . . 23California EMS Authority Core Measures .24Quality Improvement Process and Activities . 25Action to Improve 26The Plan-Do-Study-Act (PDSA) Model for Quality Improvement .27The Analysis, Design, Develop, Implement, Evaluate (ADDIE) Model . .27Observe, Orient, Decide, Act Loop . .28Education and Training . . .30Future Development . .31Performance Standards .31Annual Update . .32Appendix A –Riverside County EMS CQI Plan Review Process . .33Appendix B – Current Riverside County EMS Agency CQI Measures/Indicators. .34Appendix C – Plan, Do, Check, Act Worksheet . .41Appendix D - CQI Risk/Frequency Skill Matrix. . .42Appendix E - ALS Skills Verification Form. . . .43Appendix F - BLS Skills Verification Form . . .44Page 2 of 46
ABOUT RIVERSIDE COUNTY EMSAGENCY (REMSA)Mission statement:To assure the timely delivery of high quality, compassionate, and cost-effective emergencymedical services to the people of Riverside County and to optimize these services through abalance of collaboration with the community and regulatory leadership.Values: We value the patient as the focus of what we do. We value honesty and integrity. We value personal and organizational accountability. We value collaboration in our endeavors. We value inclusive decision-making. We value evidence-based change as an avenue to excellence.Philosophies: System success is measured in the well-being of the people we serve. Each interaction brings value to us and the EMS system. The success of the organization is success for all. Our duty is to lead intelligently and regulate with consistency.Vision:Support and uphold integrity, quality, and collaboration in the delivery of EmergencyMedical Services.Page 3 of 46
INTRODUCTIONContinuous Quality Improvement (CQI) is a formal approach to the analysis of system performanceand efforts to improve it. Riverside County EMS Agency (REMSA) is committed to the process of CQI.CQI is, by its very name, a continuous process. CQI includes such things as: Recognizing excellence, both individually and organizationally; Quantifying objectively what EMS does by trending, analyzing and identifying issues,concerns, and excellence based on those trends; Setting benchmarks; Promoting remediation rather than discipline. CQI also makes a powerful distinction betweenthe two. Remediation is education. Discipline involves licensure. Working hand in hand with training, education and with risk management; Identifying system issues when possible rather than individual issues; Promoting itself as a business standard used in corporate strategic planning; Presenting itself as an evidence-based process equal to industry programs foreducation and personnel.Continuous Quality Improvement (CQI) is an ongoing process in which all levels of healthcare workersare encouraged to team together, without fear of repercussion, to develop and enhance the systemthey work in. Based on EMS community collaboration and a shared commitment to excellence, CQIreveals potential areas for improvement of the EMS system, identifies training opportunities,highlights outstanding clinical performance, audits compliance with treatment protocols, and reviewsspecific illnesses or injuries along with their associated treatments. These efforts contribute to thecontinued success of Riverside County’s emergency medical services through a systematic process ofreview, analysis, and improvement.A by-product of the plan is the alliance of municipal agencies and private providers that offer EMSservices within Riverside County. This affords all participants (administrator to first responder) anopportunity to work jointly, even when at peak capacity, with energy and focus in a system that theycan support and have ownership in.REMSA leads and monitors the Continuous Quality Improvement (CQI) activities for all differentcomponents of the EMS System in a prospective, concurrent and retrospective manner.Page 4 of 46
Prospective- Through guiding policies, protocols, and research.Concurrent – By monitoring the electronic patient record system and engaging in ride-alongs,and through field Training Officers.Retrospective- Using data extraction, incident investigations, and targeted and routine recordsreview.Many of the QI activities take place at the organizational level.Reporting Relationships between Providers/Base Hospitals, REMSA, and EMSAPage 5 of 46
This plan is a guideline for each Riverside County provider and Base Hospital to use when writing theirorganization’s CQI plan. All EMS providers and Base Hospitals are required to submit their CQI plan toREMSA for review and approval. All CQI plans must be in accordance with the Riverside County EMSAgency’s CQI plan.The Riverside County Emergency Medical Services Agency (REMSA) is responsible for the oversight ofthe Emergency Medical Services (EMS) system in Riverside County. This system consists of AdvancedLife Support (ALS) and Basic Life Support (BLS) First Responders; ALS, BLS and Critical Care Transport(CCT) Ambulances; ALS and CCT airships; dispatch agencies with trained dispatchers; Base Hospitals;Prehospital Receiving Centers; and various specialty centers (STEMI Receiving Centers, TraumaCenters, and Stroke Receiving Centers).Guided by the REMSA Protocols, medical direction is providedby the Base Hospitals to EMS personnel in the field, as well as by the REMSA Protocol Manual.California Statute states, “The local EMS agency shall plan, implement, and evaluate an emergencymedical services system consisting of an organized pattern of readiness and response services basedon public and private agreements and operational procedures. The local EMS Agency shall beresponsible for implementation of advanced life support systems and limited advanced life supportsystems and for the monitoring of training programs. The local EMS Agency shall be responsible fordetermining that the operation of training programs at the EMT I, EMT II and EMT P level are incompliance with this division and shall approve the training programs if they are found to be incompliance with this division” (Health & Safety Code Sections 1797.204, 1797.205, and 1797.206).Each agency shall submit a CQI plan to the EMS Agency for approval (see Appendix A). The time framefor submission will be determined by REMSA in coordination with the agencies. Appropriate revisionsshall be made as requested by REMSA. Each agency shall conduct an annual review of their CQI plan.REMSA will evaluate the implementation of each agency’s CQI plan. Each agencies CQI plan will beupdated annually and re – submitted.REMSA’s CQI Plan has been written in accordance with the Emergency Medical Services System QualityImprovement Program Model Guidelines (EMSA #166, Rev. 3/04).ORGANI ZATION AND STR UC TURERiverside County is the 4th largest county in California, serving an estimated population of 2,450,758citizens (United States Census, 2018), and comprising nearly 7,300 square miles. Riverside Countyconsists of urban, suburban, rural, and wilderness areas. In 2019, there were a total of 204,1319-1-1 calls for medical aid and over 400,000 patient records generated by fire department andPage 6 of 46
ambulance responders in Riverside County. 9-1-1 calls initially enter a Public Safety Answering Point(PSAP), and generally get re-routed to a secondary PSAP, which dispatches a fire unit. At the sametime, the secondary PSAP also routes the call to the 9-1-1 Ambulance provider’s dispatcher (ifdifferent), who dispatches the ambulance to the same call. Both the fire unit and the ambulance(usually from 2 different locations) go en route to the call. In most of Riverside County, the dispatchersare trained Emergency Medical Dispatchers, and they are giving pre-arrival/post- dispatch instructionsto the reporting party and getting additional information about the call to relay to the respondingunits. In most areas of the County, the First Responder is an ALS unit. The City of Calimesa are servedby Fire Department BLS first responders.Once at the hospital, care is assumed by the Emergency Department personnel. At this point, the crewsare available to respond to other calls. All of Riverside County 9-1-1 providers are on a unified electronicPatient Care Report (ePCR) system; documentation of the call is completed at this time, unless anothercall is pending.The Riverside County EMS system is made up of the following: 13 First Responder Fire departments 1 primary 9-1-1 Ambulance provider and approximately 14 other ground transport agencies 4 primary Helicopter EMS providers (HEMS) 17 Emergency Departments (EDs) supporting the following specialty care designations: 12 Primary Stroke centers (Primary) 6 STEMI centers 4 Trauma centers (Level II)Riverside County oversees certification for over 5,000 EMS providers. These consists of approximately3,500 Emergency Medical Technicians (EMTs), 1,200 Paramedics, and 400 Mobile Intensive Care Nurses(MICN) and Registered Nurses (RNs).The Riverside County EMS Agency (REMSA) is led by an EMS Administrator and a Medical Director wholead the Administrative, Data, and Clinical and Education Services units. Leading each unit are a DeputyEMS Administrator who oversees the Administrative unit, a Supervising Research Specialist whooversees the Data and Reporting unit, and an Assistant Nurse Manager who oversees the Clinical andEducation unit. Along with support staff, each with their own area of expertise, REMSA fulfills its LEMSACQI obligations through communication, evaluation implementation, and enforcement of its requiredactivities.Page 7 of 46
REMSA Organizational ChartPage 8 of 46
EMS P ERSONNEL AND REGULATIONREMSA is charged with regulating the issuing of EMT certifications, Paramedic accreditations, and MICNauthorizations. The CA Health and Safety Code directs the state EMS Authority (EMSA) and the MedicalDirector to do this, and EMSA delegates the responsibilities for EMT certification to the local EMSagencies (LEMSAs). REMSA receives the specific direction of authority from legislation which is namedthe CA Code of Regulations (CCR), specifically Title 22, Division 9 of the CCR. These regulations giveREMSA the authority and instructions of how to implement the Health and Safety Code.EMT certification, once granted, is accepted statewide, each EMS agency is required to follow the specificcredentialing practices outlined by Title 22 and further clarified by EMSA directives. While some specificpoints are open to interpretation, REMSA policies on EMT certification follow Title 22 regulations. Thestate EMSA monitors each EMS agency to verify certification is being carried out as intended. The Statecharges their fee for certification and each local agency (REMSA included) has a fee for administeringthis responsibility for the state.The state EMSA regulates the scope of practice (SOP) for EMTs, paramedics, and holds responsibility forthe statewide licensure of paramedics. But because each LEMSA has its own medical policies andprocedures (based on the state SOP) the LEMSA Medical Director, paramedics must receive localapproval – i.e., accreditation – to practice in that region. Therefore, REMSA issues local accreditation toparamedics to practice in our county once we confirm they have been trained in our local policies andprocedures.Mobile Intensive Care Nurses (MICN’s) receive their initial training through a collaborative trainingprogram across REMSA and ICEMA. MICN’s are cultivated by our base hospitals and the hospital Prehospital Liaison Nurse, then screened as potential candidates to then be sent to the initial trainingprogram. REMSA participates with this screening process both in creation of policies identifyingqualifications, and also in ongoing competency monitoring in collaboration with the PLN. REMSA has adefined reauthorization process, and application that requires the MICN seeking to renew this credentialbe a participant in EMS education and training during the credential cycle. MICN reauthorizationcandidates maintain relevancy with the paramedic scope of practice by REMSA Policies and Proceduresmanual training updates, base station meetings, clinical ride outs and/or ALS Skills competency skills labsdays.EMSA issues a credential to practice in the EMS field, therefore a credential falls under regulation toensure correct practice and the safety of the public. The Health and Safety Code (H&SC) specificallystates that any “threat to public health and safety may result in the denial, suspension, revocation,and/or the placement of an individual on probation. It outlines what is a threat. Title 22 has differentPage 9 of 46
sections for paramedics and EMTs which more specifically explain some of the individual threats. Title22 also details the procedures on how to implement discipline against a credential. Because EMSA issuesparamedic licenses, they are responsible for any discipline against them. Since the LEMSA’s are theentities actually issuing EMT certifications, the responsibility for issuing any discipline against thecertifications also lie with the LEMSA’s. In order, to ensure a level of uniformity across all LEMSAs, EMSAalso has created documents and procedures that local agencies must follow when issuing disciplineagainst an EMT certification. REMSA follows these procedures as well as H&SC and Title 22 when issuingdiscipline against a certification. The EMT discipline regulations and guidelines are very detailed andREMSA applies these same “rules” when reviewing an MICN authorization and issuing any disciplineagainst it.SKILLS MAI NTENANCE A ND C OMPETENC YREMSA maintains Performance Standards for high risk/low frequency skills, as well as highfrequency/low risk skills. Field provider personnel at the EMT and Paramedic levels complete their SkillsCompetency Verification with the applicable form every 2 years. The EMT BLS SCV form is standardizedat the CA EMSA level, while the ALS SCV form is maintained at REMSA. The ALS SCV form was adaptedto include the BLS SCV skills of childbirth with neonatal resuscitation in 2018 in response to EMS SystemQI initiatives and stakeholder input. REMSA maintains policies to determine eligibility for SkillsCompetency Verification, form completion and audit. MICN completing their first MICN authorizationare required to complete the ALS SCV process; for reauthorization they can elect to complete the ALSSCV process or complete an 8-hour field internship shift. REMSA also focuses on specific skillscompetency and review from stakeholder group QI as needed. REMSA partnered with providers to investin skills mastery and proficiency related to cardiac arrest resuscitation since 2016.EQUIPMENT AND SUPPLI ESREMSA has developed minimum inventory and supply requirements for the different identified EMSresources deployed throughout the County’s EMS System. These inventory lists are available in REMSAoperational policy 3301 – Drug and Equipment List (https://www.remsa.us/policy/3301.pdf), as well as astandardized process for the handling of controlled substances under operational policy 3302(https://www.remsa.us/policy/3301.pdf)–. Each provider organization is inspected annually to ensurecompliance with policy requirements. During the inspection process, approximately 20% of all itemslisted as required items in Policy 3301 are inspected by REMSA personnel. Additionally, provider recordsPage 10 of 46
are inspected for such things as compliance with OSHA standards, current certification/licensure ofemployees, etc.TRANSPORTATION AND F ACILITIESRiverside County has a total of 17 prehospital receiving centers. There are six Base Hospitals, fourTrauma centers, six STEMI centers and 11 Stroke centers. In the city of Calimesa, the first responder isBLS. The city of Blythe receives prehospital medical services from Blythe Ambulance and VolunteerBlythe Fire Department. Interfacility transfers and BLS and CCT calls are serviced by 11 non-emergencyproviders. Two helicopter services are permitted by REMSA, serving both emergency and nonemergency calls. California Highway Patrol is recognized as an air rescue helicopter service. Gurney vanand wheelchair transport providers are not permitted or overseen by REMSA.Policy 3203 (http://www.remsa.us/policy/3203.pdf) delineates responsibilities of the transferringhospital, the receiving hospital, and the permitted ambulance company regarding interfacilitytransfers. Specialty Centers in Riverside County (Trauma, STEMI, and Stroke) are expected to be incompliance with all EMTALA requirements, including accepting specialty patients as a higher level ofcare as long as the specialty center has the capacity to care for these patients. All interfacility transfersmust include physician to physician contact between the sending and the receiving physicians, and thiscontact must be clearly documented in the sending hospital’s records. Time critical interfacilitytransfers requiring ALS or CCT services should have a reasonable response time of one hour in theabsence of previously agreed upon contractual obligations. Permitted Helicopters may be utilized asnecessary for such transfers. As an alternative to a CCT service or a helicopter, the sending hospitalhas the option of sending one of their own nurses along on a BLS or ALS ambulance to monitor thepatient with needs exceeding the scope of practice of a paramedic or an EMT. If an ALS service isrequested for the transfer, the sending physician must submit written orders designating the preciselevel of care deemed necessary during the transport. These orders shall be in accordance with acceptedREMSA paramedic protocols and policy and within the state-recognized paramedic scope of practice.PUBLIC EDUC ATI ON AND PREV ENTI ONREMSA collaborates with our clinical practitioners and hospitals for public education initiatives. REMSAhas also partnered with our larger department – The Emergency Management Department, to offerpublic education and prevention events. Examples include: September Preparedness Month Eventsweekly in our communities to offer hands only CPR education and disaster preparedness materia
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