EL DORADO COUNTY EMS AGENCY

ADMINISTRATIVE POLICIES
Supersedes: Policy dated July 1, 2008
Effective: July 1, 2010 EMS Agency Medical Director
Updated: July 12, 2012
Scope: Administrators

CONTINUOUS QUALITY IMPROVEMENT

AUTHORITY:

California Health and Safety Code, Division 2.5, Sec. 1797.204; California Code of Regulations, Title 22,
Sec. 100146

DEFINITIONS:
Continuous Quality Improvement (CQI) – A peer based process that conducts a clinical review of
selected cases each month, based on strict confidentiality and a shared commitment to excellent
pre-hospital care. CQI reveals potential areas for improvement of the EMS system, suggests training
opportunities, highlights outstanding clinical performance, audits compliance with treatment
protocols, and reviews specific illness or injury along with associated treatments. These efforts
contribute to the continued success of our emergency medical services through a systematic process
of review, analysis, and improvement.

POLICY:
The EMS Agency will establish and facilitate a system-wide comprehensive quality assessment and
improvement program. The program will include, but is not limited to the following activities:

1. Each agency will participate in monthly Continuous Quality Improvement Committee meetings. A
peer level representative from each agency will attend the monthly meeting.
a. Membership to include all field level pre -hospital ALS first responders, emergency medical
dispatch, base hospitals, and EMS staff/personnel.
b. Invited participants to include all BLS first responders and air medical service responders.
2. Each agency will comply with reporting and other quality assessment requirements as specified or
determined by CQI processes and/or EMS Agency.
3. Each agency will submit their individual QA/CQI plan to the EMS Agency for approval. The time
frame for submission will be 90 days from July 1, 2010.
4. Each agency shall conduct an annual review of their own individual QA/CQI plan and submit
any changes to the EMS Agency for approval.
5. The EMS Agency will evaluate the implementation of each agency’s plan annually and request
appropriate revisions as needed.
6. Patient and provider confidentiality will be strictly maintained at all times during the CQI process.
A Confidentiality agreement will be signed at the beginning of each meeting by all participants.
7. A CQI Chairperson will be appointed by the CQI Committee. The term of service will be one year.
This position will be equally rotated through all participating agencies.
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CONTINUOUS QUALITY IMPROVEMENT RESPONSIBILITIES:

EMS AGENCY:
1. Comply with all federal, state and county rules, regulations, laws and codes applicable to EMS.
2. Coordinate pre-hospital CQI committee(s).
3. Establish policies and procedures to assure medical control, which may include, dispatch, BLS,
ALS, patient destination, patient care guidelines, and quality assurance guidelines.
4. Facilitate implementation by system participants of required individual CQI programs.
5. Design system wide reports for monitoring identified problems and/or trend analysis.
6. Approve standardized corrective action plans for identified deficiencies in pre-hospital and
base hospital personnel.
7. Establish and monitor procedure for informing all field personnel of system changes.
8. Participate in ongoing audits and studies with base hospitals and ALS transport contractor
agencies including committee discussions, site visits and ongoing monitoring.
9. On call availability for unusual occurrences, disasters and major incidents.
10. Evaluate the process developed by system participants for retrospective analysis of pre-
hospital care.
11. Evaluate identified trends in the quality of pre-hospital care delivered in the system.
12. Establish audit filters and focus studies based on trend analysis.
13. Establish procedure for implementing an incident review process for pre-hospital and base
hospital personnel.
14. Monitor and evaluate the incident review process.

REPORTING / FEEDBACK
1. Evaluate data submitted from system participants and make changes in system design as
necessary.
2. Provide timely feedback to system participants for loop closure and to allow for performance
improvement.
3. Design pre-hospital research and efficacy studies regarding the pre-hospital use of any drug,
device or treatment procedure where applicable.
4. Facilitate training/education, policy and procedure revisions for quality improvement based on
case review analysis and trending provided by CQI committee and/or transport contractor
agencies.

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EMERGENCY MEDICAL DISPATCH*

1. Provide and ensure participate in initial orientation, continuing education opportunities and
other training as specified by the EMS Agency through policy or contractual obligation.
2. Develop performance standards for evaluating the quality of service provided by dispatch.
3. Appoint a CQI representative to facilitate education, consultation, and actively participate in
system wide CQI committee activities.
4. Design system for monitoring identified problems and/or trend analysis.
5. Design training plans for individual EMD deficiencies.
6. Establish a procedure for evaluation of EMDs utilizing performance standards through direct
observation.
7. Participate in ongoing committee discussions, audits, field research and studies.
8. Develop a process for case review and analysis of dispatched calls, utilizing audio, report form,
and other applicable documentation.
9. Participate in the incident review process.
10. Identify, analyze and evaluate trends in the quality of service provided to include but not
limited to: high risk calls, protocol compliance, and documentation.

PRE-HOSPITAL FIRST RESPONDER BLS AND ALS TRANSPORT CONTRACTOR AGENCIES*

1. Provide and ensure participation in initial orientation, continuing education opportunities and
other training as specified by the EMS Agency through policy or contractual obligation.
2. Develop performance standards for evaluating the quality of care provided.
3. Appoint a CQI representative to facilitate education, consultation and actively participate in
system wide CQI committee activities. Provide availability for participation of field training
officers / supervisors for CQI activities.
4. Design system for monitoring identified problems and/or trend analysis.
5. Design training plans for individual pre-hospital medical provider deficiencies.
6. Establish a procedure for evaluation of pre-hospital medical providers utilizing performance
standards through direct observation.
7. Participate in ongoing committee discussions, audits, field research, and studies.
8. Develop a process for retrospective review and analysis of field care utilizing patient care
records, audio tapes, and other applicable documentation.
9. Identify, analyze and evaluate trends in the quality of patient care to include but not limited
to: clinical assessment and treatment rendered, critical skills, protocol compliance,
documentation, and excellence in performance.
10. Participate in the incident review process.

BASE HOSPITALS*
1. Provide and participate in continuing education opportunities, certification courses and other
training as specified by the EMS Agency through policy or contractual obligation.
2. Develop performance standards for evaluating the quality of care/service provided by base
hospital personnel.
3. Base hospital coordinator or designee to facilitate education, consultation, and actively
participate in system wide CQI committee activities.
4. Design system for monitoring identified problems and/or trend analysis.
5. Design training plans for individual MICN or base hospital physician deficiencies.
6. Provide on-line medical control for EMT-P’s within the El Dorado County approved scope of
practice.
7. Establish a procedure for evaluation of base hospital personnel utilizing performance standards
through direct observation.
8. Develop a process for obtaining patient follow-up on all base directed calls.
9. Participate in ongoing committee discussions, audits, field research, and studies.

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10. Develop a process for identifying issues/problems involving pre-hospital and base hospital
personnel.
11. Develop a process for retrospective review and analysis of field care and base direction
utilizing patient care records, audio tapes, and other applicable documentation.
12. Identify, analyze and evaluate trends in the quality of patient care and base direction to
include but not limited to: clinical assessment and treatment rendered/ordered, critical skills,
protocol compliance, documentation, and excellence in performance.
13. Participate in the incident review process.

*REPORTING / FEEDBACK
1. Recommend, design and participate in training/education, policy and procedure revision for
quality improvement based on case review analysis and trending.
2. Provide feedback to system participants for loop closure and to allow for performance
improvement.
3. Implement approved changes to internal policies and procedures.

CQI REVIEW PROCESS:

Peer Review Collaborative

& Focus Studies Learning

El Dorado County
CQI Model

Better Practices Change

 Clinical Implementation
 Operational
 Organizational

This policy defines the process used to identify and report variations in practice from the El Dorado
County EMS protocols, policies or procedures, assessment/treatment guidelines, documentation
standards and recognition of excellence for exceptional assessment, treatment and superior
documentation of patient care.

1. Each Agency will review their cases for the indicators defined above.
2. The reporting agency or individual will summarize the issue or concern on the CQI Medical
Event Report Form and submit to appropriate agency CQI representative or base hospital
coordinator.
3. Personnel involved will review the case, the pertinent protocol, policy, or procedure, complete
the Medical Event Report Form with a written response or explanation of the variation, sign and
submit to their agency CQI representative within 15 days.
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4. CQI representatives will follow their agency’s policy and procedure for obtaining the
information requested. It is the responsibility of the CQI representative to document and report
their findings and actions taken to improve performance to the CQI Committee.
5. The CQI Committee will review these cases and make recommendations for improvement or
recognition of excellence. All identifying patient and provider information shall be redacted
from the CQI copy of the PCR.
6. Failure to participate in the CQI incident review process may result in disciplinary action.
7. All Incidents will be documented by the CQI Committee with the following items to be
reflected in the meeting minutes:
a. Cases reviewed.
b. Findings, recommendations, and actions taken.
c. Trends analyzed and monitored
d. Protocol, policy, and procedure evaluation and revision.
e. Education and training opportunities.
8. Reports will be secured for one year by each reporting agency as part of the CQI process,
therefore protected under California State Evidence code 1157:
a. Each agency will make their records available for audit by the El Dorado County EMS
Agency medical director.

Confidentiality Notice: The functions of the Continuous Quality Improvement Committee include
the evaluation and improvement of the quality of medical care provided in the emergency medical
system. Accordingly, the proceedings, records, and files of the El Dorado County EMS CQI
Committee are confidential by law and further are neither discoverable nor admissible in any
proceeding arising from the matters that are being reviewed and evaluated pursuant to California
State Evidence Code 1157.

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El Dorado County EMSA CQI Medical Event Report

Date: ____________ PCR #: _________ Medic Unit: _________ Name: _______________________________

Nature of Event
Documentation Error or Omission Treatment Error or Omission
Assessment Error or Omission High Risk Procedure
Adverse or Unexpected Outcome Excellence in Care
Other
Event Summary:
_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Response:
_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Follow Up Request:
1. Sign and return a copy of this form to your agency CQI representative when received. This only
acknowledges receipt of this request for information.

2. Review the case and the pertinent protocol, policy, or procedure(s). Submit a written response or
explanation of the variation to the CQI committee within 15 days.

Signed: ___________________________________________ Date: _________________________________

Event Review / Follow-Up Action:

No additional action necessary Education or training
Evaluate policy or procedure Forward for further review
Monitor and trend Other: ______________________________

Confidentiality Notice: The functions of the Continuous Quality Improvement Committee include the evaluation and
improvement of the quality of medical care provided in the emergency medical system. Accordingly, the proceedings,
records, and files of the El Dorado County EMS CQI Committee are confidential by law and further are neither discoverable
nor admissible in any proceeding arising from the matters that are being reviewed and evaluated pursuant to California
State Evidence Code 1157.