EMS REPORT FORMS Note: The Monroe County Medical Control Authority Professional Standard Review Organization will be referred to as the Continuous Quality Improvement (CQI) Committee throughout this document.1. EMS RUN REPORTS. B. Whenever possible, EMS Run Reports (BLS and ALS) on patients transported to a hospital emergency department must be signed by the physician receiving the patient. If the run report cannot be signed by a physician, an Emergency Department nurse from the receiving hospital must sign the report. This signature acknowledges receipt of the patient only and does not indicate the receiving physician's approval of pre-hospital care/instructions. C. A copy of all EMS Run Reports must be delivered to the Emergency Department of Mercy Memorial Hospital to be forwarded to the Continuous Quality Improvement Committee. All Run Reports, regardless of transport destination, and including those patients refusing treatment/transport, must be forwarded to MMH Emergency Department within 72 hours of the run. 2. INCIDENT REPORTS A. An Incident Report must be completed following any unusual event or circumstance during an EMS run. An Incident Report must be submitted upon request of the Continuous Quality Improvement Committee. Circumstances requiring an Incident Report include, but are not limited to, the following: - Performance of an unusual procedure - A potential medical/legal situation - Medication or procedural error - Radio Failure - Report of personnel complaint - Patient/family conduct - Audited run B. All Incident Reports must be delivered to Mercy Memorial Hospital Emergency Department within five (5) days of request. C. Incident Reports should include: - Run number - Date of incident - Names of personnel involved - Complete explanation of incident 3. EXCEPTION REPORT - EMT-S or EMT-P responding with a MFR agency, then performing ALS procedures. - An out-of-county EMS vehicle responding under mutual aid. - Patient transported by non-licensed EMS vehicle. - Deviation from Monroe County EMS Protocols. B. All Exception Reports must be delivered to Mercy Memorial Hospital Emergency Department within five (5) days of the incident. C. Exception Reports should include: - Run number - Date of incident - Name of personnel involved - Description of exception/deviation - Complete explanation of incident. 4. COMPLAINT/AUDIT REQUEST FORM A. All complaints and requests for audit must be submitted in writing and signed by the person submitting the complaint/audit request.B. Any complaint or audit request not made in writing or written but not signed will not be processed or acted upon. C. All Complaint and Audit requests should be submitted within five (5) days of the incident. Completed Audit/Request forms should be placed inside a sealed envelope and forwarded to the EMS Medical Director or a member of the Continuous Quality Improvement Committee .D. All Complaints and Audit Requests will be kept completely confident. Names of personnel involved and persons making complaint/audit request will be kept confidential. E. Complaint/Audit Request form should include: - Name(s) of person(s) completing form - Name(s) of person(s) involved in incident - Run number - Date of incident - Complete explanation of incident - Explanation of complaint/reason for audit. EMS REVIEW SESSIONS PURPOSE: The EMS Review sessions provide a monthly forum for: 1. continuous review of EMS performance and skill maintenance. 2. improved communication between Medical Control and EMS personnel. 3. relaying educational information to all EMS personnel, i.e.: a. Continuing medical education for state approved credit b. Medical Control Policy updates and changes 4. discussing EMS Peer Review. SCHEDULING: EMS Review Sessions will be held once a month. Date and time of each Review Session will be announced at least 30 days in advance. AGENDA: The issues to be discussed at the EMS Review Sessions will be determined by the EMS Continuous Quality Improvement Committee during their monthly meeting held at least one week before the EMS Review Session. A general theme will be discussed at each session regarding a particular aspect of EMS care. The protocols of that theme may be discussed at that time. The results of the monthly Peer Review will also be discussed. A lecture will be given on a state approved EMS topic offering continuing education credits as arranged by the Medical Control Board's EMS Instructor Coordinator. ATTENDANCE: All paramedics of transporting EMS agencies require an attendance of at minimum 6 of the monthly EMS Review Sessions over a 12 month period to maintain credentialling for Monroe County. Attendance records will be kept on the calendar year from January through December. Attendance records will be reviewed every 6 months and the paramedics will be advised of their standing. Failure to maintain this attendance record will result in the individual being reported to the Medical Control Board. Any paramedic who is subject to this requirement, but fails to meet it, will receive a minimum 2-week suspension of their Monroe County credentials. The paramedic will then be required to attend one credentialling session/day in the Emergency Department for each of the number of review sessions less than 6 for that year. Upon successful completion of the (recredentialling) process and following the period of suspension, the paramedic will be on probation for a term of one year. Failure to meet the above requirements will result in loss of credentials in Monroe County.
EMS PEER REVIEW Peer review of paramedic level performance will be done to evaluate prehospital care. Peer review will be done on a monthly basis to evaluate various parameters of skills, assessment and treatment of patients while on duty. Each month a different parameter will be evaluated. Upon completion of each month's evaluation, the information will be compiled and reviewed by the Continuous Quality Improvement Committee. This information will then be forwarded to the medics within Monroe County and will be used as a basis for improvement of EMS skills and to assure adequate performance by all medics. All paramedics associated with transporting EMS agencies within Monroe County must participate in the peer review program. Procedure: From the date of notification, paramedics have one (1) month to complete their assigned peer review record. Paramedics will receive a letter to inform them that their peer review requirement is due. In that letter a deadline will be given indicating when the reports must be completed. Failure to complete the reports by the deadline will result in the following: 1. The paramedic will be required to complete their previously scheduled peer review report, as well as an additional month's peer review report, by the end of the second month. 2. The paramedic's tardiness will be reported to the Medical Control Authority and a vote will take place to give the EMS Medical Director the power to withdraw the paramedic's credentials by the end of the second month, if the reports are not completed by that time. If by the end of the second month all peer review reports are not completed, the EMS Medical Director will have the option to withdraw the paramedic's credentials within Monroe County. If credentials are withdrawn due to failure to complete the peer review reports, the medic may be reinstated upon completion of those reports and approval by the Medical Control Board.
PROFESSIONAL STANDARDS REVIEW COMMITTEE PROCEDURES AND REQUIREMENTS
The purpose of the Professional Standards Review Committee is to review run reports, incident reports and identify concerns that arise within the prehospital phase of health care delivery. The Professional Standards Review organization for the Monroe County Medical Control Authority will be referred to as the Continuous Quality Improvement (CQI) Committee throughout these protocols. The Committee shall meet not less than 12 times per calendar year on a monthly basis. The following situations will be monitored: 1) Concerns from consumers regarding the EMS system. 2) Concerns from the pre-hospital care providers regarding the EMS system. 3) Communications between the EMS providers and hospital-based personnel (i.e., hospital administration, physicians, and nursing personnel). 4) Use of Standard Orders by pre-hospital personnel. 5 All submitted run reports. RUN REVIEW PROCESS A representative from the CQI Committee will review recorded communications of all runs requested for audit or of other concern. Run sheets and radio logs from each call will be attached and reviewed noting the accuracy of patient assessment appropriateness of treatment, compliance with protocols, completeness of written documentation, etc. Inpatient records for patient outcome may also be utilized when appropriate. REVIEW OF COMPLAINTS The following procedure is followed where concerns regarding a run are expressed either by hospital personnel, prehospital personnel or the public. 1. Request from outside the hospital: EMS Audit Request form must be completed and forwarded to either the E.D. Director's office or a representative of the Medical Control Authority. At that time the problem section of the EMS Audit Report form is completed and placed in the Audits Pending folder. 2. Request from inside E.D.: If a problem develops which cannot be resolved at the time of the on-line radio communication, the radio log shall be marked for audit. The person making the request for audit must complete the problem section of the EMS Audit Report form and place it in the folder marked AUDITS PENDING 3. Complaints regarding the quality of patient care provided by EMS personnel operating in this system will be reported promptly in writing (with 48 hours) to the EMS Medical Director. The EMS Medical Director should be contacted or, of not available, a designated alternate physician should be contacted. 4. When a problem is identified, an Audit Report form must be completed. 5. In unusual cases, either because of uniqueness or quality of care issues (exceptional or questionable), the EMS Medical Director or the EMS personnel may refer the case for discussion at the EMS Review session.
PERSONNEL QUALITY REVIEW AND CORRECTIVE ACTION PROCEDURES When there is indication of a serious problem needing correction, the EMS Medical Director or Designee will initiate a special meeting of the Continuous Quality Improvement (CQI) Committee. If the incident and run report deviate from the accepted protocol, the CQI Committee will meet within 10 working days of initial notification to the EMS Medical Director. The EMS Medical Director or Designee will send a letter to the appropriate prehospital care providers regarding the incident which the CQI Committee is reviewing. The individual or party will meet with a CQI Committee member to discuss the case. This initial meeting report is brought to the CQI Committee. The CQI Committee shall review the report and pertinent facts. The CQI Committee may either find the reported actions within acceptable guidelines, or ask the prehospital care personnel to participate in a follow-up meeting to detail his/her involvement in that particular event. The EMS Medical Director or Designee will make an immediate decision as to the severity of the complaint based on: the statement of the person making the complaint; conversations with the individual cited; and, when possible, other witnesses to the occurrence. If it appears, according to the EMS Medical Director's judgment, that care rendered in the reported situation may have adversely affected the safety, health and/or welfare of individuals who received care (due to improper performance, or failure to meet local standards for patient care) or to other health care providers, the complaint will be considered serious and handled as below. Complaints which do not appear to meet the above criteria will be considered for information purposes only. Serious complaints will be handled as follows: 1. The EMS Medical Director may order the immediate suspension of the individual(s) involved, for a period of 72 hours. Such a suspension will specify the level of care from which the individual(s) are suspended. For example, a paramedic might be suspended from functioning as a paramedic only, while still being allowed to function as an EMT. Such a suspension is from the provision of specific patient care services only, and does not imply suspension from employment by a service, which is the prerogative of that employer. 2. The individual(s) cited will be given the opportunity to provide the EMS Medical Director with a written reply to the initial complaint. The EMS Medical Director may, on review of written response to complaint, determine the complaint does not justify suspension. He may rescind suspension but must forward his judgment and the complaint to the CQI Committee as per below. 3. During the period of suspension, the EMS Medical Director will assemble a Continuous Quality Improvement Committee to investigate and review the incident. The Committee will review all available information including: a) A copy of the letter of complaint b) Date and time of incident c) Names and titles of those persons involved d) Standard EMS Report forms 4. The individual(s) cited will be given an opportunity to present their view of the complaint to the Committee. 5. Based on the information obtained, the Committee may recommend that the Medical Control Authority Advisory Board take one or more of the following actions: a. Endorsement of action b. Warning to provider c. Suggest probation - within the system d. Require retraining e. Suggest suspension f. Recommend revocation of license - from MDCIS 6. If the Committee determines that corrective action must be taken on the individual(s), the Chairman will be responsible for notifying the Michigan Department of Consumer and Industry Services - EMS Division of the outcome. If the action of the Committee involves continued suspension, such suspension will be continued for a period of five (5) working days during which time the individual or service may request an appeal of the decision made by the CQI Committee. Any request for an appeal of a decision made by the CQI Committee must be made in writing within five (5) working days of that decision. Failure to submit a request for appeal in writing within five (5) working days constitutes acceptance of the CQI Committee's decision by the individual(s) involved. If an appeal is requested, the individual(s) involved will be provided an opportunity to present their comments to an appointed Appeals Committee within five (5) working days of the request. 7. If a serious deviation from the minimum standard of medical care, protocols or operating procedures has occurred, a registered letter will be sent by the EMS Medical Director or his Designee to the individual(s) involved in the incident. This letter will include documentation of the incident, description of the review process and the recommended disciplinary measures. A copy of this letter will also be sent by registered mail to the individual's employer and to the Michigan Department of Consumer and Industry Services - EMS Division. CORRECTIVE ACTION APPEAL MECHANISM The Appeal Review Committee shall be comprised of an emergency department physician not on the review committee, one emergency department nurse, and two emergency medical technicians (of same level training, e.g., EMT or paramedic). Members shall be appointed by the chairperson of the Medical Control Board. The Appeal Review Committee shall review the actions of the Continuous Quality Improvement Committee and Medical Control Authority as well as materials supplied the individual or agency requesting the appeal. After reviewing the materials and actions, the Appeal Review Committee may either uphold the decision of the Medical Control Board or reject and/or modify that decision. Within ten (10) working days after receipt of the decision of the Appeal Review Committee, the individual or agency by written notice, may request an appellate review by the Executive Committee of the Medical Control Board. This Review Board shall meet within ten (10) working days after receipt of written notice of appeal. A decision of the Appeal Review Committee which is appealed to the Medical Control Authority Executive Committee shall then be final unless appealed to the Michigan Department of Consumer and Industry Services. Date Revised 11/04 Medical Control Approved 11/04 EMS Division Approved 11/04
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