central new york

CENTRAL NEW YORK

REGIONAL CQI MANUAL

Version 6 January 2017

2 | P a g e Central New York Regional CQI Manual

Table of Contents

3 Preface

4 Introduction 5 Authority 6 Standards

7 Reportable Incidents 9 Primary Level CQI 12 Regional Level CQI 16 Appendix 18 Sample Form for Call Review 19 Primary Level CQI Activity Form


Preface

The intent of this manual is to provide guidance regarding the development, implementation, and maintenance of the continuous quality improvement (CQI) program for the Central New York (CNY) Region. CQI is intended to provide a forum for discussion and learning. From time to time, an issue requiring corrective action may be discovered through the CQI process. If corrective action for unacceptable performance or behavior (rather than the provision of education) is required, it will be handled outside of the CQI process, according to agency, regional, and/or New York State policy and procedure, as applicable.


Introduction

The continuous quality improvement (CQI) program shall be utilized to facilitate the monitoring and evaluation of the quality and appropriateness of medical care provided by the emergency medical services (EMS) agencies in the Central New York (CNY) Region. The program will be used to identify systemic process improvements from the root cause of errors, rather than to simply place blame on an individual’s shortcomings. As such, CQI is a tool to continually hone the system and assure that the procedures employed by EMS lead to the best prehospital patient care possible. To meet the requirement of New York State Public Health Law (NYS PHL) Article 30 Section 3006, every ambulance agency and advanced life support first response agency shall establish and participate in a continuous quality improvement program. Each agency shall follow the recommendations and guidelines included in this document and the NYS DOH Bureau of Emergency Medical Services Quality Improvement for Prehospital Providers manual. While basic life support first response (BLS FR) agencies are not mandated under Article 30 to participate in a CQI program, they are an integral part of the CNY Region and are encouraged to participate in the CQI program. Notwithstanding any other provisions of law, none of the records, documentation, or committee actions or records required pursuant to NYS PHL Article 30 Section 3006(3) shall be subject to disclosure under Article 6 of the Public Officers Law or Article 31 of the Civil Practice Law and Rules, except as hereinafter provided or as provided in any other provision of law. No person in attendance at a meeting of any such committee shall be required to testify as to what transpired thereat. The prohibition related to disclosure of testimony shall not apply to the statements made by any person in attendance at such a meeting who is a party to an action or proceeding, the subject of which was reviewed at the meeting. Any person who in good faith and without malice provides information to further the purpose of this section or who, in good faith and without malice, participates on the primary level or regional level CQI committees shall not be subject to any action for civil damages or other relief as a result of such activity.


Authority

The activities, guidelines, and requirements in this manual are written in accordance with and within the authority of the laws and regulations listed below: 1. New York State Public Health Law Article 30 Section 3003

2. New York State Public Health Law Article 30 Section 3003-a 3. New York State Public Health Law Article 30 Section 3004-a

4. New York State Public Health Law Article 30 Section 3006 5. Codes, Rules and Regulations of the State of New York 405.19 6. New York State Education Law §6527 Special Provisions Under the direction of the Central New York Regional Emergency Medical Services Council (REMSCo) and Central New York Regional Emergency Medical Advisory Committee (REMAC), the Central New York Program Agency shall facilitate the continuous quality improvement program for the Central New York Region.


Standards

The activities, tasks, and decisions made in the course of the CQI process are guided by the following standards: 1. New York State Public Health Law (NYS PHL) Articles 28, 30, and 30A 2. Title 10 of the New York State Codes, Rules and Regulations Part 80 and 800 2. New York State Bureau of Emergency Medical Services Department of Health

Statewide Pre-Hospital Adult and Pediatric Treatment Protocols 3. Central New York EMS Treatment Protocols 4. New York State Department of Health Bureau of EMS Policy Statements

5. New York State SEMAC Advisories 6. Central New York EMS Policy Statements

7. Central New York EMS Procedures 8. New York State Quality Improvement for Prehospital Providers Manual 9. Central New York EMS Regional CQI Manual The Central New York Regional Medical Director shall also provide needed guidance.


Reportable Incidents

The following must be referred to the agency medical director within 24 hours. The agency medical director shall determine if the incident shall be forwarded to the CNYEMS Program Agency. Any findings that may have system impact should be forwarded to the CNYEMS Program Agency. If the agency medical director is not promptly available, the following must be referred to the CNYEMS Program Agency within 24 hours. This can be done by telephone during regular business hours, email, fax, or via the www.cnyems.org website by filling out the electronic form. For any event forwarded to the CNYEMS Program Agency, the patient chart will be forwarded to this agency within 24 hours of the referred incident. All additional paperwork shall be forwarded to the CNYEMS Program Agency within 8 days.

• Medication errors not causing patient harm • Protocol errors and deviations in violation of the “Medical Control

Agreement” of the CNYEMS protocols and “Medical Director Discussion of Protocol Deviations” of the CNYEMS procedures

The following must be referred to the agency medical director and CNYEMS Program Agency immediately. For any event forwarded to the CNYEMS Program Agency, the patient chart will be forwarded to this agency within 24 hours of the referred incident. All additional paperwork shall be forwarded to the CNYEMS Program Agency within 8 days.

• Possible unrecognized esophageal intubations • Patient abandonment

The following must be reported to the New York State Bureau of EMS by contacting the regional representative per Title 10 NYCRR Part 800.21q, , in addition to notifying the CNYEMS Program Agency and the agency medical director, immediately.

• Noncompliance with Title 10 NYCRR Part 800.15: Required Conduct • Noncompliance with Title 10 NYCRR Part 800.16: Suspension Or

Revocation Of Certification

http://www.cnyems.org/


• Death, injury, or harm of a patient, secondary to actions of commission or omission by a member of an agency.

Instances that place patients in immediate danger shall be immediately reported to the CNYEMS Program Agency. If this is witnessed by other providers, they should attempt to stop the event before it causes serious harm to the patient. If it is determined by the CNYEMS Program Agency and regional medical director that the provider’s actions likely caused harm to the patient, the provider’s privileges will be suspended, pending investigation of the incident by the appropriate body. The provider and his or her agency will be notified of this action. Corrective action for unacceptable performance or behavior (rather than the provision of education) is required, it will be handled outside of the CQI process, according to agency, regional, and/or New York State policy and procedure, as applicable. The CNYEMS Program Agency shall identify the most appropriate individual, agency, committee, or other body to address the reportable incident.


Primary Level CQI

Overview Primary level CQI may be done within an individual agency or in collaboration with other agencies, such as a county-wide CQI alliance. The majority of the CQI activities should occur at this level. As determined in New York State Public Health Law Article 30 Section 3006, every ambulance agency and advanced life support first response agency shall establish and participate in a continuous quality improvement program. Any agency or collaborative process that is utilized by an agency to fulfill the primary level CQI obligation must meet agency CQI requirements established by law under Articles 30 and 30A. (See NYS Publication Quality Improvement for Prehospital Providers, Version 1, March 2007.) Each service agency (ambulance, ALS first response, BLS first response, or public access defibrillation site) is encouraged by the CNYEMS Program Agency to have a CQI committee and a written policy thereof. Some agencies may have mandates, other than those listed in Public Health Law. Public access defibrillation sites have a mandate from the NYS Department of Health for reporting defibrillator use to the regional program agency as part of the CQI process. These forms can be found at www.cnyems.org. A policy statement is in effect to offer guidance in completing the CQI requirements for a defibrillator event. In addition, the site medical director may have specific requirements for maintaining proficiency and reporting use. Agencies that are non-transporting and not credentialed at the advanced life support level with certified personnel are required to participate in the CQI process by registering certified providers with the CNYEMS Program Agency. Continuing education and skill proficiencies shall be reported in accordance with CNYEMS Policy Statement “Registration, Continuing Medical Education and Reinstatement.” Primary Level CQI Committee Structure All primary level CQI committees should consist of a variety of providers from within the agency or agencies participating. Additionally, the highest level of



EMT certification within that service or services must be represented. A quorum shall consist of at least three people and at least one of these people must hold the highest level of EMT certification provided by the service or services. The committee shall meet no less than quarterly. Primary Level CQI Activities The primary level CQI committee should review a cross section of events at intervals not less than four times per year, based on agency/county, regional, and state guidelines for evaluation. These events may include, but are not limited to, evaluation of care or services provided, education, research projects, satisfaction surveys, or any other facet that the review of may lead to improvement of agency goals. Any serious event that is considered to adversely affect a patient shall be evaluated within 24 hours of the reported incident. Other events should be reviewed within 30 days of the reported incident. Documents that are helpful to reference during the CQI process are outlined in “Standards” above. A sample CQI meeting agenda is available in the appendix of this document. Primary Level Ongoing CQI Electronic patient care records may enable a program in which the primary level CQI can occur on an ongoing basis, rather than in quarterly meetings. Ongoing CQI within an individual agency, or in cooperation with other agencies, may meet the requirements of primary CQI, provided each agency participating in ongoing CQI has a policy in place that satisfies agency CQI requirements established by law under NYS PHL Articles 30 and 30A. Records of this process sufficient to demonstrate compliance of this requirement must be kept. Primary Level CQI Coordinator The primary level CQI committee shall have a CQI coordinator. This individual shall be knowledgeable in prehospital policies, protocols, and procedures, as well as the general CQI process. The responsibilities of the CQI coordinator may include interacting with agency medical directors, providers, educators, or supervisory staff. They may also be responsible for or assist in reviewing patient


care reports (PCRs), agency policies or standards, agency continuing education initiatives, and patient complaints. It is the coordinator’s responsibility to facilitate the committee activities and to assure that there is a written policy that governs the CQI process. The NYS publication Quality Improvement for Prehospital Providers, Version 1, March 2007, can be a useful tool in assisting agencies in this process. Primary Level CQI Reporting Requirement Every ambulance agency and advanced life support first response agency is required to report quarterly to the CNYEMS Program Agency their primary level CQI activities for the periods ending March 31st, June 30th, September 30th, and December 31st. The primary level CQI activity form is to be completed and sent to the CNYEMS Executive Director by March 31st, June 30th, September 30th, and December 31st. The form can be found in the appendix of this document or at www.cnyems.org. Record Keeping The information required to be collected and maintained, including information from the patient care report (PCR), shall be kept confidential and shall not be released except to the NYS DOH Bureau of EMS, regional level CQI, or pursuant to NYS PHL Article 30 Section 3006. All records pertaining to the CQI process must be kept in a separate, locked, and secured file. Breach of Confidentiality Any breach of confidentiality will result in a review by the Executive CQI Committee and regional medical director for determination of action. These situations will be reviewed on a case-by-case basis, and could result in removal from CQI activities to restriction of privileges to practice in the region. Appeals Any individual provider who disagrees with the educational or corrective action set forth by his or her agency may appeal this decision, in writing, to the Executive CQI Committee within 30 days of the decision.



Regional Level CQI

Overview The Regional Level CQI structure is comprised of 3 components which include the executive CQI committee, Central New York Regional Emergency Medical Advisory Committee (CNY REMAC), and Executive Session. Executive CQI Committee Structure The executive CQI committee is a subcommittee of the CNY REMAC. The CNYEMS Program Agency Executive Director will serve as the committee chairperson and the members of this committee are seated by the chairperson and regional medical director. Members of this committee must support all levels of the CQI process and any member can raise an issue of no confidence to the CNY REMAC regarding any other member of this committee. The subsequent vote of the CNY REMAC may result in a member’s removal from the committee. The executive CQI committee shall consist of the following:

• Regional Medical Director • Program Agency Executive Director • Regional Clinical Consultants • One representative from each county

Executive CQI Activities The executive CQI committee shall meet quarterly, prior to the CNY REMAC meeting, unless an urgent patient care issue requiring immediate attention arises. The executive CQI committee will handle all call reviews at the regional level. Detailed and specific documentation of individual call reviews must be maintained in a secure file with other CQI-related records. Agenda items should include the following:

• Reading and signing of the confidentiality statement • A record of those in attendance


• Review of any new call reviews • Follow-up discussion of any open call reviews • Review of emergent patient care concerns • Recognition of exceptional patient care practice

Record Keeping: The information required to be collected and maintained, including information from the patient care report (PCR), shall be kept confidential and shall not be released except to the NYS DOH Bureau of EMS, or pursuant to NYS PHL Article 30 Section 3006. All records pertaining to the CQI process must be kept in a separate, locked, and secured file. Breach of Confidentiality: Any breach of confidentiality will result in a review by the CNY REMAC and regional medical director for determination of action. These situations will be reviewed on a case-by-case basis, and could result in removal from CQI activities to restriction of privileges to practice in the region. Appeals Any individual provider who disagrees with the educational or corrective action set forth by the executive CQI committee may appeal this decision, in writing, to the CNY REMAC within 30 days of the decision. Central New York REMAC Structure

The Central New York REMAC shall conduct business pursuant to NYS PHL Article 30 Section 3004-a. The CNY REMAC shall meet quarterly unless urgent business arises that requires immediate attention. The committee chairperson is the Regional Medical Director of the CNYEMS Region. The voting members of the committee consist of the physician representatives, Agency Medical Directors and Regional Medical Director. A quorum shall consist of a simple majority of the voting members present.


Central New York REMAC Activities The CNY REMAC meetings shall be conducted in accordance with the New York State Public Officer’s Law, General Construction Law and Articles 30 and 30A of the New York State Public Health Law. When not specified by these State laws, the CNY REMAC meetings shall be conducted according to the simplified parliamentary procedures based on Roberts Rules of Order. Record Keeping: NYS Executive Order No.3 requires all meetings subject to the Open Meetings Law to be broadcast on the Internet. REMAC meetings are subject to the Open Meetings Law and will be webcast according to the NYS Information Technology Policies, Standards and Guidelines concerning webcasting. Minutes and the webcast will be maintained for each meeting. Agenda items should include the following:

• A record of those in attendance • Regional Medical Director report • Executive Director report • Committee reports • Hospital reports • Call commendations • Old business • New business

Executive Session Structure: The Executive Session of the Central New York REMAC is held to discuss any significant regional call reviews that may require a referral to the NYS DOH because of possible 10 NYCRR Part 800 issues. Discussions concerning a provider’s privileges within the CNY Region due to a significant issue are held in executive session. The CNY REMAC voting members and Executive CQI Committee members are in attendance during an executive session. This session is confidential pursuant to NYS PHL Article 30 Section 3006.


Breach of Confidentiality: Any breach of confidentiality will result in a review by the CNY REMAC and regional medical director for determination of action. These situations will be reviewed on a case-by-case basis, and could result in removal from CQI activities to restriction of privileges to practice in the region. Appeals Any individual provider who disagrees with the educational or corrective action set forth by the CNY REMAC should refer to NYS PHL Article 30 Section 3004-a regarding the appeal process.


Appendix: Sample Primary Level CQI Meeting Agenda

• Review the confidentiality policies with the committee members. o A written document should be provided and kept on file for

members to review and sign. o Reading and signing of the confidentiality statement should begin

each meeting of the committee. o More specific information can be found in NYS PHL Article 30

Section 3004-a. o There shall be no release of records, according to NYS PHL Article 30

Section 3006. o Refer to NYS DOH BEMS Policy Statement 12-02 “Prehospital

Care Reports (or updated version) for further information regarding confidentiality & disclosure of PCRs/personal healthcare information.

o Any breach in confidentiality will result in a review by the executive CQI committee for determination of action. This may result in the individual being removed from all CQI

activities. This may also result in a restriction or revocation of privilege

in the region.

• Record all those in attendance and maintain this record.

• Review any open cases after a brief overview of the case and update the written plan and evaluation of the process, accordingly.

• Recognize practices that should be encouraged or incorporated within agency standards.

o This may result in recommendations to the agency for policy or practice changes, referral to the region for future protocol changes, recognition of providers, or nominations for awards at agency, regional, or state levels.


o Regional nomination forms and categories can be obtained from the CNYEMS website.

o Annual regional nominations are considered at the March CNY Regional Emergency Medical Services Council (REMSCo) meeting and presented at the annual awards banquet.

o Recipients are nominated for the New York State Awards presented at the annual New York State conference.

• Review patient care concerns (including any requested reviews and “near

miss” cases), random samples, or specific review categories. o A request for a call review can be made by anyone. o There must be a mechanism in the primary level CQI process to

make a request for call review without disclosure and without fear of reprisal.

o Providers should have an opportunity to participate in the CQI process and appeal, if there is a disagreement.

o Agency medical directors should be involved in the reviews.

• Documentation of all cases discussed should minimally consist of the following.

o A copy of the pertinent medical records o A call summary o A discussion of positive events o A discussion of areas for improvement and correction o A final assessment and education plan


Sample Form for Call Review

Call Review Summary

Overview

Timeline

Key Events

Case Discussion

Conclusion

Recommendation for Education

Documentation of Education

Evaluation

Final Review of Case

PRIMARY LEVEL CQI ACTIVITY REPORT

Date:

Agency Name: Agency Code:

CQI Coordinator Completing Form: Email Address:

Primary Level CQI Performed:

Individual AgencyCollaborative with AgenciesCollaborative with CountyOngoing CQI

Period Ending:

March 31June 30September 30December 31

Types of Calls Reviewed:

Cardiac Arrest RSIControlled Substances StrokeNear Miss TraumaPediatric Medication Error: (see page 2)Patient Refusals Protocol Deviation: (see page 2)Other

Describe the primary level CQI performed for reported period:

Complete this section for all medication errors and protocol deviations. Add additional pages for this section if needed.

Provider Name:

Describe the Medication Error or Protocol Deviation:

Education Provided: