YOLO COUNTY EMS QUALITY IMPROVEMENT PLAN 2015

YOLO COUNTY EMS QUALITY IMPROVEMENT PLAN 2015

Contents INTRODUCTION... 3 Six Aims for Healthcare... 3 The IHI Triple Aim... 4 ABOUT THIS PLAN... 5 MISSION - VISION - VALUES... 6 Mission... 6 Vision... 6 Values... 7 DEMOGRAPHICS, ORGANIZATIONAL CHARTS, AND EMS PARTNERS... 9 Demographics... 9 Map of Yolo County... 10 YEMSA Organizational Chart... 11 YEMSA Standing Committees Organizational Chart... 12 EMS System... 13 QUALITY GUIDELINES AND COMMITTEES... 14 Quality Guidelines... 14 YEMSA Committees... 28 MANAGEMENT AND ADMINISTRATION OF TRAUMA SYSTEM... 30 DATA COLLECTION, QUALITY OF INDICATORS AND REPORTING... 31 Data Collection... 32 Quality Indicators... 33 Reporting... 34 ACTION TO IMPROVE... 35 Six Sigma... 36 Program/Project Management Model... 38 TRAINING AND EDUCATION... 38 ANNUAL UPDATE... 39 Yolo County Annual Report... 39 APPENDIX A: UNUSUAL OCCURRENCE FORM... 41 APPENDIX B: CHARTS USED FOR REPORTING... 42 APPENDIX C: PROTOCOL REVIEW PROCESS... 45 APPENDIX D: QUALITY INDICATORS... 46 2

INTRODUCTION The Yolo County Emergency Medical Service Agency (YEMSA) is patient-centered and reflects the concept that the practice of medicine is dynamic. Our services are adaptable to our changing community. YEMSA s foundation is education and quality improvement for the agency, our providers, and the community. Input from the providers and the public we serve is essential to growth and improvement. From The Institute of Medicine s pivotal 2001 report, Crossing the Quality Chasm, YEMSA s vision aligns with the six specific aims for quality improvement and with the Institute for Healthcare Improvement s (IHI) Triple Aim framework. Six Aims for Healthcare 1. Safe: - Avoiding injuries to patients from the care that is intended to help them. 2. Effective: - Providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit. 3. Patient-centered: - Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions. 4. Timely: - Reducing waits and sometimes harmful delays for both those who receive and those who give care. 5. Efficient: - Avoiding waste, including waste of equipment, supplies, ideas, and energy. 6. Equitable: - Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. 3

The IHI Triple Aim The Institute for Healthcare Improvement (IHI) supports designs concepts that simultaneously pursue three (3) dimensions of healthcare improvement, known as the Triple Aim : Improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of healthcare. 4

ABOUT THIS PLAN 100400 YEMSA designed this Quality Improvement Plan to be shared and followed by all Emergency Medical Service (EMS) providers. The YEMSA Quality Improvement Plan integrates quality improvement methods from a wide variety of sources including the IHI Triple Aim approach, Results Based Accountability, Baldrige, Deming and Six Sigma. While these quality improvement models, on the surface, seem to vary in their methodologies, their collective frameworks guide organizations to study and improve their systems of care. This Quality Improvement Plan focuses on answering five (5) fundamental questions: 1. Why are we here and why do we exist? 2. Where are we going? 3. What guides our day to day decisions? 4. How are we doing? 5. What are we doing to make things better? Taigman, M: Implementing Patient Centered Quality Management Retrieve from:http://www.naemt.org/files/implementing%20patient-centered%20quality%20management.pdf 5

MISSION - VISION - VALUES Mission Why are we here and why do we exist? Making a difference by enhancing the quality of life in our community. The mission specialty of YEMSA is to ensure emergency pre-hospital and medical services in Yolo County are provided in a manner that is timely and to the highest quality standards of care. Vision Where are we going? Yolo County Vision To guide development of unincorporated areas toward the most desirable future possible. The highest and best use of the land within Yolo County combines minimum urbanization with the preservation of productive farm resources and open space amenities. YEMSA County Vision To continually evaluate our progress of our emergency medical services through a systemic process of review, analysis and improvement. We will achieve this by: Recognize areas for improvement of the EMS system. Training opportunities. Highlight outstanding clinical performance. Monitor compliance of treatment protocols. Review specific illnesses or injuries along with associated treatments. 6

Values What guides our day to day decisions? Yolo County Core Values o Service o Performance o Integrity o Responsibility o Innovation o Teamwork YEMSA Core Values o Integrity o Professionalism o Compassion o Honesty o Community Values Statement As Yolo County employees, we recognize the benefits of living and working in Yolo. We are committed to doing right by others through public service and maintaining the trust of our residents and peers. Together, we will continue to foster a healthy, supportive and professional environment, and will always strive for excellence. 7

STARCARE is a values-based checklist developed by paramedic author/ems educator Thom Dick. STARCARE promotes a patient-centered, values-based culture as a guide for providers for decision making. Online training will be provided by YEMSA and available for all EMS Professionals. This program will be used as an EMS evaluation tool for each professional that goes through an investigation process with a patient. YEMSA will evaluate each STARCARE report, and add it to the investigation. Safe - Were my actions safe for me, for my colleagues, for other professionals and for the public? Team-based - Were my actions taken with due regard for the opinions and feelings of my co-workers, even those from other agencies? Attentive to human needs - Did I treat my patient as a person? Did I keep him or her warm? Was I gentle? Did I use his or her name throughout the call? Did I tell him or her to what expect in advance? Did I treat his or her family and/or relatives with respect? Respectful - Did I act toward my patient, my colleagues, my first responders, the hospital staff and the public with the kind of respect that I would have wanted to receive myself? Customer accountable - If I were face-to-face right now with the customers I dealt with on this response, could I look them in the eye and say, I did my very best for you? Appropriate - Was my care appropriate - medically, professionally, legally and practically - considering the circumstances I faced? Reasonable - Did my actions make sense? Would a reasonable colleague of my experience have acted similarly under the same circumstances? Ethical - Were my actions fair and honest in every way? Are my answers to these questions honest with integrity? (Used with permission of Thom Dick) 8

DEMOGRAPHICS, ORGANIZATIONAL CHARTS, AND EMS PARTNERS Why are we here and why do we exist What are we doing to make things better? Demographics Yolo County has a total area of approximately 1,023 square miles and has an estimated population of 204,593 residents. The population centers of the County, which together comprise approximately 87% of the County s population, are found in Table 1 below. Table 1: Yolo County Population Centers City Population (2010) Davis 65,622 Woodland 55,468 West Sacramento 48,744 Winters 6,624 The remaining 13% of the County s population, approximately 26,267 people, live in the unincorporated areas of the County. The population in the County grew approximately 19% between 2000 and 2010. According to the U.S. Census Bureau, approximately 10% of Yolo County s population is over 65 years of age. The median household income in the County is approximately $55,798, which is below the state median. It is estimated that 18.4% of the County s residents have incomes below the Federal Poverty Level (FPL). An estimated 36% percent of individuals earn incomes less than 200% of FPL. The highest percentages of individuals living below 200% of FPL are in the cities of Dunnigan, Knights Landing, Zamora, Madison, Woodland and Davis. Major employers in the County are University of California at Davis, the United States Postal Service, Cache Creek Casino Resort, Yolo County, the State of California, Target Corporation, United Parcel Service Incorporated, Woodland Joint Unified School District, Woodland Healthcare, Davis Joint Unified School District, and Raley s Supermarkets, among others. 9

Map of Yolo County Yolo County 1023 square miles Population 204,593 Approximately15,000 EMS transports annually 10

YEMSA Organizational Chart Board of Supervisors Emergency Medical Care Committee (EMCC) County Administrative Officer Director of Health and Human Services Agency EMS Medical Director EMS Administrator EMS Program Coordinator EMS Specialist II (0.5) EMS Specialist II (0.5) EMS Specialist I 11

YEMSA Standing Committees Organizational Chart Yolo County Health and Human Services Agency Assistant Director of Health and Human Services Agency EMS Medical Director Emergency Medical Care Committee (EMCC) Physicians Advisory Committee (PAC) Continuous Quality Improvement Committee (CQI) Pre-hospital STEMI Advisory Committee (Pre-STEMI) Pre-hospital Trauma Advisory Committee (Pre-TAC) 12

EMS System First Responders Brooks Clarksburg Davis Dunnigan Elkhorn Esparto Guinda Knights Landing Madison Rumsey UC Davis West Plainfield West Sacramento Willow Oak Winters Woodland Yocha DeHe Yolo County Zamora Receiving Hospitals Woodland Memorial Hospital Sutter Davis Hospital Mercy General Hospital UC Davis Medical Center Kaiser Permanente Vacaville Hospital North Bay Medical Center Air Transport REACH CALSTAR Interfacility Transport American Medical Response NORCAL Ambulance ProTransport-1 Sacramento Valley Ambulance Ground Transport American Medical Response 13

QUALITY GUIDELINES AND COMMITTEES Why are we here and why do we exist? Where are we going? What guides are day to day decisions? How are we doing? What are we doing to make things better? Quality Guidelines General 100400 YEMSA shall establish and facilitate a system wide quality improvement program to monitor, review, evaluate and improve the delivery of pre-hospital care services. The program shall involve all system participants and shall include, but not be limited to the following activities: Prospective - designed to prevent potential problems. Concurrent - designed to identify problems or potential problems during the course of patient care. Retrospective - designed to identify potential or known problems and improve or prevent their recurrence. Reporting/Feedback - all QI activities will be reported to YEMSA in a manner to be jointly determined. As a result of QI activities, changes in system design may be made. EMS partners in Yolo County, including 911 dispatch, First Responders, Basic Life Support (BLS) responders, Advanced Life Support (ALS) non-transporting, ALS transporting, Interfacility transports and receiving hospitals shall follow this Quality Improvement Plan and turn in an annual QI report. Each QI report will have a due date that is mutually agreed upon and set forth by YEMSA. Appropriate revisions shall be made as requested by YEMSA. Each agency shall conduct an annual review of the QI plan. YEMSA requires an annual report of the QI plan. 14

YEMSA 100404 Maintain a provider-specific written EMS CQI Program, as identified in Title 22, Chapter 12, Article 2. Such programs shall include indicators for Emergency Medical Services Quality Improvement Program Model Guidelines, which address, but are not limited to the following: Personnel Equipment and Supplies Documentation Clinical Care and Patient Outcome Skills Maintenance/Competency Transportation/Healthcare Facilities Public Education and Prevention Risk Management Other Prospective 1. Comply with all pertinent rules, regulations, laws and codes of Federal, State and County applicable to emergency medical services. 2. Coordinate pre-hospital quality improvement committees. 3. Plan, implement and evaluate the emergency medical services system including public and private agreements and operational procedures. 4. Implement advanced life support systems and limited advanced life support systems. 5. Approve and monitor pre-hospital training programs. 6. Certify/authorize pre-hospital personnel. 7. Establish policies and procedures to assure medical control, which may include dispatch, BLS, ALS, patient destination, patient care guidelines, and quality improvement requirements. 8. Facilitate implementation by system participants of required Quality Improvement plans. 9. Design reports for monitoring identified problems and/or trends analysis. 10. Approve standardized corrective action plan for identified deficiencies in pre-hospital and base hospital personnel. 15

Concurrent Activities 1. Site visits to monitor and evaluate system components. 2. On call availability for unusual occurrences, including but not limited to: 2.1 Multi-Casualty Incidents (MCI) 2.2 Ambulance Diversion Retrospective Analysis 1. Evaluate the process developed by system participants for retrospective analysis of pre-hospital care. 2. Evaluate identified trends in the quality of pre-hospital care delivered in the system. 3. Establish procedures for monitoring certifications needed to maintain Yolo County accreditation. 4. Evaluate the process and training of Emergency Medical Technician (EMT) certification and Paramedic accreditation. 5. Monitor and evaluate the incident review process. Reporting/Feedback 1. Evaluate submitted reports from system participants and make changes in system design as necessary. 2. Provide feedback to system participants when applicable or when requested on quality improvement issues. 3. Design pre-hospital research and efficacy studies regarding the pre-hospital use of any drug, device, or treatment procedure, where applicable. 16

Dispatch Prospective 1. Participation on committees as specified by YEMSA. 2. Education 2.1 Orientation to the EMS system. 2.2 Continuing education activities to further the knowledge base of the dispatcher, to include, but not limited to: 2.2.1 Tape review. 2.2.2 Educational programs based on problem identification and trend analysis. 2.2.3 Discussion of calls that are selected for review. 2.2.4 Participation in certification and training of the Emergency Medical Dispatch (EMD). 2.2.5 Establish procedure for informing all EMDs of system changes. 3. Evaluation - Develop criteria for evaluation of individual EMDs to include, but not limited to: 3.1 Tape review or other documentation as available. 3.2 Evaluation of new employees. 3.3 Daily routine. 3.4 Problem-oriented. 3.5 Design standardized corrective action plans for individual EMD deficiencies. 4. Certification 4.1 Initial certification. 4.2 Recertification. 17

Concurrent Activities 1. Establish a procedure for evaluation of EMDs utilizing performance standards through direct observation. Retrospective Analysis 1. Develop a process for retrospective analysis of dispatched calls, utilizing audio tape and dispatcher report forms, to include, but not limited to: 1.1 High-risk calls 1.2 High-volume occurrences. 1.3 Problem-oriented calls 1.4 Any call requested to be reviewed by EMS or other appropriate EMS agency (i.e. Fire Department or American Medical Response [AMR]). 1.5 Specific audit topics established through the Continuous Quality Improvement (CQI) Committee. 2. Develop performance standards for evaluating the quality of care delivered by the EMD through retrospective analysis. 3. Participation in the incident review process. 4. Comply with reporting and other quality improvement requirements as specified by YEMSA. 5. Participation in pre-hospital research and efficacy studies requested by YEMSA and/or the CQI committee. Reporting/Feedback 1. Develop a process for identifying trends in the quality of dispatch care. 1.1 Report as specified by YEMSA. 1.2 Design and participate in educational activities based on problem identification and trend analysis. 1.3 Make approved changes in internal policies and procedures based on trend analysis. 18

First Responder/Fire Agencies 100401 & 100402 Prospective 1. Participation on committees as specified by YEMSA 2. Education 19 2.1 Orientation to the EMS system. 2.2 Offer educational programs based on problem identification and trend analysis. 2.3 Establish procedure for informing all field personnel of system changes. 3. Evaluation - Develop criteria for evaluation of individual Emergency Medical Responders (EMR) and EMTs to include, but not limited to: 3.1 Patient Care Report (PCR) review/call review or other documentation as available. 3.2 Ride along and evaluation of new volunteers/employees. 3.3 Problem-oriented. Concurrent Activities 1. Ride-along - Establish a procedure for evaluation of EMRs and EMTs utilizing performance standards through direct observation. Retrospective Analysis 1. Develop a process for retrospective analysis of field care, utilizing PCRs and audio tape (if applicable) on all calls. Reporting/Feedback 1. Develop a process for identifying trends in the quality of field care. 1.1 Report as specified by YEMSA. 1.2 Design and participate in educational activities based on problem identification and trend analysis. 1.3 Make approved changes in internal policies and procedures based on trend analysis.

Advanced Life Support (ALS) Provider 100401 & 100402 Prospective 1. Participation on committees as specified by YEMSA. 2. Education 20 2.1 Orientation to EMS system. 2.2 Continuing Education. 2.3 Participate in certification courses and the training of pre-hospital care providers. 2.4 Offer educational programs based on problem identification and trend analysis. 2.5 Establish procedure for informing all field personnel of system changes. 3. Evaluation - Develop criteria for evaluation of individual Paramedics to include, but not limited to: 3.1 PCR review/tape review or other documentation as available. 3.2 Ride-along. 3.3 Evaluation of new employees. 3.4 Daily routine 3.5 Problem-oriented. 3.6 Design standardized corrective action plans for individual paramedic deficiencies. 4. Certification/Accreditation - establish procedures, based on YEMSA policies regarding: 4.1 Initial certification/accreditation. 4.2 Recertification/continuing accreditation. 4.3 International Trauma Life Support (ITLS) or Pre-hospital Trauma Life Support (PHTLS) 4.4 Advanced Cardiovascular Life Support (ACLS) 4.5 Preceptor authorization.

4.6 Other training as specified by YEMSA. Concurrent Activities 1. Ride-along - Establish a procedure for evaluation of Paramedics utilizing performance standards through direct observation. 2. Provide availability of Field Supervisors and/or quality improvement liaison personnel for consultation/assistance. 3. Provide patient information to the base hospital to facilitate obtaining patient follow-up information from receiving hospitals. Retrospective Analysis 1. Develop a process for retrospective analysis of field care, utilizing PCRs and audio tape (if applicable), to include but not limited to: 1.1 High-risk calls. 1.2 High-volume occurrences. 1.3 Problem-oriented calls. 1.4 Any call requested to be reviewed by YEMSA or other appropriate EMS agency (e.g. Fire Department or AMR). 1.5 Specific audit topics established through the CQI Committee. 2. Develop performance standards for evaluating the quality of care delivered by field personnel through retrospective analysis. 3. Participate in the incident review process. 4. Comply with reporting and other quality improvement requirements as specified by YEMSA. 5. Participate in pre-hospital research and efficacy studies requested by YEMSA and/or the CQI Committee. 21

Reporting/Feedback 1. Develop a process for identifying trends in the quality of field care. 1.1 Report as specified by YEMSA. 1.2 Design and participate in educational activities based on problem identification and trend analysis. 1.3 Make approved changes in internal policies and procedures based on trend analysis. 22

EMS Aircraft Provider 100401 and 100402 Prospective 1. Participate in YEMSA quality improvement activities. 2. Education 2.1 Orientation to EMS system. 2.2 Continuing Education (CE). 2.3 Participate in certification courses and the training of pre-hospital care providers. 2.4 Offer educational programs based on problem identification and trend analysis. 2.5 Establish procedure for informing all EMS personnel of system changes. 3. Evaluation - Develop criteria for evaluation of Nurses and Paramedics to include, but not limited to: 3.1 PCR review/tape review or other documentation as available. 3.2 PCR is fully and accurately completed, and the PCR is distributed to YEMSA and the receiving hospital per established timelines. 3.3 Evaluation of new employees. 3.4 Design standardized corrective action plans for individual Paramedic and/or Nurse deficiencies. 4. Certification/Accreditation - establish procedures, Based on YEMAS policies regarding: 4.1 Initial certification/accreditation. 4.2 Recertification/continuing accreditation. 4.3 ITLS or PHTLS. 4.4 ACLS. 23

Concurrent Activities 1. Establish a procedure to evaluate field personnel in regards to patient care. Retrospective Analysis 1. Develop a process for retrospective analysis of field care, utilizing PCRs and audio tape (if applicable), to include but not limited to: 1.1 High-risk calls. 1.2 Problem-oriented calls. 1.3 Any call requested to be reviewed by YEMSA. 1.4 Specific audit topics established through the CQI Committee. 2. Participate in the incident review process. 3. Comply with reporting and other quality improvement requirements as specified by YEMSA. 4. Participate in pre-hospital research and efficacy studies requested by YEMSA and/or the CQI Committee. 5. Provide YEMSA with clinical and response time data necessary for monitoring and evaluating the EMS system, particularly for trauma patients, as part of the EMS trauma audit process. Reporting/Feedback 1. Develop a process for identifying trends in the quality of field care. 1.1 Report as specified by YEMSA. 1.2 Design and participate in educational activities based on problem identification and trend analysis. 1.3 Make approved changes in internal policies and procedures based on trend analysis. 24

Hospital Guidelines Prospective 1. Participate in meetings as needed by YEMSA, including but not limited to: 1.1 Continuous Quality Improvement (CQI) Committee 1.2 Trauma Advisory Committee (TAC) 1.3 Pre-Hospital Trauma Advisory Committee (Pre-TAC) 1.4 Physician Advisory Committee (PAC) 2. Education 2.1 Ensure that the emergency department staff and other appropriate hospital personnel possess sufficient skills and knowledge in field procedures that are continued within the emergency department. 2.2 Participate in training of pre-hospital personnel. 2.3 Participate in HAvBED drills/exercises as directed by YEMSA and Region IV. Concurrent Activities 1. Follow and abide by the standards established for receiving hospitals, including those standards pertaining to professional staffing. 2. Provide hospital census and bed availability information to YEMSA through the EMResource TM system daily. Retrospective Analysis 1. Gather and provide statistical information as needed by YEMSA for monitoring and evaluating pre-hospital program effectiveness. Reporting/Feedback 1. Cooperate with designated Yolo County base hospital and ALS provider agencies in providing follow-up information regarding patient diagnosis, disposition, and outcome. 25

Base Hospital Guidelines 100403 Prospective 1. Participate on committees as specified by YEMSA, including but not limited to: 1.1 Continuous Quality Improvement (CQI) Committee 1.2 Trauma Advisory Committee (TAC) 1.3 Pre-Hospital Trauma Advisory Committee (Pre-TAC) 1.4 Physician Advisory Committee (PAC) 2. Education 2.1 Follow all standards, protocols, policies, procedures and contracts established by YEMSA relating to pre-hospital ALS guidelines. 2.2 Provide standardized training to MICNs and/or Physicians who are qualified to answer field calls made to the Base Hospital for online medical control. 2.3 Ensure that the emergency department staff and other appropriate hospital personnel possess sufficient skills and knowledge in field procedures that are continued within the emergency department. 2.4 Participate in training of pre-hospital personnel and assist in public education and prevention strategies to improve the health of the community. 2.5 Participate in HAvBED drills/exercises as directed by YEMSA and Region IV. 3. Evaluation 3.1 Monitor MICNs and/or Physicians who are qualified to answer calls made to the Base Hospital. This should include auditing calls for quality improvement purposes. Concurrent Activities 1. Follow and abide by the standards established for receiving hospitals, including those standards pertaining to professional staffing. 2. Provide hospital census and bed availability information to YEMSA through the EMResource TM system daily. 26

3. Base Hospital physicians: The Base Hospital shall have at least one (1) full-time emergency department physician on duty at all times. The on duty emergency department physician shall be responsible for pre-hospital management of patient care and patient destination decisions. Retrospective Analysis 1. Gather and provide statistical information as needed by YEMSA for monitoring and evaluating pre-hospital programs. 2. Data collection 2.1 Provide an annual update to YEMSA that consists of quality indicators agreed upon by the Base Hospital and YEMSA. 2.2 Develop an internal process for identifying needs for improving the base station QI program. 2.3 Participate in performance improvement action plans established by YEMSA. 2.4 Participate in data collection required by YEMSA. 2.5 Availability of records: The Base Hospital shall submit copies of all records, audio recordings, and logs pertaining to pre-hospital care of patients and personnel involved in the pre-hospital care system at the request of representatives of YEMSA. Records obtained from hospitals may be used for, but are not limited to: audit, investigation, statistical analysis, provider feedback, and quality improvement. Reporting/Feedback 1. Standards and Protocols: The Base Hospital shall implement and monitor the policies and procedures of YEMSA related to the services performed by the hospital under this agreement. 27

YEMSA Committees Physicians' Advisory Committee (PAC) The purpose of this committee is to provide advice and recommendations to the Yolo County Emergency Medical Services Agency (YEMSA) and YEMSA Medical Director on medically-related topics. Examples include Advanced Life Support (ALS) and Basic Life Support (BLS) medical treatment guidelines; new pre-hospital skills and/or medications; prehospital policies and procedures related to patient medical management; review of medical quality issues. Membership includes: YEMSA Medical Director & Administrator EMS Provider Medical Directors Base Hospital Medical Directors (Emergency Department Physicians) Base Hospital Emergency Department Managers or Nurse Liaisons YEMSA Staff Single representative from ALS field providers (by invitation of the YEMSA Medical Director) Continuous Quality Improvement (CQI) Committee The purpose of this committee is to monitor the pre-hospital care provided in Yolo County as well to oversee all necessary reviews, studies, and audits required to ensure that the CQI process is working effectively. This committee meets quarterly. Membership includes: YEMSA Medical Director & Administrator EMS Provider Medical Directors Base Hospital Medical Directors (Emergency Department Physicians) Base Hospital Emergency Department Managers or Nurse Liaisons EMS Providers, Staff, Paramedics and Emergency Medical Technicians (EMTs) CQI personnel from field providers (fire department and transport providers) CQI ST Elevation Myocardial Infarction (STEMI) The purpose of this committee is to monitor the pre-hospital care provided to patients in Yolo County who are suffering from Acute Coronary Syndrome and diagnosed with ST-Elevation Myocardial Infarction. This committee meets on a revolving cycle with other CQI-related committees. Membership includes: YEMSA Medical Director & Administrator EMS Provider Medical Directors Cath Lab Medical Director, Managers or Nurse Liaisons EMS Providers, Staff, Paramedics and EMTs One (1) designated representative from each field providers (fire personnel and transport providers) 28

QI Trauma Advisory Committee (TAC) This committee is responsible for reviewing select trauma cases occurring in Yolo County to determine if care provided was appropriate and that the destination decisions were appropriate to the injury incurred. This committee will meet in conjunction with the CQI committee meeting. Membership includes: YEMSA Medical Director & Administrator EMS Provider Medical Directors Emergency Department/Trauma Medical Directors Emergency Department Trauma Managers or Nurse Liaisons EMS Providers, Staff, Paramedics and EMTs CQI personnel from field providers (fire department and transport provider) CQI Staff from Air Ambulance (Helicopter) providers Trauma Center Staff (representing system Trauma Centers) Trauma Program Medical Directors Trauma Program Nurse Managers o o Yolo County Pre-hospital Trauma Advisory Committee (Pre-TAC) Pre-TAC convenes representatives of the trauma system, under the direction of the YEMSA Medical Director, to evaluate trauma system structures, processes, and outcomes to assure standard performance within the system, to develop and revise trauma system policies, and to assure that the goals and objectives of the Trauma System Plan are accomplished. The Pre-TAC has a broad membership that represents all trauma system partners. Membership includes: YEMSA Medical Director & Administrator EMS Provider Medical Directors Trauma Program Medical Directors Trauma Program Nurse Managers YEMSA Staff Individual representatives from field providers 29

MANAGEMENT AND ADMINISTRATION OF TRAUMA SYSTEM Local EMS Agency As the designated local Emergency Medical Services agency, YEMSA is responsible for development, evaluation, and oversight of the local trauma system. The Yolo County Trauma System is for a component of the EMS system, with the goal of improving care of injured patients and medical outcomes. EMS Medical Director The contracted EMS Medical Director is a physician who is knowledgeable in trauma system planning and who assumes total responsibility for trauma planning activities, including coordination with EMS Medical Directors from the State and neighboring systems. The Medical Director is involved in the design, implementation, continual revision, and operation of the trauma system from earliest pre-hospital contact through delivery to definitive care. He/she is responsible for developing clinical standards and subsequent policies and procedures that assure that these standards of care are observed. Medical direction of the trauma system provides the operational framework for pre-hospital personnel and seeks to assure appropriateness of all medical aspects of the pre-hospital program with the same professional accountability as medical care in healthcare facilities. The YEMSA staff supports the EMS Medical Director in system policy development, implementation, and evaluation. YEMSA maintains the Yolo County EMS Policy and Protocol Manual and Trauma Plan, which together addresses all aspects of the countywide EMS/Trauma System. 30

DATA COLLECTION, QUALITY OF INDICATORS AND REPORTING How are we doing? MEASURE IMPROVE, MEASURE IMPROVE, MEASURE- IMPROVE... Six Aims for Quality Improvement: Safe Effective Patient-centered Timely Efficient Equitable 31

Data Collection Various data systems in the YEMSA, such as CAD, Trauma 1, EMResource TM and MEDS will help contain relevant data. Electronic Patient Care Report (epcr) data elements must be National EMS Information System/California EMS Information System (NEMSIS/CEMSIS) compliant. Integration of these data systems between dispatch, EMS providers, and receiving facilities is essential in opening communication necessary to facilitating quality improvement. These data systems are used to: Prospectively identify areas for improvement and enable data driven decisions Monitor system changes after QI interventions have been implemented Monitor individual and group performance in the EMS system Support research Provide benchmarks with other EMS systems Data Quality Improvement activities include: Implementation of a user friendly epcr program for all 911 providers Implementation of a user friendly data reporting tool Integration and continuing maintenance of all data systems 32

Quality Indicators Quality Indicator Analysis - (see Appendix D for Quality Indicators) RESULTS BASED ACCOUNTABILITY (RBA) Mark Friedman - Trying Hard Is Not Good Enough: How to Produce Measurable Improvements for Customers and Communities RBA uses a practical model for developing meaningful performance measures (quality indicators) by asking three (3) simple questions: How much do we do? Input resource components (such as leadership, workforce, suppliers, equipment, etc.) are measured. These are the least important performance measures but the easiest to obtain. These performance measures assess the quantity of our efforts. How well do we do it? The efficiency of design and delivery of work processes, productivity and operational performance are measured. These performance measures assess the quality of our efforts. Is anyone better off? The result or outcome of patient care, support services, and fulfillment of public responsibilities are measured. These are the most important performance measures and the most difficult to obtain. These performance measures assess the effect of our efforts. 33

Reporting CHARTS - (See Appendix B for specific charts used to collect data) The use of charts is essential in the analysis of processes, data and quality indicators. While many different types of charts exist, the following charts provide the best process analysis. These charts are also easy to create and use. Control Charts - The control chart is a graph used to study how a process changes over time. Data are plotted in time order. A control chart always has a central line for the average, an upper line for the upper control limit and a lower line for the lower control limit. These lines are determined from historical data. (See Appendix B for examples) Pie Charts - Pie charts are generally used to show percentage or proportional data and usually the percentage represented by each category is provided next to the corresponding slice of pie. Pie charts are good for displaying data for around 6 categories or fewer. (See Appendix B for examples) Process Improvement - quality improvement Our current processes are perfectly designed to produce the results we are getting. Davis Balestracci. 34

ACTION TO IMPROVE What are we doing to make things better? YEMSA shall establish and facilitate a system wide quality improvement program to monitor, review, evaluate and improve the delivery of pre-hospital care services. The program shall involve all system participants and shall include, but not be limited to the following activities: Prospective - designed to prevent potential problems. Concurrent - designed to identify problems or potential problems during the course of patient care. Retrospective - designed to identify potential or known problems and prevent their recurrence. Reporting/Feedback - all QI activities will be reported to YEMSA in a manner to be jointly determined. As a result of QI activities, changes in system design may be made. In developing QI activities, various models and methodologies such as The Model for Improvement, Plan- Do-Study-Act (PDSA), Six Sigma - Define, Measure, Analyze, Improve, Control (DMAIC) and The Program/Project Management Model can be used by any organization s quality improvement team. The Model for Improvement PDSA Cycle Institute for Healthcare Improvement The Aim: What are we trying to accomplish? How good? By when? For whom? The Measures: How will we know a change is an improvement? What are the process and outcome measures? The Changes: What change can we make that will result in improvement? The PDSA cycle gives us a way to quickly test changes on a small scale, observe what happens, tweak the changes as necessary, and then test again before implementing anything on a broad scale. 35

Plan State objective of the test, make predictions, develop an improvement plan to carry out the test (who, what where, when) Do - Carry out the test or trial, document problems and unexpected observations, begin analysis of the data Study - Complete the analysis of the data, compare the test data to predictions, and summarize what was learned Act - What changes are to be put into policy and institutionalized? What will be the objective of the next cycle? What, if any, re-education or training is needed to effect the changes? Six Sigma Institute for Healthcare Improvement The focus of Six Sigma is reducing variation or the defect rate, measured by Sigma level, or Defects per Million Opportunities. The Six Sigma improvement framework consists of five (5) basic steps, known as DMAIC for short: Define - Define the problem in detail. Measure - Measure defects (in terms of defects per million, or Sigma level). Analyze - In-depth analysis using process measures, flow charts, defect analysis to determine under what conditions defects occur. Improve - Define and test changes aimed at reducing defects. Control - What steps will you take to maintain performance? Once an improvement plan has been implemented, the results of the improvement will be measured. Changes to the system will be integrated and standardized. A plan for monitoring future activities will be established to ensure the change continues. Findings and plans are discussed and implemented through the PAC. 36

Program/Project Title A short title that labels the program/project should be concise and clear. Purpose A clear program/project purpose related to the overall EMS Purpose to improve health and reduce pain and suffering should be clearly defined in one sentence. Vision Where we see the program/project in the future related to the overall EMS Vision should be clearly defined in one sentence. Values The main concerns and cares of the program/project related to the overall EMS Values of Six Aims should be stated. Program/Project Scope The parameters of the program/project, what s included and/or not included, what s in or out, should be defined. Program/Project Members The program/project leader and members should be listed. The roles and responsibilities of the leader and each member should be clearly defined. Measurements, Outcome Established benchmarks and measures as well as other innovative data measures that are pertinent to the improvement program/project should be established. Results and measurements from the patient s perspective are essential. Improvement Projects Define the specific work being done within the Quality Improvement program/project. Schedule The difference between a wish and a goal is that a goal contains a deadline. Intermediate and final project deadlines should be determined and followed. 37

Program/Project Management Model TRAINING AND EDUCATION What are we doing to make things better? Personnel and training needs are assessed by YEMSA through various committee forums and are also identified by performance audits by various providers, such as the Base Hospital, ALS contract provider, Fire Personnel, EMS Administrator and EMS Program Coordinator. In addition, YEMSA annually reviews the CQI plan, evaluates trends in performance measures and training priorities, and identifies potential alternative teaching methodologies. YEMSA developed an online training program to roll out Policies and Protocol updates, best practices, and reviews of current trends within the County. In addition, any new Paramedic in the county is required to attend an EMS Orientation provided by YEMSA. YEMSA conducts required annual training held in a case review format throughout the County on a bi-monthly basis. Part of the annual required training is the online training program, which is currently being established. Annual training provides updated information pertaining to new practice trends and/or changes and updates with Policies and Protocols. Current training institutions and approved CE providers are meeting system needs. ALS updates for all accredited Paramedics have been established and the course content is provided by YEMSA. MCI table top training sessions and functional exercises have also been offered by the ALS transport provider AMR. CE provider programs are verified and updated, and will be reviewed on an on-going basis. CE providers are audited and reviewed regularly. All EMT training centers are verified and audited annually and on an as-needed basis. Yolo County has no Paramedic programs. 38

ANNUAL UPDATE How are we doing? Yolo County Annual Report The EMS Medical Director will evaluate the QI Program with the PAC and EMS QI Council at least annually. This group is tasked with ensuring that the QI Plan is aligned with our strategic goals and will review the plan to identify what did and did not work. From this information, an Annual Update will be provided to the CQI Team and will include the following: Indicated monitors Define new quality indicators (if needed) Key findings and priority issues identified o Identification of any trends requiring monitoring and/or intervention Improvement action plans and plans for further action o Description of any in-house policy revisions o Description of any continuing education and skills training provided as a result of improvement plans Description of whether the goals were met and whether follow up is needed Description of next year s work plan based on the current year s indicator review (The EMS QI Program shall be reviewed by YEMSA or the EMSA at least every five [5] years). 39

Sample Work Plan Template (See Quality Indicators in Appendix D) Indicators Monitored Key Findings/Priority Issues Identified Improvement Action Plan Plans for Further Action Were Goals Met? Is Follow-up Needed? 40

APPENDIX A: UNUSUAL OCCURRENCE FORM UNUSUAL OCCURRENCE REPORT FORM Please write clearly and answer all the questions. 1) Incident Date/Time: 2) Event #: 3) Reporting Date: 4) Provider Agency Name: 5) Address or Location of Incident: 6) Person Reporting Incident: 7) Day Phone #: 8) Email: 9) Mailing Address: 9a) City: 9b) State: 9c) Zip: 10) Preferred Method of Contact: Phone Email Mail 11) Affiliation: 12) Unit #: 13) Type of Incident: Citizen Concern Communications Controlled Substance Deviation From Policy/Protocol Documentation Error/Omission Field Operations MC Patient Care Patient Maltreatment Professional Conduct Protocol Violation Treatment Error/Omission Other Affecting Patient Care Other Not Affecting Patient Care Other: 14) Incident Description: Be as specific as possible. Include: names, address, times, dates, etc. Use separate sheets of paper if necessary. 15) Attachments: Yes No # of pages or documents: I certify that all information on this form and enclosed documents, to the best of my knowledge, are true and correct. Signature Date For YEMSA Use EMSA Incident #: Final Disposition: Reviewed By: Date Received: Date Closed: CONFIDENTIALITY NOTICE Faxes/email may contain confidential information. Do not read this fax/email if you are not the intended recipient. This fax or email transmission (and any documents, files or previous email messages attached to it) may contain information that is legally privileged or is made confidential by statute. If you are not the intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any disclosure, copying, distribution or use of any of the information contained in or attached to this transmission is STRICTLY PROHIBITED. If you have received this transmission in error, please immediately notify us by phone (insert name and phone #) or email, and destroy the original transmission and its attachments without reading or saving them in any manner. 41

Brooks Capay Clarksburg Colusa Davis Esparto Knights Robins Sacramento West Winters Woodland Zamora 1 1 1 2 2 2 2 4 7 13 21 26 32 Yolo County EMS Quality Improvement Plan 2015 APPENDIX B: CHARTS USED FOR REPORTING Charts Cities Total Patients PIE CHARTS identify the most common contributing factors to a process. For example, Pie charts can make it easy to report our patients who met trauma criteria were transported to the closest and/or appropriate trauma receiving hospital. WEST SACRAMENTO Kaiser Vacaville UC Davis Med Unknown 3, 10% 1, 3% 27, 87% 42

Chief Complaint Arrest 14 6 9 4 Syncope 38 Respiratory Distress Chest Pain Other 43

Controlled Charts YEMSA will be using controlled charts. This will assist in collecting, measuring and improving its EMS system by collecting data over time. (Example): 25 20 15 10 even better better ok 5 0 today tomorrow future 44

APPENDIX C: PROTOCOL REVIEW PROCESS INTRODUCTION The protocol review process is an advisory process to the YEMSA Administrator and the YEMSA Medical Director for the formulation of medical protocols. Suggestions and/or draft protocols are accepted from committees, system participants, individuals, and/or interested parties. All draft protocols are posted on the Yolo County EMS website for public view and comment. Protocols will be evaluated on a bi-annual basis with adequate time allowed for training and distribution if changes are required. Specific recommendations for additions, deletions and/or revisions should be forwarded to YEMSA. POLICY PROCESS (406.1) I. Written Public Comment Draft A. YEMSA will distribute draft protocol(s) to the appropriate system participants and/or interested parties for written comments. B. Protocols under consideration that affect the EMS system as a whole will be sent out for review by all systems participants. A protocol under consideration that applies to a limited group will only be sent to those who would be directly affected. C. The time frame allowed for the return of comments will be thirty (30) days. Comments may be sent by email, mail or faxed to YEMSA, but must be received no later than 4 p.m. on the deadline date. D. All comments will be reviewed by the YEMSA Medical Director. All suggestions will be taken into consideration. II. Public Testimony A. Public comments will be heard at the next most appropriate Emergency Medical Care Committee (EMCC) meeting, usually held bi-monthly. B. A final draft of the protocol(s) will be distributed prior to the meeting. C. Time will be allotted at the meeting for public testimony and discussion. All recommendations will be taken into consideration during the finalization of the policy. ANNUAL POLICY REVIEW PROCESS TIMELINE Policy Review Process Deadline for protocol ideas Written public comment draft released Written comments due back to EMS Public Testimony at EMCC Finalized protocol released Update training Effective date of new protocols Timeline is subject to change Timeline open 30 days 30 days Bi-monthly Jan 1 st and July 1 st ongoing Jan 1 st and July 1 st 45

APPENDIX D: QUALITY INDICATORS 2014 Total Count Measure Numerator (or Time) Denominator TRA-1 23:26 17 TRA-2 14 17 ACS-1 555 963 ACS-2 806 963 ACS-3 22:54 90 ACS-4 13 93 ACS-5 81 94 CAR-1 0 59 CAR-2 20 59 CAR-3 N/A N/A CAR-4 N/A N/A STR-1 221 294 STR-2 256 289 STR-3 19:03 283 STR-4 39 294 STR-5 275 294 RES-1 35 294 RES-2 199 294 PED-1 7 8 PED-2 0 PAI-1 695 3049 PAI-2 220 529 SKL-1 67 78 SKL-2 66 67 RST-1 8:00 10647 RST-2 14:53 2204 RST-3 10645 14499 PUB-1 19 59 46

NOTES Measure ID Denominator Value (Population) Numerator Value (Count) Reporting Value (If you were unable to run the measure exactly as written, please indicate your methodology here) TRA-1 (mm:ss) 17 23:26 23:26 TRA-2 (Percentage) 17 14 82.40% ACS-1 (Percentage) 963 555 57.6% ACS-2 (Percentage) 963 806 84% ACS-3 (90th %ile in mm:ss) 90 22:54 22:54 ACS-5 (Percentage) 94 81 86.17% CAR-2 (Percentage) 59 20 33.90% CAR-3 (Percentage) n/a n/a n/a CAR-4 (Percentage) n/a n/a n/a STR-2 (Percentage) 289 256 88.58% STR-3 (90th %ile in mm:ss) 283 19:03 19:03 STR-5 (Percentage) 294 275 94% RES-2 (Percentage) 294 199 67.69% PED-1 (Percentage) 8 7 87.50% PAI-1 (Percentage) 3049 695 22.79% SKL-1 (Percentage) 78 67 85.89% SKL-2 (Percentage) 67 66 98.51% Zone Denominator Reporting Value RST-1 Zone A 343 4:17 Zone B 10304 8:00 RST-2 Zone A 69 6:52 Zone B 2135 14:53 RST-3 Zone A 412 69.42% Zone B 14499 72.64% 47