Performance Improvement North Carolina Performance Improvement Guidelines The purpose of this guideline is to provide direction to Agencies with respect to patient care based quality management performance improvement. Each of these topics address either an Service Delivery, Personnel Performance, or Patient Care issue which is either important to quality or has been identified as a high risk or high liability area for Emergency Medical Services. Please refer to the Stards for Medical Oversight Collection Frequently Asked Questions (FAQs) for information on how each System s Peer Review Committee must address this document. The items listed in this guideline are of more value when trended (monthly or quarterly as noted) then divided up among the yearly peer review meetings for review discussion. How frequently each item is presented discussed within the Peer Review Committee should be determined by the Systems call volume resources. Every item in this guideline is designed to be reviewed discussed at a minimum of once each year with the exception of the 6 Toolkits which are designed to be reviewed discussed twice per year. Topics are grouped into the following areas: Service Delivery: Resources Equipment Service Delivery: Time Parameters Service Delivery: Complaints Investigations Personnel Performance Patient Care: Treatment Patient Care: High Risk Patients Patient Care: High Risk Performance Stards (Page 1 of 11) 2009
Performance Improvement Topic Frequency Matory of Service Delivery: Resources Equipment 1. Vehicle Failures All On Duty Occurrences Monthly Yes 100% Number of Vehicle Failures while in Service Implement or evaluate Vehicle Maintenance Plan 2. Vehicle Crashes All On Duty Occurrences Monthly Yes 100% Vehicle Crashes while in Service Evaluate Discuss Crash etiology from vehicle, personnel, patient, any other perspectives. 3. Patient Care Equipment All On Duty Occurrences Monthly Optional 100% Number type of required equipment missing from daily State Regulatory Inspections CIS Inspectio n Evaluate establish method to assure all equipment is present on all active units. 4. Patient Care Device Failures All On Duty Occurrences while in use Monthly Yes 100% Number type of patient care or medical device failures while in use. Establish or monitor plan to assure all active units have properly working equipment. 5. First Responder On Scene % All 911 events with FR Dispatch Monthly Yes 100% % of events FR on Scene where they were dispatched Establish target work for 95% compliance Service Delivery: Time Parameters 6. Dispatch Center Time 911 Monthly Yes 100% of Emergent Dispatches 911 Call time until Notification Time Establish target work 7. Turn-out (Wheels- Rolling Time) 911 Monthly Yes 100% of Emergent Dispatches Notification until En Route Time Establish target work Performance Stards (Page 2 of 11) 2009
8. Response Time to Scene Performance Improvement of Frequency Matory All Monthly Yes 100% of Dispatches by group: Emergent 911, Non-Emergent 911, Non- Scheduled Medical Transports, Transports En Route Time until Arrival at Scene or Patient Location Establish target work 9. Response Time to Patient 911 Monthly Optional 100% of Emergent Dispatches Arrival Arrival On Scene until Arrival at Patient Time Establish target work 10. Scene Time All Monthly Yes 100% of Dispatches by group: Emergent 911, Non-Emergent 911, Non- Scheduled Medical Transports, Transports Arrival on Scene until Depart Scene Time Establish target work 11. Transport Time All Monthly Yes 100% of Dispatches by group: Emergent 911, Non-Emergent 911, Non- Scheduled Medical Transports, Transports Depart Scene until Arrive at Destination Time Establish target work Performance Stards (Page 3 of 11) 2009
12. Back in Service Time Performance Improvement of Frequency Matory All Monthly Yes 100% of Dispatches by group: Emergent 911, Non-Emergent 911, Non- Scheduled Medical Transports, Transports Arrive at Destination until Back in Service Time Establish target work 13. Dispatch Center Delays 911 Monthly Yes 100% Documented Delays from PCR Identify address 14. Response Time Delays 911 Monthly Yes 100% Documented Delays from PCR Identify address 15. Scene Time Delays 911 Monthly Yes 100% Documented Delays from PCR Identify address 16. Transport Time Delays 911 Monthly Yes 100% Documented Delays from PCR Identify address 17. Turn-Around Time Delays All Monthly Yes 100% Documented Delays from PCR Identify address 18. Frequency of ED Off-Load Delays All Monthly Optional 100% Not a current Element. Must be documented locally. Identify address Performance Stards (Page 4 of 11) 2009
19. First Responder Response Time Performance Improvement of Frequency Matory 911 Monthly Yes 100% of All with First Responder Response 90% Fractile Time of FR Response Time (Dispatch until Arrival on Scene) for all emergent events where FR was dispatched. or Establish a target work for 95% compliance Service Delivery: Complaints Investigations 20. Internal Service Delivery, Personnel, or Patient Care Complaints All Complaints Monthly Yes 100% Formal written or verbal complaints as defined by Evaluate merit address 21. External Service Delivery, Personnel, or Patient Care Complaints All Complaints Monthly Yes 100% Formal written or verbal complaints as defined by Evaluate merit address Personnel Performance 22. General PCR Documentation All Monthly Yes 10% Manual Review by Supervisor 100% Review using Quality Score Quality Score % Complete by Supervisor Manual Review Set target work for 90% compliance 23. Protocol Documentation All Monthly Yes 100% % of PCRs with Documentation of the Protocol Used Set target work for 100% compliance 24. Vital Sign Documentation All Monthly Yes 100% % of PCRs with the documentation of a minimum of one Systolic BP, Diastolic BP, Pulse, Respiratory Rate, Pain Score (if appropriate), GCS (if injury). Set target work for 100% compliance Performance Stards (Page 5 of 11) 2009
Performance Improvement Frequency Matory of 25. Skills Performed All Monthly Yes 100% Number of Skills performed by each professional Identify individuals without skill within a 6 month interval address through training/education 26. Skill Proficiency All Monthly Yes 100% Success Rate using Personnel Performance for each professional Use report to identify address individuals in need of skill training 27. Protocol Compliance All 911 Monthly Yes 100% 100% Review by Supervisor available Toolkit s identifying any deviation (missing or additional treatment) by the Primary Caregiver,, Toolkit s Set Target work for 95% compliance. Investigate deviations associated with a care issue 28. Patient Contact Numbers (Crew) All Monthly Yes 100% Number of PCR s where personnel are listed as any crew member Identify individuals without patient contact within a 6 month interval address through training/education 29. Patient Contact Numbers (1 Caregiver) All Monthly Yes 100% Number of PCR s where personnel are listed as the Primary Caregiver Identify individuals not functioning as primary patient caregivers within a 6 month interval address through training/education 30. PCR s Completed All Monthly Yes 100% Number of PCR s entered by each professional Monitor to assure all staff on roster are involved in patient care documentation maintain skills 31. Education/CME All Personnel Quarterly Yes 100% CME hours licensure status CIS s Identify address any individual not current or on track to maintain credential Performance Stards (Page 6 of 11) 2009
32. EMD Individual Dispatch Times All 911 Performance Improvement Frequency Matory of Monthly Yes, if EMD Used 100% of All Dispatches grouped by Emergent Non-Emergent 911 Call time until Dispatch of Unit for each EMD professional Establish target work for 95% compliance 33. EMD Protocol Compliance All 911 Monthly Yes, if EMD Used Based on Call Volume using Priority Dispatch Review Guideline EMD Compliance per EMD Vendor Quality Management Recommendation Establish target work for 95% compliance 34. Controlled Substance Counts All with Narcotic Use Monthly Yes 100% % of narcotic uses with sign-out counts appropriate 100% of narcotic uses should be accounted for or deviation logged Patient Care: Treatment 35. No Protocol Documented All 911 Monthly Yes 100% PCR s where no protocol (or only Universal Patient Care Protocol) is listed Set target work for 95% compliance for protocol documentation 36. No Patient Category Documented All Monthly Yes 100% PCR s with no (E09_11) Chief Complaint Anatomic Location, (E09_12) Chief Complaint Organ System, (09_13) Primary Symptom, (E09_15) Provider s Primary Impression Documented Set target work for 95% compliance for documentation of these required data elements. 37. Medication Complications All Monthly Yes 100% Medication Complications Documented in PCR Discuss address if preventable care issue. 38. Skill Complications All Monthly Yes 100% Procedure Complications Documented in PCR Discuss address if preventable care issue. Performance Stards (Page 7 of 11) 2009
39. System Triage Destination Plan Compliance All 911 Performance Improvement Frequency Matory of Quarterly Yes 100% Triage Destination based on System Plans for Pediatric, STEMI, Stroke Trauma s Toolkits Discuss findings adjust plan as needed. Work with your RAC. 40. Pain Control All Monthly Optional 100% Pain recorded as VS addressed with pain medication if pain score is greater than 6 on a scale of 10 Patient Care: High Risk Patients 41. Frequent Flyers All 911 Quarterly Optional 100% Patients accessing > 4 times per month? Set Target work for 90% compliance Discuss appropriateness of use from a patient care perspective. If inappropriate identify plan to address 42. Repeat patients within 48 hours All 911 Monthly Yes 100% Patients with repeat use in any 48 hour time period Evaluate patient care event discuss any care related issue that may have contributed. Develop implement plan to address any. Performance Stards (Page 8 of 11) 2009
Performance Improvement Frequency Matory of 43. Deaths All Monthly Yes 100% All Deaths will under Care s 44. Restraint Use All Monthly Yes 100% All Restraint use s Review Discussion of appropriateness care associated with procedure event. Address any or trends. 45. Refusals All Monthly Yes 100% review by Supervisor with concerns referred to Committee All PCRs with patient contact but nontransport 46. Cancel by FR All Monthly Yes 100% All Dispatches cancelled by a First Responder with NO Arrival On Scene or trends or trends 47. Obstetrical Deliveries All Monthly Yes 100% All Deliveries documented in PCR or trends 48. Assisted Ventilation or Invasive Airway Use All Monthly Yes 100% All BVM Invasive Airways documented in PCR Airway Evaluation Form Airway Form Review Discussion of appropriateness care associated with procedure event. Address any or trends. 49. Drug Assisted Intubation All Monthly Yes 100% Documented in PCR Airway Evaluation Form Airway Form Review Discussion of appropriateness care associated with RSI event. Address any identified issues or trends. Performance Stards (Page 9 of 11) 2009
50. Chest Decompression Performance Improvement Frequency Matory of All Monthly Yes 100% Documented in PCR Review Discussion of appropriateness care associated with procedure event. Address any or trends. 51. Cardioversion All Monthly Yes 100% Documented in PCR Review Discussion of appropriateness care associated with procedure event. Address any or trends. 52. Toolkit Results All 911 based on Toolkit Topics Twice each year Yes 100% using all 6 Toolkits Patient Care Evaluation using: -System Response Time -Trauma Care -Cardiac Arrest Care -STEMI Care -Stroke Care -Pediatric Care Toolkit s Review, Discuss, Identify, implement 1 intervention per Toolkit use (2 interventions per year) Performance Stards (Page 10 of 11) 2009
Performance Improvement Frequency Matory of 53. GCS < 9 All Monthly Yes 100% Documented in PCR Review Discussion of care associated with event. Address any or trends. 54. Abnormal Vital Signs All Monthly Yes 100% Abnormal Vital Signs in Age > 12 years as defined by: -Systolic BP < 90 -Systolic BP > 200 -Heart Rate < 40 -Heart Rate > 130 -Respiratory Rate < 8 -Respiratory Rate > 28 or trends (Pediatric VS evaluated through the Pediatric Toolkit) Patient Care: High Risk 55. Physician on Scene All 911 Monthly Yes 100% with a non- Physician on Scene 56. Multi-Patient Event All Monthly Yes 100% Documented as multipatient 57. Mass Gatherings All Monthly Yes 100% Mass Gatherings within the System 58. Police Custody All Monthly Yes 100% with patient under police custody 59. Tactical All Monthly Yes 100% Tactical Activations with Patient Contact post event. Adjust plan 60. Wilderness Rescue All Monthly Yes 100% Wilderness Rescue Patient Contacts Performance Stards (Page 11 of 11) 2009