Effective: 06-22-20
Supersedes: CM 327
Purpose: To clarify the policies and procedures for the CQI Division of the Communications Department.
Policy: The NAEMD and Mass. State 911 Legislation, 560 CMR 5.06 both require every EMD resource center to establish and maintain a quality assurance program. Brewster and EasCare Ambulance Service provided training and certification for EMDQ staff through the NAEMD QA course. Each ED-Q is responsible for maintaining their certification status, as well as completing the added protocol specific continuing education hours according to the NAEMD guidelines. They shall also complete the Brewster and EasCare Ambulance Service minimum number of weekly case reviews, complete CQI form follow-ups, and assist with remediation when necessary.
Procedure:
It is essential that EMDs closely comply with the MPDS interrogation, prioritization coding, and PDI and PAI scripts. To this purpose, Brewster and EasCare Ambulance Service will involve continuous case review and evaluation by an objective performance checklist titled Medical Dispatch Case Review Evaluation. A random sample in compliance with (NAEMD) of all medical dispatch calls will be reviewed and ensure that the EMDs compliance percentage to each area is maintained.
The QA/QI Process is dynamic and may be modified when needed to adjust to changes such as staffing and call volume. Changes to the QA Procedure will be formally outlined and issued to the CQI Team in memo form. It is the responsibility of the individual EMDQ to make sure they are following the most current QA Procedure.
Each week the ED-Q will complete the call audit/QA in accordance with the current procedural guidelines. Once completed they will run an Incident Performance Review for each call in the AQUA software to determine which category the call falls under: Meets Standard 1, Meets Standard 2, Non-Compliant1, Non-Compliant 2, or Non-Compliant 3. The QA will then fill out the appropriate CQI Feedback Form for the level the call falls under. Once this form is completed, the QA will send the form to the appropriate person according to the current procedural guidelines. If the call is a non-compliant due to a customer service-related issue, the QA will fill out the Customer Service Non-Compliant form and email is directly to the Director of Communications and the Communications Training and CQI Administrator for immediate follow up. In the event that an ED-Q member is unable to QA the required minimum number of calls for the week or follow the current procedural guidelines the ED-Q must send an email to the Director of Communications and the Communications Training/CQI Administrator for review.
Having a well-established and maintained EMD quality assurance program is essential to assure that people who call 911 will receive the best care from a trained EMD call taker. Sending feedback to EMD call takers in a timely fashion, as well as providing praise or remediation when needed is pivotal for a call taker to know when they are maintaining compliance standards. Therefore, failure to comply with this policy may result in progressive discipline. If you have any questions or concerns, please contact the Director of Communications or the Communications Training and CQI Administrator.