HomeMy WebLinkAboutalco-ems-qi-plan-2024-final
ALAMEDA COUNTY
EMERGENCY MEDICAL SERVICES
CONTINUOUS QUALITY IMPROVEMENT PLAN
2024
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
Table of Contents
I. Introduction ................................................................................................................................................... 3
AUTHORITY .................................................................................................................................................. 3
ALAMEDA COUNTY EMERGENCY MEDICAL SERVICES AGENCY ....................................................................... 3
MISSION, VISION, AND VALUES ..................................................................................................................... 4
STARCARE ................................................................................................................................................... 4
GOALS AND OBJECTIVES .............................................................................................................................. 5
II. Structure, Organizational Description, Responsibilities ......................................................................... 6
ALAMEDA COUNTY DEMOGRAPHICS .............................................................................................................. 6
ALAMEDA COUNTY ORGANIZATIONAL STRUCTURE ......................................................................................... 7
EMS SYSTEM STAKEHOLDERS ..................................................................................................................... 8
SPECIALIZED EMS PROGRAMS ..................................................................................................................... 9
QUALITY IMPROVEMENT RESPONSIBILITIES – GENERAL GUIDELINES ............................................................... 9
QUALITY IMPROVEMENT RESPONSIBILITIES – ALAMEDA COUNTY EMS AGENCY ............................................ 10
QUALITY IMPROVEMENT RESPONSIBILITIES – COMMUNICATION CENTERS ..................................................... 10
QUALITY IMPROVEMENT RESPONSIBILITIES – ALS PROVIDER AGENCIES ...................................................... 13
QUALITY IMPROVEMENT RESPONSIBILITIES – EMS AIRCRAFT PROVIDER AGENCIES ...................................... 14
QUALITY IMPROVEMENT RESPONSIBILITIES – RECEIVING CENTERS .............................................................. 14
QUALITY IMPROVEMENT RESPONSIBILITIES – BASE HOSPITAL ...................................................................... 15
QUALITY IMPROVEMENT MEETINGS ............................................................................................................. 16
III. Data Collection and Reporting ................................................................................................................ 17
EMS DATABASES AND ANALYTICS ............................................................................................................... 17
HEALTHCARE DATA EXCHANGE (HDE) ........................................................................................................ 17
UNUSUAL OCCURRENCE (UO) REPORTING ................................................................................................. 17
AD HOC SURVEYS ...................................................................................................................................... 18
IV. Evaluation of Indicators........................................................................................................................... 19
SYSTEM EVALUATION PRINCIPLES .............................................................................................................. 19
CALIFORNIA EMS CORE QUALITY MEASURES ............................................................................................. 19
ALAMEDA COUNTY EMS AGENCY INDICATORS ............................................................................................ 19
PROVIDER AGENCY INDICATORS ................................................................................................................. 22
V. Action to Improve ...................................................................................................................................... 23
IMPROVEMENT METHODOLOGIES ................................................................................................................ 23
FIELD GUIDELINES AND POLICY CHANGES ................................................................................................... 23
VI. Training and Education ........................................................................................................................... 24
PRINCIPLES ............................................................................................................................................... 24
EMS TRAINING AND EDUCATION ................................................................................................................. 24
COMMUNITY OUTREACH AND EDUCATION .................................................................................................... 25
VII. Annual Update ......................................................................................................................................... 26
CQI UPDATES - 2023 ................................................................................................................................. 26
CQI GOALS - 2024 .................................................................................................................................... 26
Appendices A-G ............................................................................................................................................. 27
APPENDIX A: EMS TELEHEALTH GUIDELINES .............................................................................................. 28
APPENDIX B: QUALITY COUNCIL CHARTER .................................................................................................. 31
APPENDIX C: UNUSUAL OCCURRENCE FORM .............................................................................................. 32
APPENDIX D: DEVELOPING AN INDICATOR.................................................................................................... 33
APPENDIX E: EMS PROVIDER QUALITY INDICATORS AND ACTIVITIES ............................................................ 37
APPENDIX F: ADDITIONAL QUALITY IMPROVEMENT METHODOLOGIES ............................................................ 40
APPENDIX G: POLICY REVIEW PROCESS ..................................................................................................... 41
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
I. Introduction
AUTHORITY
The Alameda County EMS Quality Improvement Plan satisfies the requirements of Title 22, Division 9, Chapter 12, Article 4 of the California Code of Regulations and Division 2.5, Chapter 4 of the Health and Safety Code. Additionally, EMSA document #166 “Emergency Medical Services System Quality Improvement Program Model Guidelines” provided further information on the expectations for development and implementation of a Quality Improvement Program for the delivery of EMS for Local EMS Agencies and EMS service providers
ALAMEDA COUNTY EMERGENCY MEDICAL SERVICES AGENCY
Improving patient health outcomes is at the forefront of the Alameda County EMS Agency’s Continuous Quality Improvement (CQI) program. Our mission is centered on elevating the overall quality of emergency medical services, ensuring each patient receives the best possible care.
Emergency Medical Dispatchers (EMD), Basic Life Support (BLS), and Advanced Life Support (ALS) clinicians are often the earliest point of contact in a patient’s health journey and play a pivotal role in influencing a patient’s outcome and chance for survival. The Alameda County CQI Program
aims to set new benchmarks for excellence. As the landscape of emergency healthcare evolves, our commitment remains strong to continuously improve and safeguard the health of those visiting or living in our community.
CQI is non-punitive and strongly centered in education. Mistakes threatening patient safety are rarely the fault of individuals and far more likely to be natural consequences of poorly designed systems. William Edwards Deming determined, “every system is perfectly designed to get the results it gets.” The Alameda County CQI program embodies a Just Culture® defined as “a culture that holds organizations accountable for the systems they design and for how they respond to individual behaviors in fair and just manners.” It is our responsibility as the Alameda County EMS Agency to engineer clear policies, recovery strategies, and effective barriers to achieve positive outcomes. This plan serves as a resource for each Alameda County EMS provider’s CQI Plan. All pragmatic improvement plans, and each activity within it, work best when they are simple and focused. While
numerous CQI models may vary in methodology, all focus on answering five (5) fundamental questions that are addressed throughout this plan:
Why do we do what we do?
What governs our day-to-day decisions?
What are we doing to improve?
How are we doing?
How do we
see ourselves in the future?
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
MISSION, VISION, AND VALUES
STARCARE
Enhancing the overall mission, vision, and values of Alameda County EMS is STARCARE. Paramedic author and educator, Thom Dick, developed this important framework that incorporates key values into the decision-making process for EMS clinicians. This structure is adopted locally and contributes to a more ethically driven practice within the EMS system.
afe
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 them warm? Was I gentle? Did I use their name throughout the call? Did I tell them what to expect in advance? Did I treat their family/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?
Mission
Alameda County EMS ensures the provision of quality emergency medical response services and prevention programs to improve health and safety in Alameda County.Values
Alameda County EMS values a caring environment sustained by empowerment, honesty, integrity, and mutual respect. We embrace excellence through innovation, teamwork, and community capacity building.
Vision
Helping people live healthy and fulfilling lives through training, preparedness, prevention, and medical response.
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
GOALS AND OBJECTIVES
The purpose of the Alameda County CQI program is to narrow the gap between performance and expectations with the goal of improving patient outcomes. This plan outlines our commitment to continuously monitor, review, evaluate, and improve the delivery of prehospital care services. Our program objectives are as follows:
Reduce pain and suffering and improve the health outcomes of patients in Alameda County
Assure the delivery of patient care is safe and equitable across all demographics including race, sex, and age
Assure adherence to local policies and field guidelines through establishing structure,
process, and outcome metrics
Continuously evaluate the effectiveness of local policies and field guidelines
Create a culture of learning where EMS clinicians feel safe to participate in CQI activities without fear of repercussions, and become the driving force behind system enhancements
Build consensus and jointly design system changes with all EMS stakeholders
Use data, and evidence-based improvement science, to drive decision-making processes
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
II. Structure, Organizational Description, Responsibilities
ALAMEDA COUNTY DEMOGRAPHICS
Alameda County is both geographically and demographically diverse. The entire county covers 739 square miles and includes highly dense urban areas; the shoreline of San Francisco Bay is on the western border, low- and high-density residential areas, and a high concentration of industrial sites,
and rural, wilderness and parks areas that stretch to the east. More than 1.6 million people live in Alameda County according to the 2023 Census Data.
The City of Oakland, in the north part of the County, is the largest city with a population of 412,000+. Other large cities include Fremont in the south (210,000+), the City of Hayward in the mid-part of the County (146,000+), and the City of Berkeley in the northern sector of the County (105,000+).
Approximately 160,000+ people reside in the cities of Livermore, Dublin and Pleasanton that are located in eastern Alameda County.
The vast ethnic, racial, and cultural diversity is a strength of this community. While it is difficult to quantify the number of languages spoken in Alameda County, there are five (5) recognized threshold languages, defined by the California Department of Healthcare Services as ≥3000 speakers per language or ≥5% of the Medi-Cal Population that speak the language per county. Locally, these are,
English, Spanish, Chinese (Cantonese and Mandarin), Tagalog, and Vietnamese. It is important to acknowledge while Cantonese and Mandarin are categorized as one language, they are structurally different languages.
This plan emphasizes our responsibility of collecting and analyzing data through an equity lens, ensuring all members of our community have the same access to emergency medical services and receive the same level of excellent clinical care.
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
ALAMEDA COUNTY ORGANIZATIONAL STRUCTURE
.
Alameda County Board of Supervisors David Haubert, District 1 Elisa Márquez, District 2 Lena Tam, District 3 Nate Miley, District 4
Healthcare Services Agency (HCSA) Director: Colleen Chawla
Deputy Director: Will McClurg
Operations & Regulatory Compliance Carolina Snypes EMS Coordinator RFP/Procurement Leslie Simmons EMS Coordinator Contract Compliance Scott Saulter EMS Coordinator Professional Standards Yolanda Takahashi EMS Coordinator Behavioral Health/ CATT Gerald Takahashi EMS Coordinator Training Programs Victor Pires Data Analyst
Clinical Systems of Care Dr. Zita Konik EMS Medical Director/Supervisor
Strategic & Specialized Response Jim Morrissey Supervising EMS Coordinator
Administrative Support and Finance Erica Campos Supervising Program Specialist
Health Emergency & Preparedness (HEPR) Ron Seitz Supervising Program Specialist
Injury Prevention Kat Woolbright Supervising Program Specialist
Information Systems Adele Pagán Information Systems Manager
Office of the Agency Director (OAD) Director: Aneeka Chaudry
Environmental Health Director: Ronald Browder
Behavioral Health Director: Dr. Karyn Tribble
Public Health Director: Kimi Watkins-Tartt
Emergency Medical Services (EMS)
Director: Lauri McFadden
Cynthia Frankel EMS Coordinator EMSC/Pedi Surge Elsie Kusel EMS Coordinator Specialty Programs/ Preceptor Training Andy Sulyma EMS Coordinator RDMHS Ryan Preston EMS Coordinator RDMHS
Dr. Nicole D’Arcy EMS Deputy Medical Director Mike Jacobs EMS Coordinator Systems of Care Kreig Harmon EMS Coordinator CQI/Policy Updates Naila Francies EMS Coordinator CQI/Systems of Care Lauren Friend UCSF EMS Fellow Bryan Fegurosso UCSF EMS Fellow
Michelle Barrientos Specialist Clerk II Sonya Lee Specialist Clerk I Shant’e Williams Specialist Clerk I Elise Harris Specialist Clerk I Maria Ramos Specialist Clerk I Clara Arana Specialist Clerk I
Wilman Woo Information Systems Analyst Leo Derevin Information Systems Analyst
Ysela Jimenez Community Health Outreach Worker II Carol Powers Program Specialist Senior Injury Prevention Laura Fultz Program Specialist Senior Injury Prevention
Todd Stephenson Community Health Outreach Worker II Preston Lam Program Specialist Senior Injury Prevention TeeLee Garvin Program Specialist Senior Injury Prevention Emma Olenberger Program Specialist Senior Injury Prevention
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
EMS SYSTEM STAKEHOLDERS
The Alameda County EMS system responds to approximately 160,000 medical emergencies each year and completes approximately 110,000 transports. Within the cities of Alameda, Albany, Berkeley and Piedmont, the ALS fire departments provide ambulance transport services in addition to first response. Outside of these cities, ALS fire departments provide first response units and Falck provides emergency transport services under contract with the County. Below is a list of the EMS stakeholders in Alameda County.
o Alameda City Fire Department o Albany City Fire Department o Berkeley City Fire Department o Falck Ambulance o Piedmont Fire Department Patients
o All PSAP Agencies o Alameda County Regional Emergency Communication Center (ACRECC)
o Oakland Fire Department Dispatch Center
Telehealth
o MD Ally o Tele911
Receiving Facilities
o Alameda Health System Highland (Base Designated Hospital) o Alameda Hospital o Alta Bates Medical Center; Berkeley o Alta Bates Medical Center; Summit o Eden Medical Center o John George Pavilion o Kaiser Permanente Fremont o Kaiser Permanente Oakland o Kaiser Permanente San Leandro o San Leandro Hospital o Stanford Healthcare Tri-Valley o UCSF Benioff Children’s Hospital o Washington Hospital o Willow Rock
Community Partners
o Patient Families o Community Organizations o City Councils o County Board of Supervisors o Education/Training Programs o Vendors o Insurance/Third-Party Providers o Other Regulatory Agencies
ALS Fire Departments
o Alameda City Fire Department o Alameda County Fire Department o Albany City Fire Department o Berkeley City Fire Department o Piedmont Fire Department o Fremont Fire Department o Hayward Fire Department o Livermore-Pleasanton Fire Department
o Oakland Fire Department
BLS Fire Departments
o Camp Parks Fire Department o East Bay Regional Parks Fire Department
Community/Behavioral Health Response Teams
o Community Assessment and Transport Team (CATT) o Hayward Mobile Evaluation Team (HMET) o Mobile Assistance Community Responders of Oakland (MACRO)
Air Transport Providers
o REACH o CALSTAR o East Bay Regional Parks
Interfacility Transport (IFT) Providers
o AMR (Critical Care Paramedics) o Arcadia o Bay Medic o Eagle
o Falck o Falcon CCT o Nor-Cal
o Pro Transport-1 o Royal o United
o Westmed o United
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
SPECIALIZED EMS PROGRAMS
Critical Care Paramedics (CCP) Critical Care Paramedics deliver highly specialized care when transporting patients between facilities or when responding directly to the scene of an emergency. CCPs perform detailed patient assessments, provide invasive out-of-hospital care e.g., ventilator management, and specialized treatments including advanced medication infusions. The San Francisco County EMS Agency and the Alameda County EMS Agency are jointly designing common CCP protocols, expanding CCP scope of practice, and CCP accreditation reciprocity. Community Assessment and Transport Team (CATT) The Community Assessment and Transport Team is a crisis response system intended to reduce the rate of involuntary detentions and increase the efficiency of linking clients to needed services. A behavioral health clinician is paired with an EMT in a non-emergency vehicle and offers transport for a broad range of dispositions (Psychiatric Emergency Services, Crisis Residential Treatment Facility, sobering center, shelter, emergency departments, etc.). CATT is a collaboration among core Alameda County Health Care Services Agency programs - Behavioral Health Care Services, Emergency Medical Services, and Alameda Care Connect (Whole Person Care) – as well as 911 dispatch, the County Sheriff’s Office, city police departments, city health and human services, and other relevant services to ensure a crisis response team is available to meet the needs of our community. Telehealth Telehealth is relatively new in the prehospital environment. Falck and the Hayward Fire Department (HFD) utilize different versions of telehealth for low acuity patients who may be better served by resources offered outside of the Emergency Department. This new program is intended to connect patients with the needed services while limiting demand on the hospitals. MD Ally, used by Falck, and Tele911, used by HFD, are currently activated in the field by EMS clinicians. It is our goal to integrate these services into dispatch centers to prevent unnecessary emergency responses and limit the demand on the 9-1-1 system. The EMS Telehealth Guidelines policy is attached in this plan (Appendix A).
QUALITY IMPROVEMENT RESPONSIBILITIES – GENERAL GUIDELINES
1. The EMS Agency shall establish and facilitate a system wide quality improvement program
to monitor, review, evaluate and improve the delivery of prehospital care services. 1.1 The program shall involve all system participants and shall include, but not be limited to the following activities:
1.2.1 Prospective - designed to prevent potential problems. 1.2.2 Concurrent - designed to identify problems or potential problems during the course of patient care.
1.2.3 Retrospective - designed to identify potential or known problems and prevent their recurrence. 1.2.4 Reporting/Feedback - all quality improvement activities will be reported to the EMS Agency in a manner to be jointly determined. As a result of Q.I./Q.A. activities, changes in system design may be made. 2. Each agency shall submit a Quality Improvement Plan, based on the appropriate policy to the EMS Agency for approval, no later than January 31st of each year. 3. Appropriate revisions shall be made as requested by the EMS Agency.
4. Each agency shall conduct an annual review of their QI Plan. 5. The EMS Agency will evaluate the implementation of each agency’s QI Plan.
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
QUALITY IMPROVEMENT RESPONSIBILITIES – ALAMEDA COUNTY EMS AGENCY
1. Prospective 1.1 Comply with EMS statues and regulations pursuant to Title 22, Division 9,
California Code of Regulations and Division 2.5 of the Health and Safety Code. 1.2 Coordinate prehospital quality improvement committees with the EMS system. 1.3 Plan, implement and evaluate the emergency medical services system including
public and private agreements and operational procedures. 1.4 Implement advanced life support systems and limited advanced life support systems 1.5 Approve and monitor prehospital training programs. 1.6 Certification and accreditation of prehospital personnel. 1.7 Establish policies and procedures to assure medical control and oversight, which include dispatch, basic life support, advanced life support, patient destination, patient care guidelines and quality improvement requirements. 1.8 Facilitate implementation by system participants of required Quality Improvement plans. 1.9 Design reports for monitoring identified problems and/or trends analysis.
1.10 Approve standardized corrective action plan for identified deficiencies in prehospital and base hospital personnel.
2. Concurrent 2.1 Site visits to monitor and evaluate system components 2.2 On call availability for unusual occurrences, including but not limited to:
2.2.1 Multicasualty Incidents (MCI) i. Ambulance Rerouting and Hospital Bypass 3. Retrospective 3.1 Evaluate the process developed by system participants for retrospective analysis of prehospital care. 3.2 Evaluate identified trends in the quality of prehospital care delivered in the system. 3.3 Establish procedures for implementing the Certificate Review Process for prehospital emergency medical personnel. 3.4 Monitor and evaluate the Incident Review Process.
4. Reporting/Feedback 4.1 Evaluate submitted reports from system participants and make changes in
system design as necessary. 4.2 Provide feedback to system participants when applicable or when requested on Quality Improvement issues.
4.3 Design prehospital research and efficacy studies regarding the prehospital use of any drug, device or treatment procedure where applicable.
QUALITY IMPROVEMENT RESPONSIBILITIES – COMMUNICATION CENTERS
1. Prospective 1.1 Participation on committees as specified by the EMS Agency. 1.2 Education 1.2.1 Orientation to the EMS system 1.2.2 Continuing education activities to further the knowledge base of the dispatcher, to include but not limited to: 1.2.2.1 Recording review 1.2.2.2 Educational programs based on problem identification and trend analysis
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
1.2.2.3 Discussion of selected calls 1.2.3 Participation in certification and training of the EMD 1.2.4 Establish procedure for informing all EMDs of system changes 1.3 Evaluation - Develop criteria for evaluation of individual EMDs to include, but not limited to: 1.3.1 Recording review or other documentation as available 1.3.2 Evaluation of new employees 1.3.3 Routine 1.3.4 Problem oriented 1.3.5 Design standardized corrective action plans for individual EMD deficiencies. 1.4 Certification 1.4.1 Initial certification 1.4.2 Re certification 2. Concurrent Activities 2.1 Establish a procedure for evaluation of EMDs utilizing performance standards through direct observation 3. Retrospective Analysis 3.1 Develop a process for retrospective analysis of dispatched calls, utilizing audio recording and dispatcher report form, to include but not limited to: 3.1.1 High-risk 3.1.2 High-volume
3.1.3 Problem oriented calls 3.1.4 Any call requested to be reviewed by EMS or other appropriate agency. 3.1.5 Specific audit topics established through the Quality Improvement
Committee. 3.2 Develop performance standards for evaluating the quality of care delivered by the EMD through retrospective analysis. 3.3 Participation in the incident review process 3.4 Comply with reporting and other quality improvement requirements as specified by the EMS Agency. 3.5 Participation in prehospital research and efficacy studies requested by the EMS Agency and/or the Quality Improvement Committee. 4. Reporting/Feedback 4.1 Develop a process for identifying trends in the quality of dispatch care
4.1.1 Report as specified by the EMS Agency 4.1.2 Design and participate in educational offerings based on problem identification and trend analysis
4.1.3 Make approved changes in internal policies and procedures based on trend analysis
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
PSAP and Dispatch Call Handling Structure in Alameda County
Call Location Primary PSAP Receive 9-1-1 Call Fire 1st Response Dispatch Ambulance Dispatch EMD* Provided By
Alameda City Alameda Police PSAP Call transferred from PD PSAP to ACRECC who dispatches fire units/ambulances
ACRECC dispatches city ambulances ACRECC
Alameda County (and areas served by County Fire)
County Sherriff (unincorporated and Dublin); San Leandro Police PSAP;
Calls transferred from various PD PSAPs to ACRECC who dispatches fire units
ACRECC dispatches Falck ambulances ACRECC
Albany Albany Police PSAP Albany PD dispatches fire Albany PD dispatches city None
Berkeley Berkeley PD PSAP (dual police and fire) Berkeley PD dispatches fire units Berkeley PD dispatches city ambulances ACRECC
Camp Parks City of Dublin Police PSAP Call transferred from Dublin PD PSAP to ACRECC who dispatches fire units
ACRECC dispatches Falck ambulances ACRECC
Emeryville Emeryville Police PSAP Call transferred from Emeryville PD to ACRECC who dispatches fire units
ACRECC dispatches Falck ambulances ACRECC
Fremont Fremont Police PSAP Call transferred from PD PSAP to ACRECC who dispatches fire units
ACRECC dispatches Falck ambulances ACRECC
Hayward Hayward Police PSAP Hayward PD PSAP dispatches fire units and transfers call to ACRECC
ACRECC dispatches Falck ambulances ACRECC
Livermore Livermore Police PSAP Call transferred from Livermore PD PSAP to ACRECC who dispatches fire
ACRECC dispatches Paramedic Plus ambulances ACRECC
Pleasanton Pleasanton Police PSAP Call transferred from Pleasanton PD to ACRECC ACRECC dispatches Falck ambulances ACRECC
Newark Newark Police PSAP Call transferred from PD PSAP to ACRECC who ACRECC dispatches Falck ambulances ACRECC
Oakland Oakland Police PSAP Call transferred from PD PSAP to Oakland Fire Dispatch who dispatches fire
Oakland Fire Dispatch transfers call to ACCREC who dispatches Falck
Oakland Fire Dispatch
Piedmont Piedmont Police/Fire (Joint PSAP) Piedmont PD/Fire dispatches fire and city ambulances
Piedmont PD/Fire PSAP None
East Bay Regional Parks
EBRP PSAP and dispatch EBRP dispatches Parks units and transfers call to ACRECC or to the transport city PSAPs
ACRECC dispatches Falck ambulances; local PSAPs dispatch fire units/ambulances
ACRECC
Union City Union City Police PSAP Call transferred from PD PSAP to ACRECC who dispatches fire units
ACRECC dispatches Falck ambulances ACRECC
Cellular Calls CA Highway Patrol Per response jurisdiction Varies by jurisdiction Varies by jurisdiction
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
QUALITY IMPROVEMENT RESPONSIBILITIES – ALS PROVIDER AGENCIES
1. Prospective 1.1 Participation on committees as specified by the EMS Agency. 1.2 Education 1.2.1 Orientation to EMS system
1.2.2 Continuing Education 1.2.3 Participate in certification courses and the training of prehospital care providers. 1.2.4 Offer educational programs based on problem identification and trend analysis. 1.2.5 Establish procedure for informing all field personnel of system changes
1.3 Evaluation - Develop criteria for evaluation of individual paramedics to include, but not limited to: 1.3.1 PCR review/Recording review or other documentation as available
1.3.2 Ride-along 1.3.3 Evaluation of new employees 1.3.4 Routine 1.3.5 Problem-oriented 1.3.6 Design standardized corrective action plans for individual paramedic deficiencies 1.4 Certification/Accreditation - establish procedures, Based on Alameda County policies, regarding:
1.4.1 Initial certification/accreditation 1.4.2 Recertification/Continuing Accreditation 1.4.3 ITLS or PHTLS certification 1.4.4 ACLS certification 1.4.5 PALS or PEPP 1.4.6 Preceptor authorization
1.4.7 Other training as specified by the EMS Agency. 2. Concurrent Activities 2.1 Ride-along - Establish a procedure for evaluation of paramedics utilizing performance standards through direct observation 2.2 Provide availability of Field Supervisors and/or Quality Improvement Liaison personnel for consultation/assistance. 2.3 Provide patient information to the base hospital to facilitate obtaining patient follow-up information from receiving hospitals. 3. Retrospective Analysis
3.1 Develop a process for retrospective analysis of field care, utilizing PCRs and audio recording (if applicable), to include but not limited to: 3.1.1 High-risk 3.1.2 High-volume 3.1.3 Problem-oriented calls 3.1.4 Any call requested to be reviewed by EMS or other appropriate agency.
3.1.5 Specific audit topics established through the Quality Council. 3.2 Develop performance standards for evaluating the quality of care delivered by field personnel through retrospective analysis. 3.3 Participate in the Incident Review Process 3.4 Comply with reporting and other quality improvement requirements as specified by the EMS Agency. 3.5 Participate in prehospital research and efficacy studies requested by the EMS Agency and/or the Quality Improvement Committee
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
4. Reporting/Feedback 4.1 Develop a process for identifying trends in the quality of field care.
4.1.1 Report as specified by the EMS Agency. 4.1.2 Design and participate in educational offering based on problem identification and trend analysis.
4.1.3 Make approved changes in internal policies and procedures based on trend analysis.
QUALITY IMPROVEMENT RESPONSIBILITIES – EMS AIRCRAFT PROVIDER AGENCIES
1. Assign a liaison to interact with other EMS provider agencies, base hospital(s), and EMS Agency 2. Assure Agency’s EMS personnel and pilots are currently and appropriately credentialed at all times 3. Assure Agency’s personnel are fully oriented to EMS system prior to assigning to EMS response duties 3.1 Orientation to include pertinent policies, protocols, hospital locations, map reading,
documentation requirements, etc. 3.2 Establish procedure for informing agency personnel of EMS system changes and updates
4. Provide the EMS Agency 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
5. Participate in EMS Agency Quality Improvement activities
QUALITY IMPROVEMENT RESPONSIBILITIES – RECEIVING CENTERS
1. A Receiving Hospital is a hospital designated as such by the Alameda County Health Officer and is licensed as a Basic Emergency Service or has in-house physician coverage 24 hours per day 2. A Receiving Hospital shall: 2.1 Accept all emergency patients transported by EMS system units unless ambulance
diversion has been initiated in accordance with Alameda County Ambulance Diversion Policy and the facility's approved internal diversion protocol. 2.2 Admit emergency patients to the Hospital if appropriate, the patient accepts
admission, and the Hospital has space available. If transfer to another hospital is appropriate, the patient shall be transferred according to Alameda County Interfacility Transfer Guidelines.
2.3 Procure and maintain an operational radio for two-way voice communication on the County MEDNET, meeting County specifications, and place this equipment in the emergency department. 2.4 Cooperate with the Alameda County Emergency Medical Services Agency and the Alameda County Health Care Services Agency in gathering and providing statistics and information needed for monitoring and evaluating prehospital programs. 2.5 Cooperate with designated Alameda County Base Hospitals and ALS Provider Agencies in providing follow-up information regarding patient diagnosis, disposition and outcome. 2.6 Follow and abide by the standards established for ALS programs and for Receiving Hospitals, including those standards pertaining to professional staffing.
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
2.7 Ensure that the emergency department staff, and other appropriate hospital personnel possess sufficient skill and knowledge in field procedures that are
continued within the emergency department. 2.8 Participate in the Receiving Hospital Committee and Trauma Audit Committee (TAC) meetings as requested.
2.9 Participate in training of prehospital personnel, in cooperation with and as coordinated by the EMS Agency Medical Director or designee. 2.10 Provide hospital census and bed availability information to the EMS agency through
the “Reddinet” system daily by 7:00 a.m. 2.11 Participate in “HAvBED” drills/exercises as directed by the Alameda County EMS Agency.
QUALITY IMPROVEMENT RESPONSIBILITIES – BASE HOSPITAL
1. An ALS Base Hospital is a hospital designated by the Alameda County Emergency Medical Services Agency and has:
1.1 A written contractual agreement with Alameda County 1.2 Primary responsibility for the direct, online medical control of calls received from the field.
2. The Hospital shall agree to: 2.1 Utilize voice communications and be available to field personnel through a consistent channel, frequency, or telephone number twenty-four (24) hours a day, three hundred sixty-five (365) days a year. 2.2 Provide physician response within sixty (60) seconds of receipt of call. Physician orders and consultation shall be provided directly by the physician. 2.3 Initiate a Base Hospital Report Form completed by the Base Coordinator each time that the Base Hospital is contacted by an ALS unit with patient data. 2.3.1 The document is a medical record, and as such, should meet criteria for all medical records, (e.g., must be in ink, be retained for seven (7) years, etc.) 2.4 The form must list all communications in chronological order by time and include a brief
description of all communications received or transmitted. Each form shall include: 2.4.1 Patient's run number 2.4.2 Patient's chief complaint/problem 2.4.3 Unit number 2.4.4 The Base Hospital Physician 2.4.5 Patient destination
2.4.6 Pertinent comments 2.5 Record all communications between Base Hospital and ALS units. 2.5.1 Recording are considered to be part of the patient's medical record and will be retained for a minimum of 100 days. 2.5.2 Recordings may be copied (in writing or by duplicating the recording) for teaching purposes. The patient's name should be omitted. 2.5.3 The Base Hospital shall provide a copy of any recording requested by the EMS Agency. 2.6 Abide by all standards, protocols, policies, procedures and contracts established by the County relating to prehospital ALS guidelines.
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
QUALITY IMPROVEMENT MEETINGS
The Alameda County EMS Agency hosts and facilitates numerous quality improvement-related meetings with system partners, to continue fostering collaboration and jointly design system-changes. Each meeting will have several EMS agency representatives including the EMS medical director and deputy medical director in attendance when possible. All meetings listed below are externally facing.
o Quality Council (Quality Council Charter attached as Appendix B) o Cadence: Monthly o Facilitator: Kreig Harmon; EMS Coordinator o Purpose: Advisory group to the Alameda County EMS Agency, Identifies QI needs, Present prehospital/hospital performance data, ‘catch-all’ meeting for all things clinical. o Base Tape Reviews o Cadence: Monthly o Facilitator: Kreig Harmon; EMS Coordinator o Purpose: Highland Base Hospital coordinates EMS cases to review for QA/QI o Receiving Hospital Committee o Cadence: Quarterly o Facilitator: Leslie Simmons; EMS Coordinator & Ryan Preston; RDMHS o Purpose: Forum for Hospital and ED leadership, prehospital agencies, and Alameda County EMS to discuss relevant system issues, identify areas for improvement, and review policy changes o STEMI/Cardiac Arrest Systems of Care Meeting o Cadence: April, August, November
o Facilitator: Mike Jacobs o Purpose: Presenting both prehospital/hospital performance data for acute STEMI patients, develop change ideas, shorten time to definitive treatment, and share best practices and new research o Stroke Systems of Care Meeting o Cadence: April, August, November
o Facilitator: Mike Jacobs o Purpose: To share both prehospital/hospital performance data for acute stroke patients, develop change ideas, shorten time to definitive treatment, and share best practices and new research
o Regional Trauma Coordinating Committee (RTCC) – Bay Area o Cadence: Quarterly
o Facilitator: Mike Jacobs o Purpose: Regional coordination of trauma systems of care for ten (10) Bay Area Counties, includes LEMSA, receiving center, and prehospital participation. o Data Steering Committee o Cadence: Quarterly
o Facilitator: Naila Francies o Purpose: Ensuring configuration consistency across all provider instances of ESO, compliance with timely CEMSIS data submission, improving methods of capturing clinically significant data o Basic Life Support (BLS) Provider Meeting o Cadence: Quarterly o Facilitator: Leslie Simmons o Purpose: System evaluation/coordination for IFT providers permitted to operate in Alameda County o Medical Dispatch Review Committee
o Cadence: Quarterly o Facilitator: Andy Sulyma o Purpose: Clinical and operational Coordination between the ACRECC, OFD, Falck, and the EMS Agency. o Ad Hoc Committees o Equipment and Supplies
o Policy Change Workgroups o APOT
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
III. Data Collection and Reporting
EMS DATABASES AND ANALYTICS
Accurate data collection remains a top priority as CQI activity hinges on valid documentation at the key entry point. Currently, all Alameda County prehospital organizations utilize ESO as their Electronic Health Record (EHR). ESO remains compliant with Version 3.5.0 of the National Emergency Medical Services Information System (NEMSIS) and the California Emergency Medical Services Information System (CEMSIS). All ESO data is exported in real-time to CEMSIS from each individual provider agency. The Alamea County EMS Agency has access to an ESO “umbrella” account for viewing access to these records.
It is our role as the LEMSA to integrate available data systems between all stakeholders including dispatch centers, prehospital provider agencies, receiving centers, and community partners. The Alameda County EMS Agency has access to both hospital and prehospital data systems which provides essential information for meaningful quality improvement initiatives and research projects. The databases used to collect EMS information are as follows:
ESO
Priority Dispatch AQUA Ascent
First Watch
First Pass
Biospatial
ReddiNet
Cardiac Arrest Registry to Enhance Survival (CARES)
American Heart Association:
o Get With The Guidelines (GWTG) Stroke
o Get With The Guidelines (GWTG) Coronary Artery Disease
The databases above offer varying levels of analytics and the following software programs are used to supplement and produce more sophisticated data analysis:
ESO Insights
Microsoft Excel
Microsoft Power BI
Tableau
Python
HEALTHCARE DATA EXCHANGE (HDE)
HDE allows for sharing of patient outcome information and detailed physician notes with the EMS providers who initiated care. This bi-directional communication between the receiving centers and
prehospital providers ESO platform is active for the following seven (7) hospitals St. Rose, Highland, San Leandro Hospital, Alameda Hospital, John George Psychiatric Pavilion, Washington Hospital, and UCSF Benioff’s Children’s Hospital Oakland. The remaining eight (8) acute care facilities are working towards the goal of having HDE in the next several years.
UNUSUAL OCCURRENCE (UO) REPORTING
Unusual Occurrence Reporting is designed to establish minimum criteria for EMS event notification to the LEMSA and formalize a process for operational and clinical feedback from EMS stakeholders. Information collected from these reports is crucial to identifying system issues, especially regarding patient safety, and relies on open-self reporting. Currently, UOs are completed on a PDF form and submitted through email to the EMS agency. Our goal is to begin using a combination of
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
Smartsheet’s and ImageTrend’s License Management System to simplify the process for the front-end user while improving our ability to track and manage UO events. The Alameda County Unusual
Occurrences Form is included in this plan (Appendix C).
AD HOC SURVEYS
Soliciting feedback directly from EMS clinicians is vital, and challenging, in large systems such as
Alamea County. In the past year, several surveys have been sent to EMS clinicians via google sheets and smart sheets for topics such as, education interests, policy updates, language barriers with patients, and notification of hard offload times. These online surveys have been very successful and continue to be an excellent tool for quickly receiving field input.
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
IV. Evaluation of Indicators
SYSTEM EVALUATION PRINCIPLES
What is not measured cannot be managed. Indicators, metrics, and measures are terms used interchangeably in this plan describing the same thing; they are gauges telling us how our system is doing. The purpose of organizing data into standardized formats is to create easily understandable visualizations identifying strong performance and opportunities for change. (See Appendix D: Developing an Indicator). Every system will have differences in performance. Aiming to minimize this variation is our CQI goalpost, as eliminating variation entirely is unrealistic. In any data analysis, including the quality indicators in this plan, all the below factors are considered when evaluating information:
The validity and reliability of the data input and output
Common cause variation versus special cause variation
Population dynamics: What are they doing?
Provider dynamics: What are we doing?
CALIFORNIA EMS CORE QUALITY MEASURES
Alameda County has participated in the Core Measures Project since 2010. The measures listed below are submitted to the Emergency Medical Services Authority (EMSA) annually prior to the prescribed deadline. Below is the data submitted for the year 2021.
Measure ID # Measure Name Numerator Value (Subpopulation)
Denominator Value (Population)
Reported Value (%)
TRA-2 Transport of Trauma Patients to a Trauma Center 2825 3004 94%
HYP-1 Treatment Administered for Hypoglycemia 1108 1523 73%
STR-1 Prehospital Screening for Suspected Stroke Patients 1984 2012 99%
PED-3 Respiratory Assessment for Pediatric Patients 167 176 95%
RST-4 911 Requests for Services That Included a Lights and/or Sirens Response 219550 292776 75%
RST-5 911 Requests for Services That Included a Lights and/or Sirens Transport 8508 104318 8%
ALAMEDA COUNTY EMS AGENCY INDICATORS Alamea County EMS has developed local indicators that are reported to the EMS system no less than bi-annually through various Quality Improvement and System of Care meetings. This list does not include ad hoc measures for short-term projects and will continue evolving to meet the needs of the system. Additionally, many of the metrics are dis-aggregated by race, and sex, to assess for equitable delivery of care.
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
Category Area Indicators Type
TBD TBD Process
Equipment and
TBD TBD Process
Documentation
Electronic Health
Records ≤
(4)
Clinical Care and Patient Outcomes
Stroke Blood Glucose Level - Stroke Alerts Process
Last Known Well Time - Stroke Alerts Process
Stroke Screening Documented - Stroke Alerts Process
Stroke Alerts Transported to a Stroke Receiving Center Process
Dispatched to On Scene Time (90th
th
th
th
th
th
th
Arrest
(Non-
Traumatic)
Alameda County & National
Alameda County & National
Alameda County & National
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
th
Scene Time ≤ 10 Minutes
Scene Time ≤ 20 Minutes
th
Fentanyl Administered for Pain ≥ 7
≤
Skill Maintenance and Competency
Transportation/
Public Education and Prevention
Arrest
Risk Management
Care
Opiate Withdrawal Scale ≥ 7 for Buprenorphine
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
PROVIDER AGENCY INDICATORS Each EMS provider agency is responsible for developing a CQI plan to monitor internal indicators and perform quality improvement activities pursuant to Title 22, Division 9, Chapter 12, Article 4 of the California Code of Regulations. Quality improvement indicators are not exclusive to clinical performance and should include operational metrics as well. Alameda County EMS has developed Quality Indicators and Activities Recommendations to assist in the developing metrics (Appendix E). This is only meant to be a resource and provider agencies are not obligated to adopt the metrics. These recommendations list core quality activities and quality indicators for PSAPs, Dispatch, First Responders, Transport Agencies and Receiving Hospitals.
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
V. Action to Improve
IMPROVEMENT METHODOLOGIES
Fundamentally, there are two things every quality improvement initiative needs; data to support why action is necessary, and a clear objective. Various models exist for the action of quality improvement
such as, the Institute for Healthcare Improvement (IHI) Model for Improvement, Six Sigma, and the Program/Project Management Model (Appendix F). All are proven methods and at least one of these methods should be followed when developing a system change. The Alameda County EMS Agency
predominantly uses the IHI Model for Improvement as the methodology of choice.
Image: Copyright CandieEIM
FIELD GUIDELINES AND POLICY CHANGES
Refining field guidance is key to improving the delivery of prehospital care. Applying evidence-based best practices and staying current with the latest EMS research is foundational to our approach. The Alameda County EMS Agency is committed to reviewing policies and protocols at least once annually. Input from EMS clinicians on the field guideline is invaluable to driving relevant system changes. Feedback is currently provided in various formats; our goal is to formalize and simplify this process to allow for better data collection. The policy review process is included in this plan (Appendix G).
PDSA Cycleobserve, adjust the changes as necessary, and repeat—before implementing on a large scale. PLAN
State objective of the test
Determine who will do what, where, and when
Develop a data collection plan
Establish a timeline to complete the first cycle 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
Summarize what was learned ACT
Adopt; keep and implement the changes or,
Adapt; modify and run another PDS cycle or,
Abandon; discard changes
AIM:(month) of (year) we will increase orotracheal intubation first pass success rates to 85%. MEASURES: Determine the process and outcome measures, define what success looks like locally. CHANGES: Utilize evidence-based practices where applicable and prioritize input from those who will carry out these changes.
January February March April May June July August September October November December
System input due Public Comment Periods Research & Policy Draft Development County-Wide Trainings Print Books
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
VI. Training and Education
PRINCIPLES
Training and education are fundamental to the success of quality improvement and is addressed in collaboration with quality and training experts from all partners throughout the EMS system. This section reviews EMS training as well as community outreach and education, highlighting the vital role of public engagement during medical emergencies. EMS TRAINING AND EDUCATION EMS Orientation All EMTs and Paramedics are required to completing an orientation class hosted by Alameda
County EMS within 30 days of beginning employment or field training and evaluation process. This orientation is continuously being refined to evolve with the needs of the system. Annual Policy Updates Each year, Alameda County EMS agency hosts a large train-the-trainer session to review policy changes for the coming year and subsequent training materials. This is usually accompanied by several videos created with system partners from receiving centers, and prehospital agencies. Our goal is to begin providing multiple training sessions across the county support agencies with the immense lift of training. Protocols are available via the field guideline handbook, updated and printed
annually, and via smartphone application available on iOS and android. It is our intention to avoid making protocol updates more than once annually unless necessary secondary to patient safety issues. Educational and CE Opportunities Once monthly, Alameda County Health Services Highland partners with Alameda County EMS to
host Base Tape Reviews. The Base Station Medical Director selects cases that present great learning opportunities and foster important conversations, some of which lead to system-wide policy changes. These sessions are offered ten (10) times a year and will become eligible for one credit of
Continuing Education (CE). The Stroke and STEMI Receiving Centers have expressed interest in collaborating with Alameda County to host a Stroke/STEMI EMS conference. This would be free of charge to Alameda County providers and offer a platform to showcase local subject matter experts
in these systems of care. EMS Corps Trains youth from our community as Emergency Medical Technicians (EMTs) and prepares them for careers in healthcare and public service. EMS Corps is a 5-month paid program for young people from marginalized communities between the ages of 18 and 26. Preceptor and Field Evaluator Training The Alameda County EMS Agency’s Paramedic Preceptor/Field Training Officer Workshop is a full-
day, interactive training that covers learning domains, helps refine teaching strategies, assists in developing internship/training plans and provides teaching scenarios. Other information on EMS education, training and regulations are available to participants. The workshop is facilitated by experienced, respected paramedic preceptors and field training officers.
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
COMMUNITY OUTREACH AND EDUCATION
Injury Prevention
The Safe Kids program partners with community organizations to provide public education and
assistance for reducing preventable injuries in youth including, Child Passenger Safety, Helmet Safety, and Railway Safety (what about drowning)? The Senior Injury Prevention Program (SIPP) partners with community organizations to provide public education and assistance to reduce preventable injuries to older adults including, medication management, fall prevention, bone density screening, home modifications, and physical training sessions. Stop the Bleed Stop the Bleed is a national awareness campaign and call-to-action intended to cultivate grassroots efforts that encourage bystanders to become trained, equipped, and empowered to help in a bleeding emergency before professional help arrives. Alameda County EMS Coordinator, Elsie Kusel, coordinates and teaches Stop the Bleed classes for community members across the county. CPR in Schools CPR 7 was a program developed in 2010 for public school 7th graders in Alameda County. Since the State of California recently passed legislation requiring 9th grade health science students be
trained in CPR as a graduation requirement, CPR 7 transitioned into CPR 9 using CPR Anytime training kits. ALCO EMS continues to support the school CPR training efforts. Project Heartsafe Supports placement, training, and maintenance of AEDs at public locations. Additionally, the Alameda County EMS Agency is currently in the process of purchasing 100+ Avive AEDs for local law enforcement agencies. When a cardiac arrest notification is sent through dispatch, the nearest Avive AED will initiate an alarm notification and voice message with arrest location information
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
VII. Annual Update
CQI UPDATES - 2023
2023 CQI Activities
Pediatric Medication Administration project: updated the length-based resuscitation tapes to reflect
NAEMSO recommended dosages, purchased tapes for all county provider agencies, created a training video, and implemented a 100% QA process to improve the accuracy of pediatric medication
administration
2 Began new process to reduce APOT times: implemented a Hard offload Policy allowing EMS to offload their patient in an available bed or chair if patient meets policy criteria.
3 Began QI project to reduce language barriers to care
4 Sharing system-wide performance data as standing agenda items at various QI meetings Quality
Council, Stroke/STEMI, and data steering meetings.
5 Updated CQI Plan Metrics and developed ESO Insights Dashboards
6 Protocol/Policy Updates:
Dual Sequence Defibrillation
Adopted 2021 ACS Trauma Triage Guidelines
Sexual Assault treatment updated
Human Trafficking Reporting
Buprenorphine
Removal of weight-based Pediatric Medications, replaced with Pediatape process
CQI GOALS - 2024
# 2024 CQI Goals
Update the Unusual Occurrence (UO) process to SmartSheets and ImageTrend LMS
Improve Accuracy for Pediatric Medication Administration
Re-establish Lifeack Codestat and Zoll equivalent with annotation services
Establish an easily accessible form for EMS clinicians to offer feedback on local protocols year-
round
Add and additional10-15 annual training sessions to our calendar at various provider locations
Establish and EMS Symposium with system partners
Increase documentation of ASA for STEMIs to 95% per quarter
Reduce on scene times for STEMI and Stroke to 90th percentile ≤ 15 min
Offer multiple interactive ESO Insights tutorials for Alameda County QI managers
Collect Field Training and Evaluation Plans from all providers
Incorporate CCP metrics into this CQI plan
Incorporate Dispatch MPDS metrics from ACCREC and OFD into this CQI plan
Establish a Cardiac Arrest Meeting centering Dispatch and Prehospital performance with the goal of increasing our Utstein 2 %.
Purchase 100 Avive AEDs for various Law Enforcement Agencies
Reduce APOT times – hard offload
Establish a Community Outreach and Education Meeting with all system partners and community
Create internal BI dashboards for all Systems of Care
Infrequent and LOSOP skills as condition of continuous paramedic accreditation
MD ally, dispatch diverted calls
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
Appendices
A-G
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
APPENDIX A: EMS TELEHEALTH GUIDELINES
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
APPENDIX B: QUALITY COUNCIL CHARTER
EMS Leadership/Quality Council (QC) Charter
The EMS Agency Director works with the EMS Medical Director, EMS QI Coordinator, and the Quality Council to oversee the Alameda County EMS QI program.
Quality Council Purpose:
• Serves as the Technical Advisory Group (TAG) for Alameda County EMS
• Identifies Quality Improvement needs
• Charter (and/or serve as) Quality Task Force(s) to improve system-wide processes (also known
as Process Improvement Teams)
• Provides input for the EMS System Quality Improvement Plan
• Develops Quality Indicators
• Contributes to the development of a consistent approach to developing quality indicators and
gathering and analyzing data
• Contributes to the development of a consistent approach to research
• Monitors and evaluates system data reports to identify opportunities for improvement and
training needs
Quality Council Membership:
• EMS Medical Director (Chair)
• EMS Director
• EMS Quality Improvement Coordinator
• EMS Quality Improvement Coordinators from each fire department
• Private 911 ambulance transport provider Quality Manager
• Base Hospital Paramedic Liaison Nurse
• One Paramedic and one EMT representing fire department in each of the North, South and
East zones of Alameda County (6 total members)
• One Paramedic and one EMT from the 911 private medical transport provider agency
• One representative from an air transport provider
• Two representatives from Receiving Hospitals
• One representative each from OFD dispatch and ACRECC
• One representative from a permitted IFT provider
Quality Council Chairperson: EMS Medical Director
Meetings:
• Monthly
• Two hours with a planned agenda
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
APPENDIX C: UNUSUAL OCCURRENCE FORM
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
APPENDIX D: DEVELOPING AN INDICATOR Organizing an Indicator Indicators can be organized into three categories, structure, process, and outcome. Improving
outcomes is the most important goal of quality improvement initiatives.
Results Based Accountability (RBA) Model RBA uses a practical model for developing meaningful performance measures by asking 3 simple questions: 1. How much do we do? (Structure) Input resource components are measured, such as
leadership, workforce, suppliers, equipment, etc. These are the least important measures
and the easiest to obtain. This question helps to identify things such as infrequent skills.
2. How well do we do it? (Process) The efficiency of design and delivery of work processes,
productivity and operational performance are measured.
3. Is anyone better off? (Outcome) 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 quality effect of our efforts.
Structure
“Things” within a system # of ambulances
Process
“Activities” within a system % of first-pass
intubation success
Outcome
“Results”
of a system % of cardiac arrest
survival
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
Indicator Specification Sheet (ISS) Defining performance indicators is key to ensure the data quality is consistent and reliable. An ISS should be written in locally agreed upon nomenclature and/or utilizing the NEMSIS data dictionary. Steps to developing an ISS include: 1) engaging stakeholders and subject experts for consensus on where and how to get the data, 2) identify the data sources and elements and then query the data 3) review the report and validate results.
Description
Type of Measure Structure, Process, or Outcome
Reporting Value Units %, 90th Percentile Time, etc.
Denominator Inclusion Criteria
applicable
Numerator Statement (sub-population)
Numerator Inclusion Criteria
applicable
Exclusion Criteria
Criteria
Data Elements
Indicator Formula Numeric Expression (D) and then multiply (x) by 100 to obtain the (%) value the indicator is to report. Therefore, the indicator expressed numerically is N/D = %
Example of Final Reporting 85%, or 60 minutes, etc.
Benchmarks Performance goal of 90%, or 45 minutes, etc.
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
Visualizing Data Plotting measurements over time is one of the most powerful ways to display data. Selecting the best chart to tell the story is as important at the metric itself. Use color, size, scale, and labels to clearly explain the metric. The use of charts is essential in the analysis of processes. While many different types of charts exist, the following charts provide the best process analysis. Control Charts measures how a process changes over time. If given two different numbers, one will be bigger than the other. However, if given a series of numbers over a period of time and then “plotting the dots”, a picture of a process starts to emerge. Control charts are a necessary tool all organizations should use to determine whether a process is improving or merely operating within some variation, e.g., common cause vs. special cause.
Horizontal Bar Charts identify ranked process contributing factors and/or characteristics.
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
Flow Charts provide a picture of the structure of an organization or the workflow of a process over time.
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
APPENDIX E: EMS PROVIDER QUALITY INDICATORS AND ACTIVITIES
PSAPs Dispatch Centers First Responders AmbulanceServices Receiving Hospitals
Personnel/Resource Management
Activities
• Workload Management
• Matching schedules to
demand
• Resource deployment
practices
• Risk Management
• Employee welfare
Indicators
• Workload Management
• Employee Satisfaction
• Employee Turnover
Rate
Activities
• Workload Management
• Matching schedules to
demand
• Resource deployment
practices
• Risk Management
• Employee welfare
Indicators
• Workload Management
• Employee Satisfaction
• Employee Turnover
Rate
Activities
• Workload Management
• Matching schedules to
demand
• Resource deployment
practices
• Risk Management
• Employee welfare
Indicators
• Workload Management
• Employee Satisfaction
• Employee Turnover
Rate
Activities
• Workload Management
• Matching schedules to
demand
• Resource deployment
practices
• Risk Management
• Employee welfare
Indicators
• Workload Management
• Employee Satisfaction
• Employee Turnover
Rate
Activities
• Workload Management
• Matching schedules to
demand
• Resource deployment
practices
• Risk Management
• Employee welfare
Indicators
• Workload Management
• Employee Satisfaction
• Employee Turnover
Rate
Equipment/Supplies
Activities
• Maintaining and
upgrading equipment
and information system
• Inventory Control
• Sharing of Resources
• Provider surveys/feedback
• Ease of use
• Resources involved in personnel skills training
• Resources involved equipment acquisition, associated equipment costs, maintenance, resupply and consumables
• Equipment durability/failures
Activities
• Maintaining and
upgrading equipment
and information system
• Inventory Control
• Sharing of Resources
• Provider surveys/feedback
• Ease of use
• Resources involved in personnel skills training
• Resources involved equipment acquisition, associated equipment costs, maintenance, resupply and consumables
• Equipment durability/failures
Activities
• Maintaining and
upgrading equipment
and information
systems
• Inventory Control
• Sharing of Resources
• The effect of the equipment on patient pain/suffering and outcome
• Patient surveys/feedback
• Provider surveys/feedback
• Ease of use
• Resources involved in personnel skills training
• Resources involved
associated equipment costs, maintenance, resupply and consumables
• Equipment durability/failures
• Maintaining and
upgrading equipment
and information
systems
• Inventory Control
• Sharing of Resources
• The effect of the equipment on patient pain/suffering and outcome
• Patient surveys/feedback
• Provider surveys/feedback
• Ease of use
• Resources involved in personnel skills training
• Resources involved equipment acquisition, associated equipment costs, maintenance, resupply and consumables
• Equipment durability/failures
• Maintaining and
upgrading equipment
and information
systems
• Inventory Control
• Sharing of Resources
• The effect of the equipment on patient pain/suffering and outcome
• Patient surveys/feedback
• Provider surveys/feedback
• Ease of use
• Resources involved in personnel skills training
• Resources involved equipment acquisition, associated equipment costs, maintenance, resupply and consumables
• Equipment durability/failures
• Integration of Data
Systems and Reporting
Indicators
• Integration of Data
Systems and Reporting
Indicators
• Integration of Data
Systems and
Reporting
• Documentation
reviews (especially
non-transports,
critical patients,
under-triages)
• PCR data field
compliance
• PCR Printing
compliance
• Integration of Data
Systems and
Reporting
• Documentation
reviews (especially
non-
patients, under-
triages)
• PCR data field
compliance
• PCR Printing
compliance
Activities
• Integration of Data
Systems and
Reporting
• Documentation
reviews (especially
non-
patients, under-
triages)
• PCR data field
compliance
• PCR Printing
compliance
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
PSAPs Dispatch Centers First Responders Ambulance Services Receiving Hospitals
Operations/Clinical Care/Patient Outcome
Activities
• Training link to QI
• Unusual occurrence investigations
• Error Management • Error reporting system (including self-reporting)
• Correct assignment of resources
• Call Reviews
• Peer Reviews
• Time increments
• Call volume
• Calls per call taker
• Correct prioritization
• Accuracy of location identification
• Correct provision of prearrival instructions
• Correct transfer
• Time of day distribution
• Equipment failures
• Unusual occurrence tracking
• Complaint and Commendation tracking
Activities
• Training link to QI
• Unusual occurrence investigations
• Error Management • Error reporting system (including self-reporting)
• Correct assignment of resources
• Call Reviews
• Peer Reviews
• Time increments
• Call volume
• Calls per call taker
• Correct prioritization
•
• Correct patient condition code
• Accuracy of location identification
• Correct provision of prearrival instructions
• EMD compliance
• Correct transfer
• Time of day distribution
• Equipment failures
• Unusual occurrence tracking
• Complaint and Commendation tracking
Activities
• Training link to QI
• Unusual occurrence investigations
• Error Management • Error reporting system (including self-reporting)
• Correct assignment of resources
• Call Reviews
• Peer Reviews
Indicators
• Tracking critical procedures
• Pain reduction Indicators
• Patient centered outcomes and changes
• Patient satisfaction surveys
• Verifiable and accuratedata collection
•
• Unusual occurrence tracking
• Complaint and Commendation tracking
Activities
• Training link to QI
• Unusual occurrence investigations
• Error Management • Error reporting system (including self-reporting)
• Correct assignment of resources
• Call Reviews
• Peer Reviews
• Tracking critical procedures
• Pain reduction Indicators
• Patient centered outcomes and changes
• Patient satisfaction surveys
• Verifiable and accurate data collection
• Over triage/Undertriage
• Unusual occurrences
• Complaints and Commendations
• Training link to QI
• Unusual occurrence investigations
• Error Management • Error reporting system (including self-reporting)
• Correct assignment of resources
• Call Reviews
• Peer Reviews
• Patient diagnosis
• Pain reduction Indicators
• Time to definitive treatment
• Pt length of stay
• Pt morbidity/mortality
• Verifiable and accurate data collection
• Over triage/Undertriage
• Unusual occurrence tracking
• Complaints and Commendations
Education and Skills Competency
Activities
• Training link to QI
• Continuing education
• Skills competencies
• New procedures and
technology
• Emergency Medical
Dispatch training and
continuing ed.
• Field
Training/Evaluations
• Mass casualty/disaster
drills
• Research Studies
Indicators
• Skills performance
measures
Activities
• Training link to QI
• Continuing education
• Skills competencies
• New procedures and
technology
• Emergency Medical
Dispatch training and
continuing ed.
• Field
Training/Evaluations
• Mass casualty/disaster
drills
• Research Studies
Indicators
• Skills performance
measures
Activities
• Training linked to
Quality Improvement
findings
• Continuing education
• New procedures and
technology
• Skill competencies
• Recertification
• Driver training
•
drills
• Annual EMS training
requirements
• Protocol Development
• Field
Training/Evaluations
• Research Studies
• Establish patient
outcome feedback
to field providers
• Skills performance
measures
Activities
• Training linked to
Quality Improvement
findings
• Continuing education
• New procedures and
technology
• Skill competencies
• Recertification
• Driver training
• Mass casualty/disaster
drills
• Annual EMS training
requirements
• Protocol Development
• Field
Training/Evaluations
• Research Studies
• Establish patient
outcome feedback loop
to field providers
• Skills performance
measures
Activities
• Training linked to
Quality Improvement
findings
• Continuing education
• New procedures and
technology
• Skill competencies
• Recertification
• Mass casualty/disaster
drills
• Protocol Development
• Field
Training/Evaluations
• Research Studies
• Establish patient
outcome feedback loop
to field providers
• Skills performance
measures
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
PSAPs Dispatch Centers First Responders AmbulanceServices Receiving Hospitals
Transport/Facilities
Activities
• Facility management
• Disaster
Resources/Caches
Activities
• Facility management
• Disaster
Resources/Caches
Activities
• Fleet management
• Facility management
• Resource deployment
practices
• Disaster
Resources/Caches
• Response times
• Call time increments
• Time on task
• Call volume
• Mutual aid requests
• Accident rates
• Vehicle/equipment
failure rates
• Simultaneous demand
Activities
• Fleet management
• Facility management
• Resource deployment
practices
• Disaster
Resources/Caches
• Response times
• Call time increments
• Time on task
• Call volume
• Mutual aid requests
• Accident rates
• Vehicle/equipment
failure rates
• Simultaneous demand
• Facility management
• Disaster
Resources/Caches
• Reddinet Updates
Indicators
•
of base contacts
• Time to answer
communications from
field
• Quantity of patients
received
•
of diversion
• Number of patients
received at wrong
facility
• Quantity of secondary
transfers
• Wait Times (drop times) • Community CPR
• AED Programs
• Bay Area Journal Club
• Disaster Preparedness
•
•
• When to call 911
• Vials of Life type programs
• Referrals to other social and health care
•
• Neighborhood Safety
• Violence Prevention
• Illness Prevention
•
Risk Management
Activities
• Specialized safety and
risk training
•
policy compliance
• Unusual Occurrence
investigations
• Patient/Customer
complaint Investigations
Indicators
• Illness/Injury rates and
their severity
• Unusual Occurrence
tracking including “near
misses”
Activities
• Specialized safety and
risk training
•
policy compliance
• Unusual Occurrence
investigations
• Patient/Customer
complaint investigations
Indicators
• Illness/Injury rates and
their severity
• Unusual Occurrence
tracking including “near
misses”
Activities
•
risk training
• CAL OSHA training
and policy compliance
• Unusual Occurrence
investigations
• Patient/Customer
complaint
investigations
Indicators
•
rates and their severity
• Vehicle accident rate
• “Near misses”
• Unusual Occurrence
misses”
• Patient/Customer
complaint tracking
• Medication/Treatment
error identification and
Activities
• Specialized safety and
risk training
• CAL OSHA training
and policy compliance
• Unusual Occurrence
investigations
• Patient/Customer
complaint
investigations
Indicators
• Illness/Injury/Exposure
rates and their severity
• Vehicle accident rate
• Unusual Occurrence
misses”
• Patient/Customer
complaint tracking
• Medication/Treatment
error identification and
tracking
• Specialized safety and
risk training
• CAL OSHA training
and policy compliance
• Unusual Occurrence
investigations
• Patient/Customer
complaint
investigations
Indicators
• Illness/Injury/Exposure
rates and their severity
• Unusual Occurrence
misses”
• Patient/Customer
complaint tracking
• Medication/Treatment
error identification and
tracking
• Periodic and consistent
reporting to policy-
makers and governing
entity
• Timely, accurate, and
complete data and
information delivered to
County EMS Agency
• Open Communication
• Development of a Non-
Punitive Error
Process
Activities
• Periodic and consistent
reporting to policy-
makers and governing
entity
• Timely, accurate, and
complete data and
information delivered to
County EMS Agency
• Open Communication
• Development of a Non-
Process
Activities
•
reporting to policy-
makers and governing
entity
• Timely, accurate, and
complete data and
County EMS Agency
• Open Communication
• Development of a Non-
Punitive Error
Reporting Process
Activities
• Periodic and consistent
reporting to policy-
makers and governing
entity
• Timely, accurate, and
complete data and
information delivered to
County EMS Agency
• Open Communication
• Development of a Non-
Process
Activities
• Periodic and consistent
reporting to policy-
makers and governing
entity
• Timely, accurate, and
complete data and
information delivered to
County EMS Agency
• Open Communication
• Development of a Non-
Process
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
APPENDIX F: ADDITIONAL QUALITY IMPROVEMENT METHODOLOGIES Six Sigma Model 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 six basic
steps, known as DMAIC.
Image: Copyright iCert Global Program/Project Management Model
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 STARCARE should be stated.
Program/Project Scope The parameters of the program/project, what is 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.
Alameda County EMS Continuous Quality Improvement Plan - 2024
R e v i s i o n D a t e : 1 / 3 1 / 2 0 2 4 P a g e | 41
APPENDIX G: POLICY REVIEW PROCESS Policy Review Process
1. INTRODUCTION 1.1 The policy review process is an advisory process to the EMS Medical Director for the formulation of medical protocols. Policy suggestions and/or draft policies are accepted from committees, system participants, individuals, and/or interested parties.
1.2 Policies will be evaluated on an annual basis with adequate time allowed for training and distribution. Specific recommendations for additions, deletions and/or revisions should be forwarded to the EMS Agency.
2. POLICY PROCESS 2.1 Written Public Comment Draft
2.1.1 The EMS office will distribute draft policies to the appropriate system participants
and/or interested parties for written comments. 2.1.2 Policies under consideration that affect the EMS system as a whole will be sentout for review by all systems participants. A policy under consideration that applies to a limited group will only be sent to those who would be directly affected. 2.1.3 The time frame allowed for the return of comments will be 60 days. Comments may be mailed or faxed to the EMS office but must be received no later than 4 p.m. on the deadline date. 2.1.4 All comments will be reviewed by the EMS Medical Director. All suggestions will
be taken into consideration. 2.2 Public Testimony
2.2.1 Public comments will be heard at the next most appropriate Emergency Medical
Oversight Committee (EMOC) meeting (usually in August) 2.2.2 A final draft of the policy will be distributed prior to the meeting. 2.2.3 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. 3. ANNUAL POLICY REVIEW PROCESS TIMELINE
Policy Review Process Timeline
Deadline for policy ideas April
Written public comment draft released May
Written comments due back to EMS June
Public Testimony at EMOC July
Finalized policies released August
Update training August/September
Effective date of new policies January 1 of Policy Year
Specific dates set annually. Subject to change.