1 Del. Admin. Code § 710-13.0

Current through Reigster Vol. 28, No. 6, December 1, 2024

Section 710-13.0 - Statewide Basic Life Support Quality Assurance/Quality Improvement

13.1 The Commission hereby establishes a Statewide Basic Life Support (BLS) Quality Assurance and Quality Improvement working group.

13.2 Purpose. The Quality Assurance/Quality Improvement working group (QA/QI), under direction of the State Medical Director or the designee is responsible for assuring and improving the quality of Basic Life Support within the EMSS that are served by the State of Delaware.

13.3 Definitions

13.3.1 "Quality assurance" or "QA" means the retrospective review or inspection of services or processes that is intended to identify problems.

13.3.2 "Quality improvement" or "QI" means the continuous study and improvement of a process, system, or organization.

13.4 Objectives

13.4.1 Conduct medical incident reviews (QA)

13.4.2 Collect patient care statistics to evaluate EMS effectiveness and identify trends (QI)

13.4.3 Provide constructive feedback on quality improvement to all EMS Providers within the State of Delaware

13.4.4 To coordinate the findings of quality assurance activities with the content of EMS Provider continuing education programs

13.4.5 To provide assistance to EMS providers with local agency QA/QI programs.

13.5 Emergency Medical Services Provider Agencies Quality Assurance and Improvement Requirements:

13.5.1 EMS provider agencies must appoint a Quality Assurance Manager

13.5.2 The Quality Assurance Manager is charged with the responsibility of assuring that reasonable standards of care and professionalism are met within their respective EMS provider agency.

13.5.3 The Quality Assurance Manager should attend a quality management training program.

13.5.4 The Quality Assurance Manager shall implement a Quality Assurance and Improvement Program within their agency or department.

13.5.5 The Quality Assurance Manager shall perform monthly reviews of their data collection and conduct formal reviews with their personnel.

13.5.6 The Quality Assurance Manager will work closely with the Statewide QA/QI working group on emergency medical services policies, guidelines, protocols and system performance.

13.5.7 The Quality Assurance manager will consult with their county and State EMS Medical Director.

13.5.8 The Quality Assurance manager will consult with the Delaware State Fire School Director or its designee.

13.6 Statewide QA/QI Improvement Working Group

13.6.1 The goal of this working group is to make sure BLS is meeting all State standards and is providing the best patient care to the citizens and visitors of Delaware.

13.6.2 The statewide BLS QA/QI working group shall be comprised of:

13.6.2.1 2 BLS representatives, Delaware EMT certified, from each county;

13.6.2.1.1 1 selected from names submitted by the County Firefighter's Association; and

13.6.2.1.2 1 selected from names submitted by the County EMS or Chief's Association;

13.6.2.2 The BLS Medical Director or the designated agent;

13.6.2.3 1 representative from the State Fire Prevention Commission, who shall chair the working group;

13.6.2.4 1 representative from the Delaware State Fire School;

13.6.2.5 1 representative from the Office of Emergency Medical Services; and

13.6.2.6 1 representative from the Delaware Volunteer Firefighter's Association.

13.7 Working Group Responsibilities

13.7.1 Responsible to assure reasonable standards of care and professionalism are met within the State's BLS system.

13.7.2 Participate in patient care report review audits, data collection, and evaluation of system performance.

13.7.3 Maintain strict confidentiality of patient information, personnel and Q/A topics.

13.7.4 Each working group member MUST sign a confidentiality statement to be provided by the Office of Emergency Medical Services.

13.7.5 Make sure information disseminated is protected from discovery of protected healthcare information.

13.7.6 Make recommendations for changes to policies, guidelines and protocols.

13.7.7 Attend a quarterly meeting to discuss QA/QI issues.

13.7.8 Design and implement QI projects that are practical and able to collect patient care statistics to evaluate system effectiveness and identify trends in patient care.

13.7.9 Establish clinical benchmarks to measure the State's BLS system.

13.8 Medical Incident Review and Analysis

13.8.1 The QA/QI process evaluates all aspects of patient care and emergency medical services performance in the BLS system. QA/QI process shall evaluate the Key Performance Indicators (KPI) of the EMS system as defined by the SFPC.

13.8.2 Quarterly reports will be developed through the State's patient care reporting system. A percentage of the patient care reports will be reviewed using a designated and approved auditing tool as developed by the QA/QI working group and approved by the Commission.

13.8.3 The QA/QI working group shall review these reports during the quarterly meeting.

13.8.4 The primary goal is to identify and address any problem or improvement areas and recommend potential solutions:

13.8.4.1 Knowledge or skill issues

13.8.4.2 Documentation issue

13.8.4.3 Resource issue

13.8.4.4 Protocol issue

13.8.4.5 Communication issue

13.8.4.6 Statewide system issue

13.8.4.7 Conduct issue

13.8.5 The QA/QI working group shall provide constructive feedback and recommendations to improve the State's BLS system.

13.8.5.1 Recommend changes to policy, procedures, or protocols

13.8.5.2 Recommend changes in operational procedures or equipment

13.8.5.3 Recommend training

13.8.6 All working group recommendations will be forwarded to the appropriate EMS provider agency or agencies and to the Commission.

1 Del. Admin. Code § 710-13.0

17 DE Reg. 982 (4/1/2014)
24 DE Reg. 471 (11/1/2020)
28 DE Reg. 41 (7/1/2024) (Final)