65- 625 C.M.R. ch. 5, § 8

Current through 2024-51, December 18, 2024

Section 625-5-8 - QUALITY ASSURANCE AND QUALITY IMPROVEMENT PROGRAM (QA/QI)

A.Overview

Each EFDA shall establish a continuous quality assurance, improvement and management program. The Bureau will establish a single QA/QI Program to be used by EFD As and EFDs. Any person engaged in a QA/QI review of EFDs must be properly certified by the protocol vendor as an EFD case reviewer.

B.Responsibilities

EFDAs must:

1. Participate in a Bureau approved QA/QI program;

2. Conduct the QA/QI program as required by Maine law and this chapter; and

3. Designate a QA/QI Manager to oversee the EFDA's QA/QI program.

C.Levels

Each QA/QI program must comprise the following levels:

1. Field level-Direct Observation.

2. Administrative level-Case review, identification of positive and negative trends.

3. Management level-High-level coordination of fire oversight.

D.Scope

The goal of QA/QI is to ensure effective and efficient Emergency Fire Dispatch. Each EFD employed by an EFDA must be regularly and routinely evaluated to ensure compliance with Emergency Fire Dispatch protocol and operating policies and procedures. Evaluation, using the selected protocol vendor's standards and evaluation instruments, must be qualitative and quantitative and must include retrospective review of non-edited logged recordings of Emergency Fire Dispatch calls and any associated documentation. Cases chosen for evaluation must be randomly selected and equitably representative of each EFD's work.

1.Tracking

The following variables must be tracked for each EFD:

a. Address/location, phone number;

b. Chief complaint/incident type selection;

c. Systemized interrogation questions;

d. Post-Dispatch Instructions;

e. Pre-Arrival Instructions;

f. Dispatch code selection;

g. Overall or aggregate performance score; and

h. Customer Service score.

2.Data Maintenance

Data must be maintained electronically at each EFDA and must include:

a. Individual compliance;

b. Shift compliance; and

c. Service compliance.

3.Reporting

EFDA's must report compliance results monthly to the Bureau in the format requested by the Bureau by the 15th day of the month for the previous month.

4.Challenging Callers and Text Messaging

Challenging callers ( e.g.,hysterical, speech or hearing impaired, developmentally disabled, non-English speakers, etc.) and persons requesting Emergency Fire Dispatch via text message are not exceptions to the Emergency Fire Dispatch requirements. Challenging callers must receive the same systematized and comprehensive approach to Emergency Fire Dispatch as any other caller.

5.Case Review

a. Random Case Review

EFDAs will conduct random case reviews of a minimum number of Emergency Fire Dispatch cases according to the following table:

Yearly Number of 9-1-1 Calls	Estimated Yearly Fire Calls	Monthly Call Review as Second Discipline
0 to 10,000	0 to 1,000	30
10,001 to 50,000	1,001 to 5,000	61
50,001 to 150,000	5,001 to 15,000	65

The number of case reviews in the above table assumes that each EFDA is also providing Emergency Medical Dispatch Protocols and assumes fire calls account for 10% of the total number of 9-1-1 calls.

b. Focused Case Review

Every EFDA must have a Focused Call Review Plan. The structure of the Focused Call Review Plan should clearly indicate how calls will be selected for a given month. Focus reviews should address data that cannot be captured during random case review such as, but not limited to:

1. Case review of infrequently used protocols.

2. Case review of EFDs not selected by random case review.

3. Specific investigations that arise in the field

4. High risk calls that should be screened for compliance.

6.Follow-up on QA findings

a. EFDAs must mitigate all noted deviations to protocol;

b. EFDAs must emphasize retraining and behavior modification in their QA/QI programs; and

c. EFDAs must provide regular feedback to EFDs.

65- 625 C.M.R. ch. 5, § 8