Md. Code Regs. 30.03.06.05

Current through Register Vol. 51, No. 24, December 2, 2024

Section 30.03.06.05 - Quality Improvement

A. The hospital of which the base station is a unit, or the free standing emergency center if the base station is within a free standing emergency center, shall:

(1) Monitor and participate in MEMRAD;

(2) Monitor their utilization of CHATS alerts; and

(3) Participate in mitigation strategies to improve systems efficiencies and patient safety.

B. The base station director and base station coordinator shall:

(1) Assure that online medical direction and consultation provided by the base station is:

(a) Timely,

(b) Appropriate, and

(c) Otherwise consistent with Maryland Medical Protocols for Emergency Medical Services Providers;

(2) Assure the MIEMSS approved Prehospital Consultation/Interventions Radio Report Forms are complete, signed and linked to the patient record through a patient identifier;

(3) Develop and implement a process which facilitates monthly quality assurance/quality improvement review of EMS consults which:

(a) Reviews all priority one/critical patient consults and select lower priority consults for a minimum of 30 consults per month;

(b) Allows for ongoing documentation of tracking, trending, loop closure and retention of Quality Assurance/Quality Improvement review findings for 5 years;

(c) Notifies EMS operational programs upon discovery of patient care, quality or protocol variance issues involving EMS providers or the EMS system;

(d) Notifies EMS operational programs and MIEMSS Office of the State Medical Director upon discovery of conduct that is specifically prohibited under the requirements of COMAR 30.02.04.01;

(e) Monitors hospital's response rates to MEMRAD notifications and alerts;

(f) Participates in local, regional, and State EMS quality improvement activities;

(g) Provides patient follow-up data as required by MIEMSS for public health oversight purposes to determine the appropriateness and outcome of EMS care for:

(i) Inpatients, and

(ii) Outpatients; and

(iii) Reports as required by MIEMSS for quality assurance and performance improvement purposes.

C. The State EMS Medical Director through the MIEMSS regional medical directors shall:

(1) Coordinate online medical direction functions; and

(2) Regularly review the quality improvement activities of approved base stations.

Md. Code Regs. 30.03.06.05

Regulation .05 amended effective July 1, 2002 (29:12 Md. R. 931); recodified from .04 effective 43:20 Md. R. 1110, eff. 10/10/2016