Continuous Quality Improvement

Overview

The goal of the San Joaquin County Emergency Medical Services Continuous Quality Improvement (CQI) program is to establish a system wide process for evaluating and improving the quality of prehospital care in San Joaquin County.

Based on EMS community collaboration and a shared commitment to excellence, CQI reveals potential areas for improvement of the EMS System, identifies training opportunities, highlights outstanding clinical performance, audits compliance with treatment protocols, and reviews specific illnesses or injuries along with their associated treatments. These efforts contribute to the continued success of our emergency medical services through a systematic process of review, analysis and improvement.

Current CQI Projects

Effective July 1, 2006, all advanced life support (ALS), base hospital, and dispatch providers are required to submit quarterly CQI reports summarizing their provider specific CQI indicators, activities, and findings. The initial quarterly report for 3rd quarter 2006 (July 1, 2006 to September 31, 2006) is due on or before October 27, 2006. Thereafter, all quarterly reports will be due on the last Friday of the month following the end of the quarter (4th quarter 2006 is due on January 26, 2007).

In addition to the quarterly CQI reports for provider specific CQI indicators, the EMS Agency is requiring all ALS providers and the base hospital to collect and submit monthly reports for the following system-wide quality indicators:

• Advanced airway skill success rate
• EMS Policy No. 5103, Determination of Death compliance
• EMS Policy No. 550.04, Pediatric Trauma Triage Criteria compliance

CQI Council Meetings

The CQI Council meets the second Wednesday of the even-numbered months at 1300 hrs. Click here to view the CQI Council meeting schedule. The CQI Council membership consists of the following quality improvement liaison personnel:

• EMS Medical Director
• EMS CQI/Trauma Coordinator
• EMS Prehospital Operations Coordinator
• Base Hospital Medical Director
• Base Hospital Liaison Nurse
• Receiving Hospital Liaison – (chosen by the receiving hospital nurse liaisons)
• One representative from each of the authorized advanced life support (ALS) emergency ambulance providers and first response agencies operating in San Joaquin County
• One representative from the County’s designated EMS dispatch center.

Date	Location
February 14, 2007	SJGH Hospital Conference Room 2
April 11, 2007	SJGH Hospital Conference Room 2
June 13, 2007	SJGH Hospital Conference Room 1a/1b
August 8, 2007	SJGH Hospital Conference Room 2
October 10, 2007	SJGH Hospital Conference Room 2
December 12, 2007	SJGH Hospital Conference Room 2

Note: Occasionally ad hoc CQI meetings are scheduled with specific providers to address unusual occurrences, incidents, or performance issues. Prior to attending any CQI meeting, participants must sign an Acknowledgement of CQI Confidentiality form. If you have any questions please contact Anna Valdez at (209) 468-6818 or by e-mail at avaldez@sjgov.org.

CQI Reports

• PDSA Report, Pediatric Trauma Triage Criteria, CY 2005
• PDSA Report, Receiving Hospital Delay/Diversion, May 2006
• PDSA Report, Receiving Hospital Delay/Diversion, June 2006
• PDSA Report, Receiving Hospital Delay/Diversion, July 2006
• PDSA Report, Receiving Hospital Delay/Diversion, August 2006
• PDSA Report, Receiving Hospital Delay/Diversion, September 2006
• PDSA Report, Receiving Hospital Delay/Diversion, October 2006
• PDSA Report, Receiving Hospital Delay/Diversion, November 2006
• PDSA Report, Receiving Hospital Delay/Diversion, December 2006
• PDSA Report, Receiving Hospital Delay/Diversion, January 2007

CQI Resources

• Authority for EMS Quality Improvement
• Emergency Medical Services System Quality Improvement Program Model Guidelines
• Leadership Guide to Quality Improvement for Emergency Medical Services Systems
• National EMS Research Agenda

CQI Forms

• Acknowledgement of CQI Confidentiality
• Advanced Airway Skills Data Spreadsheet
• Base Hospital Internal Audit Report for EMS Policy No. 550.04, Pediatric Trauma Triage Criteria
• Base Hospital Internal Audit Report for EMS Policy No. 5103, Determination of Death
• Internal Audit Report for EMS Policy No. 550.04, Pediatric Trauma Triage Criteria
• Internal Audit Report for EMS Policy No. 5103, Determination of Death
• Unusual Occurrence Report

CQI Policies

• EMS Policy No. 6620, Continuous Quality Improvement Process
• EMS Policy No. 6630, Continuous Quality Improvement Council
• EMS Policy No. 6680, Research Studies