Regulation .05 Quality Improvement.
Regulation .05 Quality Improvement.LinkCopy Citation
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.