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Last updated 10.2006
TITLE: Quality Improvement Responsibilities NUMBER: 800.1SECTION: Quality Assurance
EFFECTIVE DATE: 9/1/99 REVISED/REVIEWED: 10/1/06
INTRODUCTION
The purpose of the quality improvement program is to ensure that prehospital patient care provided within the Loyola Emergency Medical Services System is uniformly and consistently of the highest possible quality. The Loyola Emergency Medical services System Quality Improvement program is further designed to comply with Emergency Medical Services and Trauma Center Code requirements for quality improvement measures for both adult and pediatric patient care. Participation at all levels within the Loyola EMS System is required to meet this goal. Data, analysis and reports submitted to and analyzed by the System Quality improvement program hall be considered confidential under Section 8-2101 of the Illinois Code of Civil Procedure {735 ILCS 5/8-2101}.
RESOURCE HOSPITAL
1. Coordinate all quality improvement activities within the system.
2. Provide continuing education.
3. Report all system data to the state as required by Illinois Department of Public Health.
ASSOCIATE HOSPITAL COORDINATORS
1. On a monthly basis, review telemetry log sheets
2. Participate in Quality Improvement Activities as required by the Resource Hospital.
3. Coordinate the investigation and resolution of all problems relating to their hospital and those providers designated as their responsibility. Report legal/ethical provider problems to the Resource Hospital.
4. Assure that the physicians and nurses are informed of any changes to the SOPs or Policies and Procedures within the system.
SYSTEM DEPARTMENT COORDINATORS
1. Review ambulance run reports for accuracy and deficiencies and follow up with individual prehospital providers as necessary.
2. Participate in periodic ambulance inspections.
3. Assures inventory of controlled substances (EMT-P only).
4. Maintains and assures proper equipment and supplies on the ambulances.
5. Assure proper staffing with qualified personnel at all times.
6. Monitor daily checklist.
7. Prepare written reports as required by IDPH and Loyola Emergency Medical Services System for QA purposes.
8. Deliver the original copies of all Data forms for the preceding month to the Loyola EMS office by the 15th of the following month.
9. Participate in system-wide quality improvement data collection projects as designated by the system.
PREHOSPITAL PROVIDERS
1. Thoroughly and accurately complete all documentation relating to a run immediately after the run is completed.
2. Leave two copies of the run form at the receiving hospital following a run. (One for the patient’s chart and one for the EMS office).
3. Assure completion of all Loyola Emergency Medical Services System requirements for continuing education.
4. Report any problems using the Request for Clarification supplied by the Resource Hospital or your Associate Hospital.
REPORTING OF DATA
4. Quality improvement measure of both adult and pediatric patient care should be performed on a quarterly basis and made available to the Department of Public Health upon request.
5. Quality improvement data and analysis shall be reported to the Loyola University Medical Center, Center for Clinical Effectiveness.
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