The purpose of a Quality Improvement (QI) program is to assist EMS Providers, Medical Control Hospitals, EMS Agencies and other system participants with a mechanism to evaluate the Emergency Medical System of a given area. The system-wide QI program of the Hudson Valley is designed to ensure continuous improvement in pre-hospital performance and quality patient care to the residents and visitors of the Hudson Valley Region.

A system-wide QI program incorporates methods of evaluation composed of structure, process, and outcome evaluations to focus on improvement efforts, interventions to decrease the causes, and steps to improve the overall process.

From Article 30 of the New York State Public Health Law:

Section 3006. Quality Improvement Program

•  1. By January first, nineteen hundred ninety-seven, every ambulance service and advanced life support first response service shall establish or participate in a quality
  improvement program, which shall be an ongoing system to monitor and
  evaluate the quality and appropriateness of the medical care provided by
  the ambulance service or advanced life support first response service,
  and which shall pursue opportunities to improve patient care and to
  resolve identified problems. The quality improvement program may be
  conducted independently or in collaboration with other services, with
  the appropriate regional council, with an EMS program agency, with a
  hospital, or with another appropriate organization approved by the
  department. Such program shall include a committee of at least five
  members, at least three of whom do not participate in the provision of
  care by the service. At least one member shall be a physician, and the
  others shall be nurses, or emergency medical technicians, or advanced
  emergency medical technicians, or other appropriately qualified allied
  health personnel. The quality improvement committee shall have the
  following responsibilities:

  (a) to review the care rendered by the service, as documented in
  prehospital care reports and other materials. The committee shall have
  the authority to use such information to review and to recommend to the
  governing body changes in administrative policies and procedures, as may
  be necessary, and shall notify the governing body of significant
  deficiencies;

  (b) to periodically review the credentials and performance of all
  persons providing emergency medical care on behalf of the service;

  (c) to periodically review information concerning compliance with
  standard of care procedures and protocols, grievances filed with the
  service by patients or their families, and the occurrence of incidents
  injurious or potentially injurious to patients. A quality improvement
  program shall also include participation in the department’s prehospital
  care reporting system and the provision of continuing education programs
  to address areas in which compliance with procedures and protocols is
  most deficient and to inform personnel of changes in procedures and
  protocols. Continuing education programs may be provided by the service
  itself or by other organizations; and

  (d) to present data to the regional medical advisory committee and to
  participate in system-wide evaluation.

  2. The information required to be collected and maintained, including
  information from the prehospital care reporting system which identifies
  an individual, shall be kept confidential and shall not be released
  except to the department or pursuant to section three thousand four-a of
  this article.

  3. Not withstanding any other provisions of law, none of the records,
  documentation, or committee actions or records required pursuant to this
  section shall be subject to disclosure under article six of the public
  officers law or article thirty-one of the civil practice law and rules,
  except as hereinafter provided or as provided in any other provision of
  law. No person in attendance at a meeting of any such committee shall be
  required to testify as to what transpired thereat. The prohibition
  related to disclosure of testimony shall not apply to the statements
  made by any person in attendance at such a meeting who is a party to an
  action or proceeding the subject of which was reviewed at the meeting.
  The prohibition of disclosure of information from the prehospital care
  reporting system shall not apply to information which does not identify
  a particular ambulance service or individual.

  4. Any person who in good faith and without malice provides
  information to further the purpose of this section or who, in good faith
  and without malice, participates on the quality improvement committee
  shall not be subject to any action for civil damages or other relief as
  a result of such activity.
  To ensure compliance with Article 30, and to assist in maintaining high standards of care, we would ask that your QA/QI Plan be updated on a regular basis, and if your plan is greater than five (5) years old, we will be asking for a new one!

To receive a copy of the Regional Quality Improvement Guidelines, please Click Here or call the Regional Office at (845) 245-4292

Please direct any questions regarding Regional Quality Improvement issues to the Hudson Valley Regional EMS Council Quality Improvement Coordinator atqaqi@hvremsco.org

For further information on Quality Improvement processes contact the following websites:

• A Leadership Guide to Quality Improvement for EMS Systems – www.nhtsa.dot.gov/people/injury/ems/leaderguide/index.html
•  Baldrige National Quality Program – www.quality.nist.gov
• National EMS-C Data Analysis Resource Center –  http://www.nedarc.org/nedarcCanHelp/whoIsNEDARC.html
• NYS DOH Quality Improvement for Prehospital Providers

“Quality Improvement is the organized creation of beneficial change; the attainment of unprecedented levels of performance…a breakthrough!”

– James N. Eastham Jr., ScD