Joint Commission International Accreditation Standards for Medical Transport Organizations

Transcription

1 Effective 1 July 2015 Joint Commission International Accreditation Standards for Medical Transport Organizations English 2nd Edition

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3 Contents General Eligibility Requirements... 1 Section II: International Patient Safety Goals... 3 International Patient Safety Goals (IPSG)... 5 Section III: Health Care Organization Management Standards Governance, Leadership, and Direction (GLD) Quality Improvement and Patient Safety (QPS) Exposure to and Transmission of Biologic and Chemical Agents (BCA) Facility Management and Safety (FMS) Staff Qualifications and Education (SQE) Management of Information (MOI) Section IV: Patient-Centered Standards Access to Care and Continuity of Care (ACC) Patient and Family Rights (PFR) Assessment of Patients (AOP) Care of Patients (COP)

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5 General Eligibility Requirements General criteria for eligibility for Joint Commission International accreditation are as follows: 1) The medical transport organization is located outside of the United States and its territories. 2) The medical transport organization is currently in operation as a transport organization and is licensed to operate by the appropriate authorities (if required) and is in compliance with relevant laws and regulations. 3) The medical transport organization assumes, or is willing to assume, responsibility for improving the quality of its care or services. 4) The medical transport organization provides services addressed by the standards in this 2nd Edition. 5) The medical transport organization agrees to meet the conditions described in the Accreditation Participation Requirements found in this manual. Additional requirements are the following: 6) The medical transport organization provides transportation to a) at-risk individuals with needs for medical rescue and/or monitoring, support and potential medical intervention during transportation; and/or to b) individuals who are not at-risk who require transportation from one care setting to another or between care settings and noncare settings such as the individuals residence. 7) The medical transport organization is either a public or private entity, and provides services under contract with a health care organization or public agency, on a fee-for-service basis, or a mixture of arrangements for obtaining and paying for the transport services.

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7 Section II: International Patient Safety Goals

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9 International Patient Safety Goals (IPSG) Changes to the IPSG Chapter Standard Change Explanation Note: This table lists changes to requirements in this chapter only. Requirements that were in this chapter in the 1st edition of this manual and are now contained either in their entirety or in part in another chapter of this 2nd edition are listed in that chapter s Changes table. The following standards appeared in this chapter of the 1st edition standards but were deleted from this edition (listed with 1st edition numbers): Goals, Standards, Intents, and Measurable Elements Goal 1: Identify Patients Correctly Standard IPSG.1 The transport organization develops and implements a process to improve accuracy of patient identifications. Intent of IPSG.1 The identification process used throughout the transport organization requires at least two ways in which to identify a patient, such as the patient s name, identification number, birth date, a bar-coded wristband, or other

10 ways. To ensure that the right individual is transported safely to the right destination, two different patient identifiers are required for any type of transport. For example, patients are identified before transporting from one health care organization to another, or from a health care organization to home or from home to a health care organization. When an individual is comatose or unable to communicate, the transport organization seeks others who can identify the individual to be transported. Measurable Elements of IPSG.1 1. Patients are identified using two patient identifiers prior to transport. 2. Patients are identified before discharge to a receiving individual or organization. 3. The patient identification process is carried out by the individual providing the transportation. Goal 2: Improve Effective Communication Standard IPSG.2 The transport organization develops and implements a process to improve the effectiveness of verbal and/or telephone communication. Standard IPSG.2.1 The transport organization develops and implements a process for handover communication. Intent of IPSG.2 and IPSG.2.1 Effective communication, which is timely, accurate, complete, unambiguous, and understood by the recipient, reduces errors and results in improved patient safety. Communication can be electronic, verbal, or written. Patient transport circumstances that can be critically impacted by poor communication include verbal or telephone patient transport orders, verbal or telephone communication of critical information such as the patient s clinical status, and handover communications at the beginning and end of transport. Handover communications can also be referred to as handoff communications. The most error-prone communications are transport orders given verbally and those given over the telephone, when permitted under local laws and regulations. Different accents, dialects, and pronunciations can make it difficult for the receiver to understand the order being given. For example, a transport driver may not verify the address or location of the individual requiring transport or understand the name and correct spelling of the individual to be transported.. In addition to accents and dialects, background noise, interruptions, and unfamiliar names and terminology often compound the problem. Once received, a verbal order must be transcribed as a written order. Verbal and telephone orders for transport are entered into a log, journal or electronic system for review and verification. Breakdowns in communication can occur during any handover of patients and patient care information. For example, if the driver did not receive the communication that the patient being transported from one organization to another was thought to have an infectious disease, the driver would not take appropriate precautions or properly clean the vehicle after transport. Standardized, critical content for communication between the driver and the sending or receiving organization, the patient, family, caregivers, and health care providers can significantly improve the outcomes related to handovers of patient care. 3 6 Measurable Elements of IPSG.2 1. The complete verbal transport order is documented and read back by the receiver and confirmed by the individual giving the order. 2. The complete telephone transport order is documented and read back by the receiver and confirmed by the individual giving the order. 3. The transport organization develops and implements a process to improve the effectiveness of verbal and/or telephone communication.

11 Measurable Elements of IPSG Standardized critical content is communicated between health care provider organizations and transport workers during handovers. 2. Standardized forms, tools, and methods support a consistent and complete handover process. 3. Data from handover communications are tracked and used to improve approaches to safe handover communication. Goal 3: Improve the Safety of High-Alert Medications Standard IPSG.3 The transport organization develops and implements a process to improve the safety of high-alert medications including concentrated electrolytes. Intent of IPSG.3 When medications are used during the patient transport process, appropriate management is critical to ensuring patient safety. Any medication, even those that can be purchased without a prescription, if used improperly can cause injury. However, high-alert medications cause harm more frequently, and the harm they produce is likely to be more serious when they are given in error. This can lead to increased patient suffering and potentially additional costs associated with caring for these patients. High-alert medications include medications that are involved in a high percentage of errors and/or sentinel events, such as insulin, heparin, or chemotherapeutics; and medications whose names, packaging and labeling, or clinical use, look alike and/or sound alike, such as Xanax and Zantac or hydralazine and hydroxyzine There are many medication names that sound or look like other medication names. Confusing names is a common cause of medication errors throughout the world. Contributing to this confusion are incomplete knowledge of drug names; newly available products; similar packaging or labeling; similar clinical use; similar strengths, dosage forms, and frequency of administration; and illegible prescriptions or misunderstanding during issuing of verbal orders. Lists of high-alert medications and look-alike/sound-alike medications are available from organizations such as the World Health Organization (WHO) and the Institute for Safe Medication Practices (ISMP), as well as in the literature. A frequently cited medication safety issue is the incorrect or unintentional administration of concentrated electrolytes (for example, potassium chloride [equal to or greater than 2 meq/ml concentration], potassium phosphate [equal to or greater than 3 mmol/ml concentration], sodium chloride [greater than 0.9% concentration], and magnesium sulfate [equal to or greater than 50% concentration]). Errors can occur when transport staff are not properly oriented to the transport vehicle when contract or new transport workers have not been properly oriented, or during emergency transport. The most effective means to reduce or to eliminate these occurrences is to develop a process for managing high-alert medications that includes removing them from vehicles when not required or proper secure storage on the vehicle. The transport organization that provides medical services and interventions during transport makes a list of all medications that pose a significant risk to patients. The list includes medications identified as high risk for

12 adverse outcomes as well as those at risk for look-alike/sound-alike confusion. Information from the literature and/or Ministry of Health may also be useful in helping to identify which medications should be included. 7 9 These medications are stored in a way that reduces the likelihood of inadvertent administration or ideally provides directions on the proper use of the medication. Strategies to improve the safety of high-alert medications may be tailored to the specific risk of each medication and should include consideration of prescribing, preparation, administration, and monitoring processes, in addition to safe storage strategies The transport organization also identifies any areas and/or vehicles where concentrated electrolytes may be clinically necessary depending on the need of transport patients. Measurable Elements of IPSG.3 1. The transport organization has a list of all high-alert medications, including look-alike/sound-alike medications and concentrated electrolytes that are available for use during transport. 2. The transport organization has a process that prevents inadvertent administration of concentrated electrolytes during transport. 3. The transport organization implements strategies to improve the safety of high-alert medications, which may include specific storage, prescribing, preparation, administration, or monitoring processes. 4. The location, labeling, and storage of high-alert medications, including look-alike/sound-alike medications, is uniform throughout the transport organization and vehicles used to meet the medical needs of transport patients. Goal 4: Ensure Correct-Site, Correct-Procedure, Correct- Patient Surgery Standard IPSG.4 Not applicable to medical transport organizations Goal 5: Reduce the Risk of Health Care Associated Infections Standard IPSG.5 The transport organization adopts and implements evidence-based hand-hygiene guidelines to reduce the risk of health care associated infections. Intent of IPSG.5 Infection prevention and control are challenging in most health care settings including transport organizations, and rising rates of health care associated infections are a major concern for patients, health care practitioners, and transport workers. For example, transport workers assist patients into and out of transport vehicles as well as handle wheelchairs, walkers and other assistive devices, all of which are potentially contaminated. Central to the elimination of these and other infections is proper hand hygiene. Internationally acceptable hand-hygiene guidelines are available from the World Health Organization (WHO), the United States Centers for Disease Control and Prevention (US CDC), and various other national and international organizations. The transport organization adopts and implements currently published evidence-based hand-hygiene guidelines. Hand-hygiene guidelines are posted in appropriate staff areas, and staff are educated in proper

13 hand-washing and hand-disinfection procedures. Soap, disinfectants, and towels or other means of drying are located in those areas where hand-washing and hand-disinfecting procedures are required. Measurable Elements of IPSG.5 1. The transport organization has adopted currently published, evidence-based hand-hygiene guidelines. 2. The transport organization implements an effective hand-hygiene program. 3. Hand-washing and hand-disinfection procedures are used in accordance with hand-hygiene guidelines throughout the transport organization. Goal 6: Reduce the Risk of Patient Harm Resulting from Falls Standard IPSG.6 The transport organization develops and implements a process to reduce the risk of patient harm resulting from falls. Intent of IPSG.6 Many injuries to patients are a result of falls. The risk for falls is related to the patient, the situation, and/or the location. Risks associated with patients might include patient history of falls, medications use, alcohol consumption, gait or balance disturbances, visual impairments, altered mental status, and the like. Patients who have been initially assessed to be at low risk for falls may suddenly become at high risk. Reasons include, but are not limited to, surgery and/or anesthesia, sudden changes in patient condition, and adjustment in medications. Patients transported from home to hospital or to home following discharge from the hospital may be at risk for falls. Thus, the transport organization uses a checklist or criteria to identify the types of patients who are considered at high risk for falls. An example of a situational risk is the patient who arrives at the outpatient department from a long term care facility via medical transport for a radiologic examination. The patient may be at risk for falls in that situation when transferring from transport vehicle cart to exam table, or when changing positions while lying on the narrow exam table. Specific locations may present higher fall risks because of the services provided. For example, a patient transported from home to a hospital physical therapy department may be at risk for falls from muscle fatigue from using specialized equipment such as parallel bars, freestanding staircases, and exercise equipment. In the context of the populations it serves, the type of transport services it provides, and its transport vehicles, the transport organization has a process and criteria to identify patients at risk for falls, and take action to reduce the risk of falling.. A fall reduction program may include the communication of known fall risk information prior to transport such as in a hospital discharge summary, or information from the patient s family when transporting patients from their home or a long-term care setting. The transport organization has a responsibility use criteria that identify the locations (such as the physical therapy department), situations (patient transfers from wheelchairs or carts, or the use of patient-lifting devices), and types of patients (such as patients with gait or balance disturbances, visual impairments, altered mental status, and the like) who may be at high risk for falls. The transport organization establishes a fall-risk reduction program based on appropriate staff training, support for patients at known risk, and use installation of hand rails, seat belts and other support aids in the air, land or water transport vehicles.

14 Measurable Elements of IPSG.6 1. The transport organization implements a process to identify all patients whose condition, diagnosis, situation, or location identifies them as at high risk for falls. 2. The transport organization trains staff to use criteria to identify patients at risk for falls. 3. Measures are implemented to reduce transport related fall risk for those identified patients, situations, and locations assessed to be at risk. Goal 7: Reduce the Risk of Vehicle-Related Accidents and Injuries Standard IPSG.7 The transport organization develops and implements policies and processes to reduce the risks of vehicle accidents and risks related to vehicle operation that can result in injuries. Intent of IPSG.7 Vehicle accidents can be the result of multiple factors from poorly maintained equipment to adverse driving conditions to operator fatigue. This is equally true for land, air and water transport. The prevention of accidents is a high priority for transport organizations to protect patients, operators and staff on the transport vehicle. Poor weather is a major contributor to accidents for land, water and air transport. It is important to be aware of weather risks with accurate and timely weather information and it is equally important for the transport vehicle operator to be guided by policies, procedures and training how to interpret the risks and take risk mitigation actions. Weather risks can vary widely from sand storms in arid regions to monsoons in tropical regions to volcano ash impeding vision to high rough seas. Transport vehicles need to be in safe operating condition in accordance with vehicle/vendor manufacturer recommendations, organization policy, and applicable country laws and regulations. In addition, good communication and information systems and alert operators are necessary to manage road, air, and water risks when they arise, with or without advance warning. Measurable Elements of IPSG.7 1. The transport organization is aware of the known and likely weather and other road, air and water risks to vehicle operation in their area of operation. 2. The transport organization trains operators on how to manage weather and other risk during vehicle operation and uses trained, rested operators when adverse conditions exist at the time of transport. 3. The transport organization ensures that vehicles are in safe operating condition to manage transport risks when they arise. 4. The transport organization maintains records on all vehicle accidents and uses to information to develop risk reduction strategies. References 1. Ong MS, Coiera E. A systematic review of failures in handoff communication during intrahospital transfers. Jt Comm J Qual Patient Saf Jun;37(6): Rabøl LI, et al. Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals. BMJ Qual Saf Mar;20(3): Craig R, et al. Strengthening handover communication in pediatric cardiac intensive care. Paediatr Anaesth Apr;22(4): Drachsler H, et al. The Handover Toolbox: A knowledge exchange and training platform for improving patient care. BMJ Qual Saf Dec;21 Suppl 1:i

15 5. Johnson M, Jefferies D, Nicholls D. Developing a minimum data set for electronic nursing handover. J Clin Nurs Feb;21(3 4): Segall N, et al. Can we make postoperative patient handovers safer? A systematic review of the literature. Anesth Analg Jul;115(1): Institute for Safe Medication Practices. Medication Safety Tools and Resources. Accessed Jun 20, Khoo AL, et al. A multicenter, multidisciplinary, highalert medication collaborative to improve patient safety: The Singapore experience. Jt Comm J Qual Patient Saf May;39(5): Shaw KN, et al.; Pediatric Emergency Care Applied Research Network. Reported medication events in a paediatric emergency research network: Sharing to improve patient safety. Emerg Med J. Epub 2012 Oct Ching JM, et al. Using lean to improve medication administration safety: In search of the perfect dose. Jt Comm J Qual Patient Saf May;39(5): Darker IT, et al. The influence of Tall Man lettering on errors of visual perception in the recognition of written drug names. Ergonomics Jan;54(1): Institute for Healthcare Improvement (IHI). How-to Guide: Prevent Harm from High-Alert Medications. Cambridge, MA: IHI, Accessed Jun 20, GuidePreventHarmfromHighAlertMedications.aspx. 13. Ostini R, et al. Quality use of medicines Medication safety issues in naming; look-alike, sound-alike medicine names. Int J Pharm Pract Dec;20(6): Agency for Healthcare Research and Quality. Patient Safety Primers: Medication Errors (Updated: Oct 2012.) Accessed Aug 14, primer.aspx?primerid Boushon B, et al. How-to Guide: Reducing Patient Injuries from Falls. Cambridge, MA: Institute for Healthcare Improvement, Accessed Jun 20, HowToGuideReducingPatientInjuriesfromFalls.aspx. 16. Dykes PC, et al. Fall prevention in acute care hospitals: A randomized trial. JAMA Nov 3;304(17): Francis DL, et al. Quality improvement project eliminates falls in recovery area of high volume endoscopy unit. BMJ Qual Saf Feb;20(2): Johnson M, George A, Tran DT. Analysis of falls incidents: Nurse and patient preventive behaviours. Int J Nurs Pract Feb;17(1): Miake-Lye IM, et al. Inpatient fall prevention programs as a patient safety strategy: A systematic review. Ann Intern Med Mar 5;158(5 Pt 2):

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17 Section III: Health Care Organization Management Standards

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19 Governance, Leadership, and Direction (GLD) Changes to the GLD Chapter Note: The chapter overview provides definitions for the levels of leadership referred to in the standards. Standard Change Explanation Note: This table lists changes to requirements in this chapter only. Requirements that were in this chapter in the 1st edition of this manual and are now contained either in their entirety or in part in another chapter of this 2nd edition are listed in that chapter s Changes table. The following standards appeared in this chapter of the 1st edition standards but were deleted from this edition (listed with 1st edition numbers): Overview Providing excellent medical transport services requires effective leadership. Leadership comes from many sources in an organization, including governing leaders, clinical leaders and managerial leaders, and others who hold positions of leadership, responsibility, accountability, and trust. These individuals must be identified and involved in ensuring that the organization is an effective, efficient resource for the community and its patients.

20 In particular, these leaders must define the organization s mission and make sure that it has the resources needed to fulfill its mission. For many organizations, this does not mean adding new resources but using current resources more efficiently, even when they are scarce. Also, leaders must work together well to coordinate and integrate all the transport organization s activities, including those land, water and air services when part of the mission. Effective leadership begins with understanding the roles, responsibilities, interaction, and authority- ty of individuals in the organization and how these individuals work together. Those who govern, manage, and lead an organization have both authority and responsibility. Collectively and individually, they are responsible for complying with law and regulation, and for meeting the organization s responsibility to the patient population served. Note: In all GLD standards, the term leaders is used to indicate that one or more individuals are accountable for the expectation(s) found in the standard. Leadership is used to indicate that a group of leaders is collectively accountable for the expectation(s) found in the standard. 1 3 Standards, Intents, and Measurable Elements Mission of the Organization Standard GLD.1 The medical transport organization defines its mission and makes it known to the community it serves. Intent of GLD.1 Defining the mission of an organization helps focus its resources and activities and makes it clear to the community which patients should seek services from the organization and what service the organization provides. A mission statement describes the a) goals of the organization, b) types of transport services provided, for example, emergency medical transport and/or nonemergency transport, c) catchment/service areas, and d) population served, including any designation of public/private payment. Measurable Elements of GLD.1 1. The organization has defined its mission. 2. The mission addresses elements a) through d) in the intent. 3. The mission statement is made known to the community. Governance/Ownership of the Organization Standard GLD.2 Governance/ownership structure is described in written documents, such as bylaws, policies and procedures, or articles of incorporation.

21 Standard GLD.2.1 Governance/ownership responsibilities and accountabilities are described in written documents. Intent of GLD.2 and GLD.2.1 There is an entity (for example, a ministry of health), an owner(s), or a group of identified individuals (for example, a board or governing body) responsible for overseeing the operation of the organization and accountable for providing quality services to its community. The responsibilities and accountabilities of governance are described in a document that identifies how they are to be assigned and carried out. The organization s governance and management structure is presented in an organizational chart or other document. Lines of authority and accountability are shown in this chart. The individuals represented on the chart are identified by title or name. Measurable Elements of GLD.2 1. The organization s current governance/ownership structure is described in written documents. 2. There is an organizational chart or document. 3. Those responsible are identified by title or name. 4. The documents are available to staff and the community. Measurable Elements of GLD Governance/ownership approves the organization s mission statement. 2. Governance/ownership approves the policies and plans to operate the organization. 3. Governance/ownership approves the budget and allocates the resources required to meet the organization s mission. 4. Governance/ownership appoints the organization s senior manager(s) or director(s). Standard GLD.2.2 Governance/ownership supports and promotes quality management and improvement efforts. Intent of GLD.2.2 The titles or location of the governance/ownership structure are not as important as are the responsibilities that must be carried out for the organization to have clear leadership, operate efficiently, and provide quality services. An area of high importance is the continuous involvement of governance/ownership in shaping and promoting the organization s quality program. This includes approving the quality plan and receiving regular reports on the achievements of the quality program. The identification of individuals in a single organizational chart does not ensure good communication and cooperation between those who govern and those who manage the organization. This is particularly true when the governance/ownership structure is separate from the organization, such as a distant owner or a national or regional health authority. Thus, those responsible for governance/ownership develop a process for communication and cooperation with the organization s managers and other leaders in carrying out the organization s mission and plans. Measurable Elements of GLD Governance/ownership approves the quality plan and supports quality management and improvement efforts within the organization. 2. Governance/ownership minutes document the review and any actions taken on quarterly reports on the quality and patients safety program including adverse and sentinel events.

22 3. Governance/ownership develops an effective, collaborative communication processes with management. 4. Governance/ownership and management at least annually evaluate the effectiveness of the communication processes. Standard GLD.2.3 The transport organization provides all services within business, financial, ethical, and legal norms that protect patients and their rights. Intent of GLD.2.3 The transport organization has ethical and legal responsibilities to the individuals and populations it serves. The leaders understand these responsibilities as they apply to the organization s business and clinical activities. The leaders create guiding documents, such as the organization s mission, to provide a consistent framework to carry out these responsibilities. The organization operates within this framework to honestly portray its services to the individuals and populations it serves; provide clear policies on the selection of receiving organizations for emergency transport patients; monitor the accuracy of bills; and to resolve conflicts such as those involving financial incentives and payment arrangements. Measurable Elements of GLD The transport organization s leaders establish a framework for the ethical management of the organization including the ethical and legal norms that protect patients and their rights. 2. The transport organization honestly portrays its services to the individuals and populations it serves. 3. The transport organization provides clear policies on the selection of receiving organizations for emergency transport patients. 4. The transport organization monitors the accuracy of bills. 5. The transport organization resolves conflicts such as those involving financial incentives, payment arrangements, and ethical conflicts. Standard GLD.2.4 There is full disclosure of the ownership of the transport organization. Intent of GLD.2.4 The transport organization makes available to the public documents describing the details of its ownership in full, including whether the organization is a unit of government, an independent organization, a subsidiary of another organization, or another legal organization; all business and other licenses held, and whether they are current; any contractual, business, or financial relationship with another transport organization, health care organization, or business or individual; and all names under which the organization operates or is commonly known by within its community. Measurable Elements of GLD The organization has a document explaining the details of its ownership and licensure including a) through d) in the intent. 2. The document is accessible to the public from the organization s web site or by other means.. 3. The document is kept current.

23 Organization Leadership Standard GLD.3 A senior manager or director is responsible for operating the organization and for complying with applicable laws and regulations. Intent of GLD.3 Effective leadership is essential for an organization to operate efficiently and fulfill its mission. Leadership is what individuals provide together and individually to the organization and can be carried out by any number of individuals. The senior manager or director is responsible for the overall, day-to-day operation of the organization. This includes the procurement and inventory of essential supplies, maintenance of any physical facility, maintenance of transport vehicles and transport equipment, financial management, quality management, and other responsibilities. The individual selected or appointed by the governing body/owner to carry out these functions has the education and experience to do so. This senior manager or director cooperates with the organization s leaders to define the organization s mission and plan the policies, procedures, and clinical and non-clinical services related to that mission. Once approved by the governing body, the senior manager or director is responsible for implementing all policies. The senior manager or director is responsible for the organization s; compliance with applicable law and regulation, response to any reports from inspecting and regulatory agencies, and processes to manage and control human, financial, and other resources. Measurable Elements of GLD.3 1. The senior manager or director manages the day-to-day operation of the organization including human, physical, financial and other resources and the carries out approved policies. 2. The senior manager or director has the education and experience to carry out his or her responsibilities. 3. The senior manager or director recommends policies to the governing body. 4. The senior manager or director ensures compliance with applicable laws and regulations and responds to any reports from inspecting and regulatory agencies. Standard GLD.4 Clinical leadership and/or supervision is consistent with the clinical needs of patients and the services provided by the transport organization. Intent of GLD.4 When the mission and services of the transport organization include the transport of emergency patients and those who require treatment and medical services during transport, there is a physician or other qualified individual who plans and monitors the provision of the medical services. The individual s role includes a) the development, implementation, and monitoring of clinical dispatch functions; b) the development, implementation, and monitoring of all patient care and transport protocols; c) the training/education and performance monitoring of employees that provide medical care; and d) the medical component of the organization s quality monitoring and improvement program

24 When the mission and services of the transport organization do not include the transport of emergency patients, there is an individual with clinical knowledge who participates in the planning and monitoring of the transport services. Important considerations include the resuscitation training of transport staff, infection control issues, and the criteria for determining the deterioration of a patient s condition for which urgent care is needed and how to access that care. This individual s role includes e) the development, implementation, and monitoring of the dispatch functions; f) the development, implementation, and monitoring of the transport functions; g) the training/education and performance monitoring of employees that provide the transport; and h) the transport component of the organizations quality monitoring and improvement program. To accomplish these responsibilities, the individual must have training and experience related to the types of transport services provided by the organization. When required by law or regulation, the individual is a qualified health care practitioner with training and experience related to the transport services provided. Measurable Elements of GLD.4 1. There is an appropriately licensed and trained individual who is accountable for the planning and monitoring of the clinical component of all transport activities of the organization consistent with the mission and services of the transport organization. 2. For emergency medical transport services there is a physician accountable for a) through d) in the intent, and for nonemergency transport services there is an individual accountable for e) through h) in the intent. 3. The individual has relevant clinical training and experience consistent with the mission and services of the transport organization. Standard GLD.5 The organization s medical and managerial leaders are identified and are collectively responsible for defining the organization s mission and creating the plans and policies needed to fulfill the mission. Intent of GLD.5 The leaders of an organization arise from many sources. The governing body/owner names the senior manager or director. The senior manager or director may name other leaders accountable for services provided by the transport organization, for example, a medical leader when emergency transport is provided. It is important that all leaders of an organization are recognized and brought into the process of defining the organization s mission. Based on that mission, the leaders work collaboratively to develop the plans and policies needed to fulfill the mission. When owners or agencies outside the organization set the mission and policy framework, the leaders work collaboratively to carry them out. Measurable Elements of GLD.5 1. The leaders of the organization are identified. 2. The leaders are collectively responsible for defining the organization s mission. 3. The leaders are collectively responsible for creating the policies and procedures necessary to carry out the mission. 4. The leaders work jointly to carry out the organization s mission and policies. Standard GLD.5.1 Organization leaders plan with community leaders and the leaders of other organizations to meet the community s emergency and medical transport system needs.

25 Intent of GLD.5.1 An organization s mission commonly reflects the needs of its community. The needs of communities usually change over time. Sudden changes, such as natural disasters and outbreaks of infectious diseases, and mass disasters will precipitate rapid change. The transport organization needs to plan to respond quickly and effectively to an emergency, disaster, or epidemic in the community (for example, floods, earthquakes, worker injuries from a factory explosion, flu outbreaks). The transport organization has an identified role in the disaster plan, such as the transport of patients from one hospital to another, or the transport and treatment of injured individuals or the transport of materials and supplies. The organization tests its identified role at least once a year to ensure readiness. Thus, it is important for the leaders of a health care organization to meet with, and plan with, recognized community leaders as well as the leaders of other transport and medical care provider organizations in the community. For example, relationships with nursing home associations, fire brigades, directors of hospital trauma units and others should be considered. Measurable Elements of GLD The organization plans its response to likely community emergencies, epidemics, and natural or other disasters. 2. The transport organization s leaders plan for meeting the community needs with community organizations and the leaders of other transport, social care and medical care provider organizations, including public safety agencies and government and private organizations in its community. 3. The organization tests its role in the disaster plan once a year and includes resources associated with disaster response. 4. At the conclusion of every test, a debriefing of the test is conducted and the results are communicated to participating staff. Standard GLD.6 The organization s clinical and/or nonclinical leaders implement measures to monitor and improve the transport program. Intent of GLD.6 One of the most important responsibilities of a leader, clinical or managerial, is to implement the organization s quality management and improvement program (see GLD.4, intent items d and h), in particular, the organization s monitoring and improvement priorities. Directors are responsible for ensuring that the monitoring activities provide the opportunity for the evaluation of staff as well as the processes of transport and any clinical care provided. The leaders of the transport organization develop a quality plan for the organization and seek approval of the annual plan by the governance/ownership of the organization. A primary responsibility of leaders is to set priorities. Organizations typically find more opportunities for quality monitoring and improvement than they have human and other resources to accomplish. Therefore, the leaders provide focus for the transport organization s quality monitoring and improvement activities. The leaders use available data and information to identify priority areas. Many improvements require technological and other support to carry out. The leaders understand this and make resources available for priority improvements. Measurable Elements of GLD.6 1. Leaders of the transport organization develop a written quality plan for the organization. 2. Leaders present the improvement priorities to governance/ownership on an annual basis for approval.

26 3. Leaders select and implement quality monitors that address the priority improvements identified for transport and clinical services provided by the organization. 4. Quality monitors include measures related to staff performance. 5. Leaders provide resources to carry out the improvement activities. Standard GLD.7 The transport organization s leaders provide management of contracts for services. Intent of GLD.7 Transport organizations have the option to either provide services directly or arrange for such services through referral, consultation, contractual arrangements, or other agreements. Such services may range from the lease of its transport vehicles, the employment of drivers or emergency medical technician from an agency, or possibly contracts with a hospital for medications or medical equipment, to the provision of financial accounting services. In all cases, there is leadership oversight for such contracts or other arrangements to ensure that the services meet patient needs and the organization s needs. All contracts are monitored as part of the organization s quality management and improvement activities and to identify contracts that should or should not be renewed. Measurable Elements of GLD.7 1. There is a process for leadership selection and monitoring of contracts. 2. Services provided under contracts and other arrangements meet patient needs. 3. Contracts and other arrangements are monitored as part of the organization s quality management and improvement program. Standard GLD.8 Leaders create and support a culture of safety program throughout the transport organization. Standard GLD.8.1 Leaders implement, monitor, and takes action to improve the program for a culture of safety throughout the transport organization. Intent of GLD.8 and GLD.8.1 A culture of safety has been defined as follows: "The safety culture is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, [a transport organization s] health and safety management. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures." 7 Safety and quality thrive in an environment that supports teamwork and respect for other people, regardless of their position in the organization. Leaders demonstrate their commitment to a culture of safety and set expectations for those who work in the organization. Behaviors that are not consistent with a safe culture or that intimidate others and affect morale or staff turnover can be harmful to patient care. Key features of a program for a culture of safety include acknowledgment of the risks of providing transport activities and the determination to achieve consistently safe operations; an environment in which individuals are able to report errors or near misses without fear of reprimand or punishment; encouragement of collaboration across ranks and disciplines to seek solutions to safety problems; and

27 organizational commitment of resources, such as staff time, education, a safe method for reporting issues, and the like, to address safety concerns. 2,8 16 Health care continues to have a culture of individual blame, which impairs the advancement of a safety culture. There are instances in which individuals should not be blamed for an error; for example, when there is poor communication between patient and staff, when there is a need for medical support during transport and nontransport is provided, or when roads are slick resulting in an accident. However, certain errors are the result of reckless behavior and do require accountability. Examples of reckless behavior include failure to follow hand-hygiene guidelines when transporting infectious patients, not slowing down when after being warned of hazardous driving conditions. A culture of safety includes identifying and addressing issues related to systems that lead to unsafe behaviors. At the same time, though, transport organizations must maintain accountability by establishing zero tolerance for reckless behavior. Accountability distinguishes between human error (such as a mix-up), at-risk behavior (for example, taking shortcuts), and reckless behavior (such as ignoring required safety steps). Leaders evaluate the culture on a regular basis using a variety of methods, such as formal surveys, focus groups, staff interviews, and data analysis. Leaders encourage teamwork and creates structures, processes, and programs that allow this positive culture to flourish. Leaders must address undesirable behaviors of individuals working at all levels of the organization, including management, clinical and management staff, and governing body members. Measurable Elements of GLD.8 1. Leaders establish and support an organizational culture that promotes accountability and transparency. 2. Leaders develop and document a code of conduct and identifies and corrects behaviors that are unacceptable. 3. Leaders provide education and information (such as literature and advisories) relevant to the organization s culture of safety to all individuals who work in the organization. 4. Leaders define how issues related to a culture of safety within the organization are identified and managed. 5. Leaders provide resources to promote and support the culture of safety within the organization. Measurable Elements of GLD Leaders provide a simple, accessible, and confidential system for reporting issues relevant to a culture of safety in the organization. 2. Leaders ensure that all reports are investigated in a timely manner. 3. Leaders use measures to evaluate and monitor and improve the safety culture within the organization. 4. Leaders implement a process to prevent retribution against individuals who report issues related to the culture of safety. References 1. Kovner AR, Fine DJ, D Aquila R. Evidence-Based Management in Healthcare. Chicago: Health Administration Press, The Joint Commission. From Front Office to Front Line: Essential Issues for Health Care Leaders, 2nd ed. Oak Brook, IL: Joint Commission Resources, National Collaborating Centre for Methods and Tools. Informed Decisions Toolbox: Tools for Knowledge Transfer and Performance Improvement. Randall T, et al (Updated: Sep 23, 2011.) Accessed Jun 24, view/eng/46.html. 4. IMPACT: International Medical Products Anti- Counterfeiting Taskforce. Facts, Activities, Documents: The Handbook. Rome: Agenzia Italiana del Farmaco, Accessed Jun 24, impact.pdf.4.

28 5. Gostin LO, Buckley GJ, Kelley PW. Stemming the global trade in falsified and substandard medicines. JAMA Apr 24;309(16): World Health Professions Alliance. WHPA Joint Statement on Counterfeiting of Medical Products. Mar Accessed Jun 24, en/20activities/30publichealth/50counterfeits/ WHPA_Joint_Statement_on_Counterfeiting.pdf. 7. Health and Safety Commission (HSE), Committee on the Safety of Nuclear Installations. Organising for Safety: Third Report of the ACSNI Study Group on Human Factors. Sudbury, England: HSE Books, Agency for Healthcare Research and Quality. International Use of the Surveys on Patient Safety Culture. Mar Accessed Jun 24, patientsafetyculture/pscintusers.htm. 9. Agency for Healthcare Research and Quality. Patient Safety Primers: Safety Culture. Sep (Updated: Oct 2012.) Accessed Jun 24, Agency for Healthcare Research and Quality. TeamSTEPPS : National Implantation: About TeamSTEPPS. Accessed Jun 24, El-Jardali F, et al. Predictors and outcomes of patient safety culture in hospitals. BMC Health Serv Res Feb 24;11: Sorra J, et al. Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report. Rockville, MD: Agency for Healthcare Research and Quality, Jan Accessed Jun 24, Thomas L, Galla C. Building a culture of safety through team training and engagement. BMJ Qual Saf May;22(5): Wagner C, et al. Assessing patient safety culture in hospitals across countries. Int J Qual Health Care Jul;25(3): Weaver SJ, et al. Promoting a culture of safety as a patient safety strategy: A systematic review. Ann Intern Med Mar 5;158(5 Pt 2): World Health Organization (WHO). Human Factors in Patient Safety: Review of Topics and Tools. Geneva: WHO, Apr Accessed Jun 24, methods_measures/human_factors/human_factors_ review.pdf.

29 Quality Improvement and Patient Safety (QPS) Changes to the QPS Chapter Standard Change Explanation Note: This table lists changes to requirements in this chapter only. Requirements that were in this chapter in the 1st edition of this manual and are now contained either in their entirety or in part in another chapter of this 2nd edition are listed in that chapter s Changes table. The following standard appeared in this chapter of the 1st edition standards but was deleted from this edition (listed with 1st edition numbers): Overview The overall program for quality and patient safety in the transport organization is approved by governance/ownership (see GLD.2.2), with the leaders deciding the structure and allocating the resources required to implement the program. Leaders also identify the transport organization s overall priorities for measurement and improvement (see GLD.6). The standards in this Quality Improvement and Patient Safety (QPS) chapter identify the necessary activities to support the data collection, data analysis, and quality improvement for the identified priorities. This includes the organization s response to sentinel events, adverse events, and near-miss events. The standards also describe the need for staff training and communication of quality and patient safety information. The standards do not identify an organizational structure, such as a department or unit, as this is up to each transport organization to determine who will lead the program and how it will be structured.

30 Standards, Intents, and Measurable Elements Note: In all QPS standards, leaders are individuals and leadership is the collective group. Accountabilities are described at the individual or collective level. (Also see the Governance, Leadership, and Direction [GLD] chapter for other related requirements.) Quality Program Organization Standard QPS.1 A qualified individual implements the transport organization s program for continuous improvement in quality and patient safety and manages the activities needed to carry out an effective program within the organization. Intent of QPS.1 The continuous improvement in quality and patient safety requires a well-implemented program. While governance approves the program and leadership provides resources to implement the program, it takes daily capable guidance and management to carry out the program and make continuous improvement part of the fabric of how the transport organization meets its mission and strategic priorities. A qualified individual(s) sees that the program is put into operation. This takes knowledge and experience in the many facets of data collection, data validation, and data analysis, and in implementing sustainable improvements. The individual(s) with oversight for the quality program also selects any quality program staff with those capabilities needed for the program. These individuals may be dedicated to the quality and patient safety program or may have other responsibilities within the transport organization. Training and communication are also essential. The quality program staff support data collection by assisting with data collection issues such as creating forms to collect data, identifying which data to collect, and how to validate data. The quality program staff are thus constantly involved in training and communicating quality and patient safety issues throughout the transport organization. Measurable Elements of QPS.1 1. An individual(s) who is experienced in the methods and processes of improvement is selected to implement the transport organization s quality and patient safety program. 2. The individual(s) with oversight for the quality program selects and supports qualified staff for the program. 3. The quality program implements a training program for all staff that is consistent with staff s roles in the quality improvement and patient safety program. 4. The quality program is responsible for the regular communication of quality issues to all staff. Data Collection for Quality Monitoring Standard QPS.2 The organization s leaders identify key measures (indicators) to monitor the organization s clinical and managerial structures, processes, and outcomes. Intent of QPS.2 Quality management and improvement are data driven. Because most organizations have limited resources, they cannot collect data to monitor everything they want. Thus, each organization must choose which

31 processes and outcomes are most important to monitor based on its mission, patient needs, and services. Monitoring often focuses on those processes that are high risk to patients, provided in high volume, or are problem prone. Note: For all transport organizations, the measures include relevant aspect of the following: a) The use of screening guidelines to understand and prioritize patient need and select the appropriate transport b) Availability, content and use of records and information related to the patient c) Procurement of routinely required supplies needed to provide transport d) Risk management e) Utilization management f) Staff expectations and satisfaction g) Patient demographics and diagnoses h) Financial management i) Transport request call waiting times j) Response times actual against standards k) Vehicle reliability and critical failures l) Vehicle accidents m) Staff injuries n) High risk patients o) Patient complaints and resolutions For transport organizations that provide emergency medical services the measures also include relevant aspects of the following as appropriate to the services provided: p) Patient assessment q) Any invasive procedures r) Use of medications and medication errors s) Use of narcotics, sedatives, and paralytics t) Use of blood and blood products u) Infection, biologic, hazardous material control v) Management of pain An organization s leaders are responsible for making the final selection of the priority measures to be included in the organization s monitoring activities (see GLD.6). The measures selected relate to the important areas identified above in this intent statement.. For each of these areas, leaders decide the process, procedure, or outcome to be measured; how measurement will be accomplished; and the frequency of measurement. Identifying the process, procedure, or outcome to be measured is clearly the most important step. The measure needs to focus on, for example, risk points in processes, procedures that frequently present problems or are performed in high volume, and outcomes that can be clearly defined and are under the control of the organization. Frequency of data collection is associated with how often the particular process is used or procedure performed. Sufficient data from all cases or a sample of cases are needed to support conclusions and recommendations. New measures are selected when a current measure no longer provides data useful for the analysis of the process, procedure, or outcome. A primary purpose of monitoring is to prevent errors, such as intubation or medication errors. Also, monitoring helps reduce risks, such as vehicle breakdowns and accidents. Data collected from monitoring are critical to designing, creating, and maintaining a safe environment for patients, staff, and bystanders. When errors or adverse events occur, the organization and its leaders evaluate the processes that led to the error or event. This evaluation is based on the collection of data on the targeted area.

32 Faulty processes are redesigned, tested, and monitored to ensure that the same or similar errors or events do not occur again. To monitor processes, the organization needs to determine how to organize the monitoring activities, how often to collect data, and how to incorporate data collection into daily work processes. Measurable Elements of QPS.2 1. Monitoring includes measures related to structures, processes, and/or outcomes. 2. The scope, method, and frequency are identified for each measure. 3. For all organizations, monitoring includes the areas identified as a) through o) in the intent statement. 4. For those organizations providing emergency medical transport services, areas p) through v) in the intent statement are also monitored. Analysis of Monitoring Data Standard QPS.3 Individuals with appropriate experience, knowledge, and skills systematically aggregate and analyze data in the organization. Intent of QPS.3 To reach conclusions and make decisions, data must be aggregated, analyzed, and transformed into useful information. Data analysis involves individuals who understand information management, have skills in data aggregation methods, and know how to use various statistical tools. Data analysis involves the individuals responsible for the process or outcome being measured. These individuals may be clinical, managerial, or a combination of both. Thus, data analysis provides continuous feedback of quality management information to help those individuals make decisions and continuously improve processes. The organization determines how often data are aggregated and analyzed. The frequency depends on the activity or area being measured, the frequency of measurement, and the organization s priorities. Thus, aggregation of data at points in time enables the organization to judge a particular process s stability or a particular outcome s predictability in relation to expectations. Measurable Elements of QPS.3 1. Data are aggregated, analyzed, and transformed into useful information. 2. Individuals with appropriate clinical or managerial experience, knowledge, and skills participate in the process. 3. The frequency of data analysis is appropriate to the process being studied and meets organization requirements. Standard QPS.3.1 Data are intensively assessed when significant unexpected events and undesirable trends and variation occur. Intent of QPS.3.1 When an organization detects or suspects undesirable change from what is expected, it initiates intense analysis to determine where best to focus improvement. In particular, intense analysis is initiated when levels, patterns, or trends vary significantly and undesirably from what was expected;

33 that of other organizations; or recognized standards. For organizations that provide emergency transport services, certain events always result in intense analysis to understand the cause and prevent recurrence. When appropriate to the transport organization s services, these events include significant adverse drug reactions; significant medication errors; significant airway management failures; significant untoward sedation events; For all transport organizations the events to be analyzed include organization-operated vehicle accidents resulting in injury or death to staff or public; medical equipment failures resulting in patient injury or death; communication failures (lost calls) resulting in patient injury or death; and patient deaths within 24 hours after a response that resulted in nontransport. Each organization identifies significant events and the process for their intense analysis. When undesirable events can be prevented, the organization redesigns processes to prevent the event from reoccurring. Measurable Elements of QPS Intense analysis of data takes place when significant adverse levels, patterns, or trends occur. 2. The organization identifies significant events and establishes the process for intense analysis of these events. 3. Significant events are analyzed when they occur. 4. The events listed in the intent, when appropriate to the transport organization s services, are analyzed when they occur. Standard QPS.3.2 The transport organization uses a defined process for identifying and managing sentinel events. Intent of QPS.3.2 A sentinel event is an unanticipated occurrence involving death or serious physical or psychological injury. Serious physical injury specifically includes loss of limb or function. Such events are called sentinel because they signal the need for immediate investigation and response. Each transport organization establishes an operational definition of a sentinel event that includes at least a) an unanticipated death, including, but not limited to, o death that is unrelated to the natural course of the patient s illness or underlying condition such as unanticipated death during transport o suicide during transport; o staff or citizen death as the result of vehicle accident. b) rape, violence such as assault (leading to death or permanent loss of function); or homicide (willful killing) of a patient, staff member, practitioner, or other individual during transport. The transport organization s definition of a sentinel event includes a) and b) above and may include other events as required by laws or regulations or viewed by the organization as appropriate to add to its list of sentinel events. All events that meet the definition of sentinel event must be assessed by performing a credible root cause analysis. Accurate details of the event are essential to a credible root cause analysis, thus the root cause analysis needs to be performed as soon after the event as possible. The analysis and action plan is completed within 45 days of the event or becoming aware of the event. The goal of performing a root cause

34 analysis is for the organization to better understand the origins of the event. When the root cause analysis reveals that systems improvements or other actions can prevent or reduce the risk of such sentinel events recurring, the transport organization redesigns the processes and takes whatever other actions are appropriate to do so. It is important to note that the terms sentinel event and medical error are not synonymous. Not all errors result in a sentinel event, nor does a sentinel event occur only as a result of an error. Identifying an incident as a sentinel event is not an indicator of legal liability. Measurable Elements of QPS The leaders of the transport organization establish a definition of a sentinel event that at least includes a) and b) found in the intent. 2. The transport organization completes a root-cause analysis of all sentinel events in a time period specified by the organization s leaders that does not exceed 45 days from the date of the event or when made aware of the event. 3. The transport organization s leaders takes action on the results of the root cause analysis. Standard QPS.3.3 The transport organization uses an internal process to validate data. Intent of QPS.3.3 A quality improvement program is only as valid as the data that are collected. If data are flawed, quality improvement efforts will be ineffective. The reliability and validity of measurements are thus at the core of all improvements. To ensure that good, useful data have been collected, an internal data validation process needs to be in place. Data validation is most important when a) a new measure is implemented; b) data will be made public on the organization s website or in other ways; c) a change has been made to an existing measure, such as the data collection tools have changed or the data abstraction process or abstractor has changed; d) the data resulting from an existing measure have changed in an unexplainable way; or e) the data source has changed, such as when part of the patient record has been turned into an electronic format and thus the data source is now both electronic and paper. Data validation is an important tool for understanding the quality of the data and for establishing the level of confidence decision makers can have in the data. Data validation becomes one of the steps in the process of setting priorities for measurement, selecting what is to be measured, extracting or collecting the data, analyzing the data, and using the findings for improvement. When a transport organization publishes data on quality of services, patient safety, or other areas, or in other ways makes data public, such as on the organization s website, the organization has an ethical obligation to provide the public with accurate information. Leaders are accountable for ensuring that the data are valid. Reliability and validity of measurement and quality of data can be established through an internal data validation process or, alternatively, can be judged by an independent third party. Measurable Elements of QPS Data validation is used by the quality program as a component of the improvement process selected by leadership. 2. Data are validated when any of the conditions noted in a) through e) in the intent are met. 3. An established methodology for data validation is used. 4. Leaders of the transport organization assume accountability for the validity of the quality and outcome data made public.

35 Quality Improvement Standard QPS.4 Improvement in quality and safety is achieved and sustained. Intent of QPS.4 The information from data analysis is used to identify potential improvements or to reduce (or prevent) adverse events. Routine measurement data, as well as data from intensive assessments, contribute to this understanding of where improvement should be planned and what priority should be given to the improvement. In particular, improvements are planned for the priority data collection areas identified by the transport organization. After an improvement(s) is planned, data are collected during a test period to demonstrate that the planned change was actually an improvement. To ensure that the improvement is sustained, measurement data are then collected for ongoing analysis. Effective changes are incorporated into standard operating procedure, and any necessary staff education is carried out. The transport organization documents those improvements achieved and sustained as part of its quality management and improvement program. Measurable Elements of QPS.4 1. Improvements in quality and patient safety are planned, tested, and implemented. 2. Data are available to demonstrate that improvements are effective and sustained. 3. Policy changes necessary to plan, to carry out, and to sustain the improvement are made. 4. Successful improvements are documented. Standard QPS.5 An ongoing program of risk management is used to identify and to proactively reduce unanticipated adverse events and other safety risks to patients and staff. Intent of QPS.5 Transport organizations need to adopt a proactive approach to risk management. One such way is a formalized risk management program whose essential components include a) risk identification; b) risk prioritization; c) risk reporting; d) risk management; e) investigation of adverse events; and f) management of related claims. An important element of risk management is risk analysis, such as a process to evaluate near misses and other high-risk processes for which a failure would result in a sentinel event. One tool that provides such a proactive analysis of the consequences of an event that could occur in a critical, high-risk process is failure mode and effects analysis. The transport organization can also identify and use similar tools to identify and to reduce risks, such as a hazard vulnerability analysis. To use this or similar tools effectively, the organization s leaders need to adopt and to learn the approach, to agree on a list of high-risk processes in terms of patient and staff safety, and then to use the tool on a priority risk process. Following analysis of the results, the organization s leaders take action to redesign the process or

36 similar actions to reduce the risk in the process. This risk-reduction process is carried out at least once per year and documented. Measurable Elements of QPS.5 1. The transport organization s risk management framework includes a) through f) in the intent. 2. At least annually, a proactive risk-reduction exercise is conducted on one of the priority risk processes. 3. High-risk processes are redesigned based on the analysis of the test results. References 1. Leonard M, et al., editors. The Essential Guide for Patient Safety Officers, 2nd ed. Oak Brook, IL: Joint Commission Resources, Pilz S, et al. [Quality Manager 2.0 in hospitals: A practical guidance for executive managers, medical directors, senior consultants, nurse managers and practicing quality managers.] Z Evid Fortbild Qual Gesundhwes. 2013;107(2): German. 3. Schilling, L., et al. Kaiser Permanente's Performance Improvement System, Part 1: From Benchmarking to Executing on Strategic Priorities. Jt Comm J Qual Patient Saf Nov;36(11): Schilling L, editor. Implementing and Sustaining Improvement in Health Care. Oak Brook, IL: Joint Commission Resources, Shabot, M, et al. Memorial Hermann: High Reliability from Board to Bedside. Jt Comm J Qual Patient Saf, 2013 Jun, 39(6), The Joint Commission. Tools for Performance Measurement in Health Care: A Quick Reference Guide, 2nd ed. Oak Brook, IL: Joint Commission Resources, Nolan KM, Schall MW, editors. Spreading Improvement Across Your Health Care Organization. Oak Brook, IL: Joint Commission Resources, Vannan E. Quality data An improbable dream? Educause Quarterly Jan 1;(1): Bronnert J, et al. Data quality management model (updated). J AHIMA Jul;83(7): Kahn MG et al. A pragmatic framework for single-site and multisite data quality assessment in electronic health record-based clinical research. Med Care Jul;50 Suppl:S Oh JY, et al. Statewide validation of hospital-reported central line associated bloodstream infections: Oregon, Infect Control Hosp Epidemiol May;33(5): The Joint Commission. Benchmarking in Health Care, 2nd ed. Oak Brook, IL: Joint Commission Resources, 2007.

37 Exposure to and Transmission of Biologic and Chemical Agents (BCA) Changes to the BCA Chapter Standard Change Explanation BCA.1 BCA.2 BCA.3 BCA.3.1 BCA.3.2 BCA.4 BCA.5 BCA.5.1 BCA.6 Note: This table lists changes to requirements in this chapter only. Requirements that were in this chapter in the 1st edition of this manual and are now contained either in their entirety or in part in another chapter of this 2nd edition are listed in that chapter s Changes table. The following standard appeared in this chapter of the 1st edition standards but was deleted from this edition (listed with 1st edition numbers): Overview The goal of a transport organization is to prevent or limit the exposure of patients and staff to biologic and/or chemical agents and prevent the transmission of such agents. The organization develops a proactive program to reduce the risks of acquiring and transmitting harmful or infectious agents between the community and the transport organization, within the organization and its vehicles, and between the organization and receiving organizations. The core issues are the same for organizations that primarily provide transport to those organizations that transport sick or emergency patients. Because frequently the infectious status of a patient is not known, consistent precautions and measures must be taken for all patients being transported. For example, a patient being transported home from a transplant unit with a suppressed immune system should not be concerned that a tuberculosis (TB) patient may have been transported to the pulmonary clinic in the same vehicle that morning.

38 The actual program implemented may differ from organization to organization, depending on the organization s geographic location, transport volume, population served, type of clinical activities provided by the receiving or sending organization, and the number of employees of the transport organization. Certain infections present in the community such as TB, hepatitis, and HIV/AIDS pose a particular risk as the status of individual patients being transported may not be known. In addition, in disaster or multi-victim situations other contagions and/or contaminants may be evident. The risk of exposure to chemical and biologic agents varies depending on the types of research, manufacturing, and other industry as well as the threat of terrorist activities, protests, and riots. Effective programs have in common identified leaders, appropriate policies and procedures, staff education, and coordination throughout the transport organization. Effective programs also consider the safety and health of its staff first as they may be the leadership needed to respond to events, exposures, and disasters in the community. Standards, Intents, and Measurable Elements Direction, Coordination, and Focus of the Program Standard BCA.1 One or more qualified individuals provide leadership and direction for all infection prevention and control activities. Intent of BCA.1 The goal of the transport organization s infection prevention and control program is to identify and to reduce the risks of acquiring and transmitting infections among patients, staff, health care professional, contract workers, volunteers, students and family members. The risks and program activities may vary among transport services based on the services provided, patient populations served, geographic location, patient volume and number/types of employees. Thus, the direction and leadership must consider many factors which may influence the risks for all. The acceptable qualifications of the individual providing oversight will be matched to the complexity of the organization s infection control program. Education, training, experience and even certification in infection control need to match the program s complexity and level of risks. Measurable Elements of BCA.1 1. One or more individuals provide leadership and direction for the infection prevention and control program 2. The individual(s) is qualified for the organization s size, complexity of activities, and level of risks, as well as the program s scope. 3. The individual(s) fulfills program responsibilities as assigned or described in a job description.

39 Standard BCA.2 There is a designated coordination mechanism for all infection prevention and control activities that involves physicians, nurses, paramedics, EMTs and others as appropriate to the services provided by the transport organization. Intent of BCA.2 Infection control issues in a transport organization extend to the facility from which vehicles are dispatched, the land, air or water transport vehicles themselves, the staff driving or flying the vehicle and providing services to the patient on the vehicle and to the receiving organization or individual such as a family member in the patient s home. This takes coordination and involvement of all participants. For example, the transport of an infectious disease patient requires precautions and cleaning so that an immunocompromised patient transported next will be safe. Experts in infection control need to advise the transport organization and provide a review of the organization s program. Measurable Elements of BCA.2 1. There is a designated mechanism for the coordination of the infection prevention and control program among all parties and organizations involved. 2. Coordination of an infection prevention and control activities involves physicians, nurses, paramedics, EMTs, and others based on the size, type and complexity of the transport services provided. 3. Infection prevention and control experts advise and review the transport organization s program. 4. All patient, staff, vehicles, and other areas of the organization are included in the infection control program. Standard BCA.3 The organization describes in a plan, policy or procedure the focus of the infection prevention and risk reduction program. Intent of BCA.3 Each transport organization, in coordination with local health departments, must establish those epidemiologically important infections, infection sites, and associated devices that will provide the focus of efforts to prevent and reduce the incidence of infections. For emergency medical transport organizations the infections, sites and equipment will be different than other types of transport services. While different, infection risks are present in all types of transport services. The transport organization has a written document that describes the infection prevention and risk reduction program appropriate for the organization. Organizations consider, as appropriate to the services provided, infections that involve the a) respiratory tract such as the procedures and equipment associated with intubation, mechanical ventilatory support, tracheostomy, and so on; b) intravascular invasive devices such as the insertion and care of central venous catheters, peripheral venous lines, and so on; c) wounds such as their care and type of dressing and associated aseptic procedures; and d) communicable diseases such as influenza, tuberculosis, and hepatitis. Measurable Elements of BCA.3 1. The organization has established the focus of the program to prevent or reduce the incidence of infections. 2. The focus includes a) through d) as appropriate to the transport organization.

40 3. There is a written document that describes the organizations infection prevention and risk reduction program. 4. All transport organizations are aware of the communicable diseases present within the community and patient population served. Standard BCA.3.1 The infection prevention and control program is based on current scientific knowledge, accepted practice guidelines, applicable laws and regulations, and standards for sanitation and cleanliness. Intent of BCA.3.1 Information is essential to an infection prevention and risk reduction program. Current scientific information is required to understand and to implement effective surveillance and control activities and can come from many national or international sources; for example, the United States Centers for Disease Control and Prevention (US CDC), the World Health Organization (WHO), regional public health protection agencies, and other similar organizations can be a significant source of evidence-based practices and guidelines. In addition, publications and professional organizations address standards related to environmental sanitation and cleanliness in transport vehicles. Practice guidelines provide information on preventive practices and infections associated with clinical and support services. Applicable laws and regulations define elements of the basic program, the response to infectious disease outbreaks, and any reporting requirements. Measurable Elements of BCA The infection prevention and risk reduction program is based on current scientific knowledge, and accepted practice guidelines and standards from national or local agencies for sanitation and cleanliness. 2. The program is in compliance with local laws and regulations. 3. Infection prevention and risk reduction program data are reported to public health agencies as required. 4. The organization takes appropriate action on reports from relevant public health agencies. Standard BCA.3.2 The transport organization identifies the policies and processes associated with the risk of infection and implements strategies to reduce infection risk. Intent of BCA.3.2 Transport organizations face different infection risk depending on the type of patient transported, or in the case of emergency medical transport, the risks depend on the assessment and care of patients using many simple and complex processes are provided, each associated with a level of infection risk to patients and staff. It is thus important for an organization to review those processes and, as appropriate, implement needed policies, procedures, education, and other activities to reduce the risk of infection. For an emergency medical transport organization, the infection risk-reduction activities include, as appropriate to the patients transported, a) cleaning and sterilization, in particular, invasive equipment; b) laundry and linen management; c) disposal of infectious waste and body fluids; d) the handling and disposal of blood and blood components; e) disposal of sharps and needles; and f) the management of hemorrhagic patients.

41 Measurable Elements of BCA The organization has identified those processes associated with infection risk and implemented procedures to reduce infection risk in those processes. 2. For emergency medical transport organizations, a) through f) are considered when appropriate to the services provided. 3. All transport organizations have clear procedures for vehicle cleaning and disinfection that are followed. Standard BCA.4 Gloves, masks, protective clothing, soap, and disinfectants are available and used correctly when required. Intent of BCA.4 Hand hygiene, barrier techniques, and disinfecting agents are fundamental to infection prevention and control. The organization identifies those situations in which the use of masks and gloves is required and provides training in their correct use. Soap and disinfectants are located in those areas where hand washing and disinfecting procedures are required. Staff are educated in proper hand washing and disinfecting procedures. Measurable Elements of BCA.4 1. The organization identifies those situations for which gloves, masks and/or other barrier precautions are required. 2. Gloves, masks, and/or other barrier precautions are correctly used in those situations. 3. Surface disinfection procedures are implemented for areas and situations identified as at risk for infection transmission. 4. Soap, disinfectants, and towels or other means of drying are located in areas where hand-washing and hand disinfection procedures are required. Exposure to Hazardous Materials, Biologic, and Chemical Agents Note: the standards in this section only apply to those organizations that provide emergency medical transport services. Standard BCA.5 The organization has a BCA program that includes a written plan for the inventory, handling, storage, and use of stocked hazardous materials and the control and disposal of self-generated hazardous materials and waste. Intent of BCA.5 Hazardous materials and wastes are identified by the organization and safely controlled according to a written plan. Such materials and wastes include chemicals, medical gases, vehicle fuel, hazardous gases and vapors, and other regulated medical and infectious wastes. The plan provides processes for a) handling, storage, and use of hazardous materials; b) the inventory of hazardous materials and wastes; c) reporting and investigation of spills, exposures, and other incidents; d) proper disposal of hazardous wastes; e) proper protective equipment and procedures during use, spill, or exposure;

42 f) documentation, including any permits, licenses, or other regulatory requirements; and g) proper labeling of hazardous materials and wastes. Information is essential to a BCA control program. Current scientific information is required to understand and implement effective surveillance and control activities; practice guidelines provide information on preventive practices and infections associated with clinical services; and applicable laws and regulations define elements of the basic program and reporting requirements. For an organization to have an effective BCA control program, it must educate staff members about the program when they begin work in the organization and regularly thereafter. The education program includes professional staff, clinical and nonclinical support staff, and even patients and families, if appropriate. The education focuses on the procedures and practices that guide the organization s BCA control program. The education also includes the findings and trends from the monitoring activities. Measurable Elements of BCA.5 1. The emergency medical transport organization has implemented a BCA program that includes a written plan for the inventory, handling, storage, and use of stocked hazardous materials and the control and disposal of self-generated hazardous materials and waste. 2. The BCA control program is based on current scientific knowledge, accepted practice guidelines, and applicable law and regulation. 3. Hazardous materials and wastes are managed according to a plan that includes a) through g) found in the intent statement. 4. The organization provides education on BCA control practices to staff, patients, and, as appropriate, family and other caregivers. Standard BCA.5.1 One or more qualified individual provides direction to the program and coordination of all infection and BCA control activities. Intent of BCA.5.1 The BCA control program has direction and coordination appropriate to the size of the organization and scope of the program. One or more individuals, acting on a full-time or part-time basis, provide that oversight. Their qualifications depend on the activities they will carry out and may be met through education; training; experience; and certification or licensure. Measurable Elements of BCA One or more individuals oversee the infection and BCA control program. 2. The individual(s) are qualified for the scope and complexity of the program. 3. The individual(s) fulfills program oversight responsibilities as assigned or described in a job description. Standard BCA.6 The organization develops and implements a plan for response and mitigation of hazardous materials incidents.

43 Intent of BCA.6 Mitigation of specialized incidents involving hazardous materials requires a carefully delineated plan that describes roles, responsibilities, and processes to ensure appropriate utilization of resources and effective interagency communications. The plan should include, at a minimum, the following: a) Protocols for identification of potential and actual hazardous materials incidents; b) Defined roles and responsibilities for managing communications, triage, medical response, treatment, transport, and the hazardous substance(s); c) Protocols for identifying the hazardous substance(s); d) Criteria for responding to and containing the incident such as potential of harm, designated spill site, initial isolation zone, protective action zone, topography, weather, wind conditions, available resources, staging areas, command distance, communications, decontamination, and evacuation; e) Protocols for identifying, isolating, and initiating early treatment of contaminated victims; and f) Roles and responsibilities of other local and regional agencies that are involved in the hazardous materials response in order to ensure coordinated response. The highest priority in any potential hazardous materials incident is to ensure the safety of the rescuer and responding personnel. The organization implements the following work practices: 1) Personnel assigned hazardous materials duty are identified; 2) Responding personnel are trained to manage the level of exposure risk in which they practice; 3) Responding personnel functioning in contaminated areas have appropriate protective equipment; and 4) Responding personnel can operate or appropriately use the equipment to minimize their exposure potential. Rescuers involved in the mitigation of a hazardous materials incident are at increased risk of injury and medical complications resulting from the situational stresses of the rescue environment. In addition, rescuers may become ill or prostrated from using the required specialized equipment that protects them. The organization develops guidelines for monitoring of personnel in these circumstances to ensure their continued ability to perform safely; and protocols for treatment of ill or injured hazardous materials personnel. Staff understand and implement processes for hazardous materials incidents. Measurable Elements for BCA.6 1. The organization has a plan for responding to and mitigating hazardous materials incidents that includes a) through f) in the intent statement. 2. The plan protects rescue staff and minimizes their exposure to hazardous materials including 1) through 4) in the intent statement. 3. Rescue personnel are monitored during a hazardous materials incident. 4. Staff understand and implement processes for hazardous materials incidents.

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45 Facility Management and Safety (FMS) Changes to the FMS Chapter Standard Change Explanation Note: This table lists changes to requirements in this chapter only. Requirements that were in this chapter in the 1st edition of this manual and are now contained either in their entirety or in part in another chapter of this 2nd edition are listed in that chapter s Changes table. The following standards appeared in this chapter of the 1st edition standards but were deleted from this edition (listed with 1st edition numbers): Overview Not all transport organizations will have a physical environment with workers and drivers ready to be dispatched. Some transport organizations will only have a garage or other site for holding and servicing the vehicles. In fact, the servicing may be managed at an independent location under a contract. These transport organizations may only have a seating area for patients and families waiting for transport or an area for drivers to rest between transports.

46 Other transport organizations that provide emergency transport will have dispatch centers, worker rest and sleeping areas, training areas, equipment and supply storage areas, and areas to clean, disinfect and restock vehicles. Such emergency transport organizations may have one or several buildings within their service areas. These standards apply to both types of transport organizations however with different expectations for compliance depending on their physical environments. Finally, transport vehicles when used in these and other standards includes land, air and water vehicles depending on the services provided by the transport organization. Thus, the standards in this chapter may apply to a garage holding land ambulances to hangers at airport holding rescue planes and helicopters and to docking areas for rescue boats. All transport organizations work to provide safe, functional, and supportive work sites, equipment and transport vehicles. All transport vehicles are consistently maintained to insure reliability and safety. In particular, management must strive to identify and reduce hazards and risks to both staff and the public; prevent accidents and injuries; and maintain safe environments and working conditions. Effective management includes review, planning, education, implementation, and monitoring. It also involves the following: The leaders plan the space, equipment, and resources needed to safely and effectively support the services provided. All staff are educated about the organization s environments and vehicles, how to reduce risks, and how to monitor, report, and, if appropriate, resolve situations that pose risk. Performance criteria are used to measure and monitor important systems and identify needed changes/improvements. Planning should consider the following seven areas, when appropriate to the organization s physical environments, vehicles, and scope of services provided by the transport organization: 1) Safety Buildings, grounds, equipment, and systems do not pose hazards. 2) Vehicle maintenance Vehicle safety and the safe operation of vehicles. 3) Security Property and occupants (employees, visitors, patients, and families) are protected from harm and loss. 4) Hazardous materials Handling, storage, and use of any hazardous materials or waste. 5) Safety Property and occupants are safe and protected from fire and smoke. 6) Medical equipment Equipment is selected, maintained, and used in a manner to reduce risks. 7) Utility systems Electrical, water, and communication systems are safely maintained to minimize the risks of operating failures. Laws, regulations, and inspections by local authorities determine in large part how a physical environment is designed, used, and maintained. All organizations, regardless of size and resources, must comply with these requirements. Standards, Intents, and Measurable Elements Planning and Direction Standard FMS.1 The transport organization complies with relevant laws, regulations, vehicle, equipment, and physical environment inspection requirements.

47 Intent of FMS.1 The first consideration for any transport organization is to understand what laws, regulations and other requirements apply to any physical environment, equipment, and transport vehicles owned or operated by the organization. There should be special attention paid to any sleeping areas, cooking areas, and bathrooms, when present, because these areas, along with any equipment in them, are shared by all staff, and possibly patients, and need to be clean and sanitized. The organization s leaders, including governance and senior management, are responsible for knowing what national and local laws, regulations, and other requirements apply to the organization s physical environment and vehicles; implementing the applicable requirements or approved alternative requirements; and planning and budgeting for the necessary upgrading or replacement as identified by monitoring data or to meet applicable requirements, and then to show progress toward meeting the plans. planning and budgeting for upgrading or replacement of essential systems, equipment, buildings or components. When the organization has been cited for not meeting requirements, the leaders take responsibility for planning for and meeting the requirement in the prescribed time frame. Measurable Elements of FMS.1 1. The organization s leaders know what laws, regulations, and other requirements apply to the organization s physical environment, equipment, and vehicles. 2. The leaders implement the applicable requirements or approved alternatives. 3. The leaders ensure that the organization meets the conditions of physical environment inspection reports, periodic equipment review, vehicle maintenance records, and/or citations. 4. The organization plans and budgets for the upgrading or replacing of systems, vehicles, buildings, or components needed for the continued safe and effective operations. Standard FMS.2 The transport organization plans and implements a program to manage its physical environment that includes inspection and risk reduction. Intent of FMS.2 Prevention and planning are essential to creating a safe physical environment. To plan effectively, the organization must be aware of all risks. The goal is to prevent accidents and injuries, promote and maintain a safe and secure working condition and environment, and reduce and control hazards and risks. This can be done by comprehensively inspecting the physical environment, noting everything from sharp and broken furniture that could injure to locations where there is no escape from fire. This periodic inspection is documented and helps the organization plan and carry out improvements and budget for longer-term upgrading or replacement. By understanding the risks present in the organization s physical environment, the organization can develop a proactive plan to reduce those risks for patients, families, staff, and visitors. This plan includes safety, security, and hazardous materials. Measurable Elements of FMS.2 1. The organization has a program to prevent injury and maintain a safe operating and work environment for staff, patients, families and others.

48 2. The program includes safety, security, and hazardous materials. 3. The organization has a documented, current, and accurate inspection of its physical environments. 4. The organization has a plan to reduce evident risks based on the inspection. Standard FMS.3 The transport organization plans and implements an inspection and maintenance program to identify and reduce evident risks and provide safe transport vehicles. Intent of FMS.3 Prevention and planning are essential to creating a fleet of safe transport vehicles. To plan effectively, the organization must be aware of all the risks present. The goal is to prevent accidents and injuries, maintain safe and secure conditions, and reduce and control hazards and risks to staff, patients, and bystanders. This can be done by comprehensively inspecting and maintaining all vehicles and associated equipment, noting everything from workability and cleanliness to functionality and the manufacturer s recommended service and maintenance anything that could compromise patient health, well being or care if the vehicles were to not function appropriately. This periodic inspection is documented and helps the organization plan and carry out improvements and budget for longer-term vehicle need and replacement. Also included are safe operating practices and training. Measurable Elements of FMS.3 1. The organization has a program to manage its vehicle fleet that includes regular maintenance and a documented, current, accurate inspection of each transport vehicle. 2. Manufacturers recommendations for service and preventive maintenance are performed and other identified risks are reduced based on the inspection of each vehicle. 3. All vehicles are clean and in working order when in use. 4. The program includes the tracking of vehicle failures and staff and patient injuries. Standard FMS.4 The transport organization plans, tests and implements a program to ensure that all occupants are safe from fire, smoke, or other emergencies in any physical environments owned or used by the organization. Intent of FMS.4 Fire is an ever-present risk where staff work and live, where patients may wait for transport, where vehicles are stored and where hazardous materials are stored. Thus, every organization needs to plan how it will keep its occupants safe in case of fire, fumes (an example is gasoline/diesel vapors or carbon monoxide such as in a fleet shop with poor ventilation systems next to crew living quarters), smoke, or other facility emergencies. The organization s fire safety program includes a) prevention of fires through the reduction of risks, such as safe storage and handling of potentially flammable materials; b) safe and unobstructed means of exit in the event of fire or fumes; c) early warning or detection systems such as fire patrols, smoke detectors, or fire alarms; d) suppression mechanisms such as water hoses, chemical suppressants, or sprinkler systems e) inspection, testing, and maintenance of fire protection and safety systems, consistent with requirements; f) a process for testing (at least twice per year) the plan for safely evacuating the building or physical space in the event of fire or smoke; g) necessary education of staff to effectively protect and evacuate patients when an emergency occurs; and

49 h) participation of staff members in at least one emergency preparedness test per year. These actions, when combined, give staff, patients and any visitors adequate time to safely exit the facility in the event of fire or smoke. These actions are effective no matter what the age, size, or construction of the building. For example, a small, one-level brick building will use different methods than a large, multilevel wooden structure. This applies to all the environments used by the transport organization whether owned, leased, or simply occupied. As a component of the comprehensive program, the organization develops and implements a policy regarding smoking that applies to all patients, families, staff, and visitors; and eliminates smoking in the organization s physical environments and transport vehicles. All inspections, testing, and maintenance are documented. Measurable Elements of FMS.4 1. The organization s fire safety program includes a) through h) in the intent. 2. All inspections, testing, and maintenance are documented. 3. The organization has implemented a policy to eliminate smoking in the organization s physical environments and transport vehicles that applies to all staff, patients, and visitors. Medical Equipment, Communication, and Utility Systems Standard FMS.5 The transport organization plans, implements and monitors a program for purchasing, inspecting, testing, and maintaining equipment. Intent of FMS.5 Decisions for purchasing equipment and supplies should be based on recommendations from government agencies, national or international professional organizations, or other authoritative sources. A transport organization that provides primarily transport of patients and families between health care facilities, from home to hospital and home again, etc. needs to ensure that equipment used in transport is inspected, tested and maintained. This would include any assistive devices to help patients enter and leave a transport vehicle, or brace them during transport, or lock down a wheel chair during transport, for example. Emergency medical transport organizations keep equipment in stock and on the vehicle, such as durable medical equipment, communication equipment, point of care testing supplies, and so on. For all transport organizations, to ensure that all equipment is available for use, employees are trained on the equipment s use, and equipment is functioning properly, the organization plans and conducts a) an inventory of equipment; b) regularly inspections of equipment; c) tests and documents employee training on the equipment; d) tests equipment as appropriate to its use and requirements; and e) conducts preventive maintenance. Qualified individuals provide these services. Equipment is inspected and tested when new and then on an ongoing basis, as appropriate to the age and use of the equipment or based on manufacturer s instructions. Inspections, testing results, and any maintenance are documented. This helps ensure the continuity of the maintenance process and helps when doing capital planning for replacements, upgrades, and other changes.

50 Measurable Elements of FMS.5 1. The organization uses the recommendations of professional organizations and other authoritative sources in making resource decisions. 2. Equipment is planned and managed throughout the organization including a) through e) in the intent. 3. Qualified individuals provide these services. 4. Monitoring data are collected and documented for the equipment management program. 5. Monitoring data are used for planning and improvement. Standard FMS.6 Electrical power is available 24 hours a day, seven days a week, through regular or alternate sources, to meet essential communication, dispatch and operational needs. Intent of FMS.6 All transport organizations need dependable power to recharge communication devices, to recharge equipment, recharge electric assisted transport vehicles, and provide emergency lighting in any patient waiting areas. For emergency medical transport organizations, communication and dispatch services are provided on a 24- hour basis, every day of the week. Thus, an uninterrupted source of electrical power is essential. Regular and alternate sources are identified and alternate sources periodically tested. Measurable Elements of FMS.6 1. Electrical power is available 24 hours a day, seven days a week. 2. Alternative power sources are identified. 3. Alternative sources of power are tested and results documented at least twice a year or more frequently if required by laws and regulations, manufacturer s recommendations, or condition of the source of emergency power. 4. When emergency sources of power require a fuel source, the organization establishes and has available, the necessary amount of on-site fuel. Staff Education Standard FMS.7 The transport organization educates and trains all staff members about their roles in providing a safe working environment, including all physical environments, equipment, and transport vehicles. Intent of FMS.7 The staff of the transport organization need to be educated and trained to carry out their roles in identifying and reducing risks, protecting others and themselves, and creating a clean, safe and secure physical environment and vehicles. For example, drivers need to be educated on the correct use of seat belts and restraints and on conditions that would warrant the violation of existing traffic laws. The program for training and education includes: a) staff member roles in the organization s plans for fire safety, security, and emergencies; b) the operation and maintenance of communication equipment; and

51 c) preventive vehicle maintenance and safe vehicle operation. Each organization must decide the type and level of training for staff and then carry out and document a program for this training and education. The program can include group instruction, printed educational materials, a component of new staff orientation, or some other mechanism that meets the organization s needs. The program includes instruction on the processes for reporting potential risks, reporting incidents and injuries, and handling hazardous and other materials that pose risk to themselves and others. Staff responsible for operating or maintaining communications and medical equipment receive special training. Similarly, staff that operate or maintain transport vehicles receive training on driving, flying or boating standards, safe emergency and nonemergency ambulance operations, use of safety restraints in vehicles, responsibilities when accidents occur, and vehicle cleanliness. The training can be from the organization, the manufacturer of the vehicle or equipment, some other knowledgeable source, or any combination thereof. The organization has an organized program designed to periodically test staff knowledge on emergency procedures, including fire safety procedures; the response to hazards such as the spill of a hazardous material; and the use of medical equipment that pose risks to patients and staff. Knowledge can be tested through a variety of means such as individual or group demonstrations, the staging of mock events such as an epidemic in the community, the use of written or computer tests, or other means suitable to the knowledge being tested. The organization documents who was tested, the results of the testing, recommendations learned as a result of the testing, and mitigation of potential problems. Measurable Elements of FMS.7 1. There is planned staff education that includes at least a) through c) in the intent to ensure that staff members can effectively carry out their responsibilities. 2. Staff knowledge is tested at least annually regarding their role in providing a safe working environment. 3. Staff training and testing are documented as to who was trained and tested and the results. Reference 1. Prüss A, Giroult E, Rushbrook P, editors. Safe Management of Wastes from Health-Care Activities. Geneva: World Health Organization, Accessed Jun 24, medicalwaste/wastemanag/en/index.html.

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53 Staff Qualifications and Education (SQE) Changes to the SQE Chapter Standard Change Explanation Note: This table lists changes to requirements in this chapter only. Requirements that were in this chapter in the 1st edition of this manual and are now contained either in their entirety or in part in another chapter of this 2nd edition are listed in that chapter s Changes table. The following standards appeared in this chapter of the 1st edition standards but were deleted from this edition (listed with 1st edition numbers): Overview A transport organization needs an appropriate variety of skilled, qualified people to fulfill its mission and meet patient needs. The type and mix of staff will vary by the mission of the transport organization and the services provided. For emergency transport organizations the identification of needed staff is the dual responsibility of clinical and management leaders. Recruiting, evaluating, and maintaining staff are best accomplished through a coordinated, efficient, and uniform process. It is also essential to document skills, knowledge, education, and work experience. It is particularly important to carefully review the credentials of medical and nursing staff because they are involved in clinical care processes and work directly with patients. Similarly, for all transport organizations, and especially for those that provide primarily transport services, the qualifications, driving record and driving skill are important staff recruitment and selection criteria.

54 All transport organizations need an ongoing program to evaluate staff and provide experiences and training that will continually improve skills, knowledge, and behaviors and provide staff with opportunities to learn and advance personally and professionally. Thus, in-service education and other learning opportunities should be offered to staff, with content based upon needs identified through the quality management process. Standards, Intents, and Measurable Elements Planning Standard SQE.1 Transport organization leaders define the desired education, skills, knowledge, and other requirements to plan the number of staff needed and develop a job description for each staff member. Intent of SQE.1 The organization s leaders define the particular requirements of staff positions, and identify the number of each type of staff position needed to deliver the services that meet the organizations mission.. They define the desired education, skills, knowledge, and any other requirements as part of human resource planning. Leaders include the following factors in projecting staffing needs: a) The organization s mission for example; emergency medical transport or other transport services. b) The mix of patients served by the organization and the complexity and severity of their needs for example, all those transported are considered patients however will have varying levels of needs that must be monitored or treated during transport of all types. c) The services provided by the organization for example, interfacility transport, the transport of children or the disabled, the transport of frail or morbidly obese individuals that need special considerations. d) The technology used in patient care for example, special lifts, gurneys, medical gases, defibrillators. Individual staff members have their responsibilities defined in a job description that is kept current. The job description is the basis for their assignment, orientation to their work, and evaluation of how well they fulfill job responsibilities. The organization complies with laws and regulations that define desired education levels, skills, or other requirements of individual staff members or that define staffing numbers or mix of staff for the organization. For example, all drivers of transport vehicles may be required to have a special driving permit, or laws and regulation may limit what drugs can be carried and administered during emergency transport. The organization also complies with laws that guide the termination of staff. Measurable Elements of SQE.1 1. The organization includes at least a) through d) in the intent when planning staffing levels and requirements. 2. The desired education, skills, and knowledge are defined for staff members. 3. Applicable laws and regulations are incorporated into the planning. 4. Staff positions have a job description that is kept current. Standard SQE.2 There is a current staffing plan for the transport organization, that is developed by the appropriate clinical and managerial leaders, and that identifies the number, types, and desired qualifications of staff.

55 Intent of SQE.2 Appropriate and adequate staffing is critical to all transport organizations. Staff planning is carried out by the organization s managerial leaders, and also clinical leaders for emergency medical transport organizations. The planning process uses recognized methods for determining levels of staffing. The type and number of staff comply with any applicable laws and regulations. The plan is written and identifies the number and types of required staff and the skills, knowledge, and other requirements needed in each department and service. The plan addresses the reassignment of staff from one type of transport to another in response to service demands or staff shortages; the consideration of staff requests for reassignment based on cultural values or religious beliefs; and the policy and procedure for transferring responsibility from one individual to another (for example, between a first responder, paramedic, nurse, and/or physician) when the responsibility would fall outside such an individual s normal responsibility area. Planned and actual staffing is monitored on an ongoing basis, and the plan is updated as necessary by the appropriate managerial and clinical leaders. Measurable Elements of SQE.2 1. There is a written plan for staffing the organization developed by the managerial and clinical leaders based on the mission and services provided. 2. The number, types, and desired qualifications of staff are identified in the plan using a recognized staffing method that meets laws and regulations. 3. The plan addresses the assignment and reassignment of staff. 4. The plan addresses the transfer of responsibility from one individual to another. 5. The effectiveness of the staffing plan is monitored and revised and updated when necessary. Standard SQE.3 Transport organization leaders develop and implement processes for recruiting, evaluating, appointing, and terminating staff as well as other procedures identified by the organization. Intent of SQE.3 The organization provides an efficient, coordinated, or centralized process for recruiting individuals for available positions; evaluating the training, skills, and knowledge of candidates; appointing individuals to the organization s staff; and terminating staff. If the process is not centralized, similar criteria, processes, and forms result in a uniform process across the organization. There is medical and nursing or other clinical participation in recommending the number and qualifications of staff needed to provide clinical services to patients during emergency transport, and in making staffing decisions. Measurable Elements of SQE.3 1. There is a process in place to recruit and evaluate prospective staff. 2. There is a process in place to appoint, evaluate, and terminate staff. 3. The process is uniform across the transport organization.

56 Standard SQE.4 The transport organization uses a defined process to ensure that staff knowledge and skills are consistent with the organization s mission. Standard SQE.4.1 There is documented personnel information for each staff member. Intent of SQE.4 through SQE.4.1 Qualified staff members are hired by the organization through a process that matches the requirements of the position with the qualifications of the prospective staff member. When hired, the new staff member is further evaluated to ensure that he or she can actually assume those responsibilities found in the job description. This evaluation is carried out before or when first starting to perform work responsibilities. This evaluation of necessary skills and knowledge and of desired work behaviors is carried out by the department or service to which the staff member is assigned. The organization defines the process for and the frequency of the ongoing evaluation of staff abilities. Ongoing evaluation ensures that training occurs when needed and that the staff member is able to assume new or changed responsibilities. While such evaluation is best carried out in an ongoing manner, there is at least one documented evaluation each year for each staff member. Each staff member in the organization has a record with information about his or her qualifications, results of evaluations, and work history. These records are standardized and kept current. Measurable Elements of SQE.4 1. The organization uses a defined process to match staff knowledge and skills with the mission of the organization. 2. New staff members are evaluated at the time they begin their work responsibilities. 3. The frequency of ongoing staff evaluation is defined by the organization. 4. There is at least one documented evaluation of staff each year or more frequently as defined by the organization. Measurable Elements of SQE There is a current, standardized personnel file for each staff member. 2. Personnel files contain the qualifications of the staff members. 3. Personnel files contain the results of evaluations. 4. Personnel files contain the work history of the staff member. 5. Personnel files contain a record of in-service education attended by the staff member. Orientation and Education Standard SQE.5 All staff members are oriented to the transport organization and to their specific job responsibilities upon appointment to the staff.

57 Intent of SQE.5 The decision to appoint an individual to the staff of an organization sets several processes in motion. To perform well, a new staff member needs to understand the entire organization and how his or her specific responsibilities contribute to the organization s mission. This is accomplished through a general orientation to the organization and his or her role in the organization, and a specific orientation to the job responsibilities of his or her position, for example, in emergency medical transport organizations dispatch center staff are oriented and trained in policies and procedures, in standards and guidelines used to triage and handle calls, and in the use of equipment in the dispatch center. The orientation includes, as appropriate to the mission and services provided, documentation requirements, error reporting, clinical and management protocols, disaster response, and so forth. Contract workers and volunteers are similarly oriented to the organization. Measurable Elements of SQE.5 1. New staff are oriented to the mission and services of the organization, their individual job responsibilities, and their specific assignments. 2. All transport organization staff (including contract staff and volunteers) have an orientation to infection control practices, the quality reporting process and patient safety. 3. Contract workers and volunteers are oriented to the organization, job responsibilities, and their specific assignments. Standard SQE.6 Each staff member receives ongoing in-service and other education and training to maintain or advance his or her skills and knowledge. Intent of SQE.6 To maintain acceptable staff performance, teach new skills, and provide training on new equipment and procedures, the organization provides or arranges for facilities, educators, and time for ongoing in-service and other education. This education is relevant to each staff member as well as to the continuing advancement of the organization in meeting patient needs. For example, staff may receive education on safety, infection control, advances in medical practice, or new technology. Each staff member s educational achievements are documented in his or her personnel record. To the extent possible, continuing education should be needs based and reflect improvement activities identified in quality management activities. Measurable Elements of SQE.6 1. Organization staff are provided ongoing in-service education and training. 2. Facilities, educators, and time are provided or arranged to support staff education and training. 3. The education is relevant to each staff member s ability to meet the organization s mission. Standard SQE.6.1 Transport organization staff members who provide patient care and other staff identified by the organization are trained in basic or advanced cardiac, pediatric, and trauma life support, as appropriate for their job description and can demonstrate appropriate competence in resuscitative techniques.

58 Intent of SQE.6.1 Each organization identifies those staff to be trained in life support techniques, and the level of training (basic or advanced) appropriate to their role in the organization. The appropriate level of training is repeated on the requirements and/or a time frame as identified by a recognized training program, or every two years if a recognized training program is not used. There is evidence to show if each staff member attending the training actually achieved the desired competency level. Measurable Elements of SQE Staff members to be trained in life support techniques are identified. 2. The appropriate level of training is provided with sufficient frequency to meet staff needs. 3. The desired level of training for each individual is repeated based on the requirements and/or time frames established by a recognized training program or every two years if a recognized training program is not used. 4. There is evidence to show if a staff member passed the training. Staff Credentials Standard SQE.7 The transport organization has an effective process to gather, verify, and evaluate the staff s credentials and maintain a current file on all staff members. Standard SQE.7.1 The transport organization has an effective process to identify job responsibilities and make work assignments based on the staff member s credentials and any regulatory requirements. Standard SQE.7.2 The transport organization has an effective process for staff participation in the organization s quality improvement activities, including evaluating individual performance when indicated. Intent of SQE.7 through SQE.7.2 The organization needs to ensure that it has a qualified staff that matches its mission, resources, and patient needs appropriately. The staff is responsible for carrying out triaging and dispatching activities, driving vehicles, and providing direct patient care, all of which contribute to the overall patient outcomes. The organization must ensure that staff are qualified and must specify the types of duties they are permitted to provide. To ensure this match, the organization evaluates each staff member s credentials upon appointment to the staff. An individual s credentials consist of an appropriate current professional license, completion of education, any additional training and experience, driver s/pilot s license, and driving/flying record when applicable. The organization develops a process to gather this information, verify its accuracy from the original source if possible, and evaluate the information in relation to the needs of the organization and its patients. This process can be carried out by the organization or by an external agency. The process applies to employed and contract staff members and to volunteers. For example, the emergency medical transport organization verifies current professional licenses, certifications, education, and training of staff who treat patients. For staff who operate vehicles, the emergency medical transport organization verifies current driver s/pilot s license and driving/flying records. Assignments made by the organization are consistent with any applicable laws and regulations.

59 Staff with a clinical role are required to actively participate in the organization s clinical quality improvement program. If, at any point during clinical quality monitoring, evaluation, and improvement, a staff member s performance is in question, the organization has a process to evaluate (and limit, if necessary) that individual s responsibilities. Measurable Elements of SQE.7 1. The organization has a process in place to gather the credentials of each staff member. 2. Licensure, education, training, and experience are documented. 3. Licensure, education, and training are verified from the original source when possible. 4. There is a record maintained on every staff member that contains copies of any required license, certification, registration, or driving record. Measurable Elements of SQE The licensure, education, training, and experience of a staff member are used to make work assignments. 2. The process takes into account relevant laws and regulations. 3. The process supports staffing plans. Measurable Elements of SQE Staff members participate in the organization s quality improvement activities. 2. The performance of individual staff members is reviewed when indicated by the findings of quality improvement activities. 3. Appropriate information from the review process is documented in the staff s credentials or other file. Standard SQE.8 The transport organization has a process to ensure that staff /individuals who are neither employees nor contractors of the organization, but accompany a patient during a transfer, and provide services to the patient, have valid credentials. Intent of SQE.8 The transport organization may be called to a hospital to transport a critically ill patient and who is accompanied by a physician and nurses from the hospital. These hospital staff may bring equipment and medications from the hospital. The medical transport organization must have a process to verify that the critically ill patient is being cared for by qualified individuals. Measurable Elements of SQE.8 1. The transport of critically ill patients is within the scope of services of the organization. 2. The transport organization has a process to ensure that staff accompanying a critically ill patient are appropriate and qualified. 3. The transport organization understands the accountability for the quality and safety of the care provided during transport. References 1. Fiore AE, et al.; US Centers for Disease Control and Prevention.. Prevention and control of influenza:

60 Recommendations of the Advisory Committee on Immunization Practices (ACIP), MMWR Recomm Rep Aug 8;57(RR-7): Advisory Committee on Immunization Practices; US Centers for Disease Control and Prevention. Immunization of health-care personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep Nov 25;60(RR-7): Lin CJ, Nowalk MP, Zimmerman RK. Estimated costs associated with improving influenza vaccination for health care personnel in a multihospital health system. Jt Comm J Qual Patient Saf Feb:38(2): Joint Commission Resources. Gearing up for flu season: Encouraging vaccination for staff. Joint Commission: The Source Nov;9(11):6 7, Perlin JB, et al. Developing a program to increase seasonal influenza vaccination of healthcare workers: Lessons from a system of community hospitals. J Healthc Qual. Epub 2013 Mar Chen KP, Ku YC, Yang HF. Violence in the nursing workplace A descriptive correlational study in a public hospital. J Clin Nurs Mar;22(5 6): The Joint Commission. Preventing Violence in the Health Care Setting. Sentinel Event Alert No. 45. Jun 3, Accessed Jun 24, sea_45.pdf. 8. Kaplan B; Pişkin R, Ayar B. Violence against health care workers. Medical Journal of Islamic World Academy of Sciences. 2013;21(1): Wu S, et al. A study on workplace violence and its effect on quality of life among medical professionals in China. Archives of Environmental & Occupational Health Feb 28. Accessed Jun 24, #.Ua3qXUDVA1J. 10. ECRI Institute. Violence in healthcare facilities. Healthcare Risk Control Mar;2:1 17. Accessed Jun 24, RM/HRC_TOC/SafSec3.pdf.

61 Management of Information (MOI) Changes to the MOI Chapter Standard Change Explanation * The Management of Information (MOI) chapter in this edition was named Management of Communication and Information (MCI) chapter in the 1st edition standards. Note: This table lists changes to requirements in this chapter only. Requirements that were in this chapter in the 1st edition of this manual and are now contained either in their entirety or in part in another chapter of this 2nd edition are listed in that chapter s Changes table. The following standards appeared in this chapter of the 1st edition standards but were deleted from this edition (listed with 1st edition numbers): Overview Transport organizations seeks to obtain, manage, and use information to improve individual patient transport processes and overall transport organization performance. In addition, medical transport organizations rely on information about the science of care, and information on the needs and care of individual patients being transported. Like all resources, information is a resource that must be managed effectively by the organization s leaders. Over time, with the appropriate management of information, organizations become more effective in identifying information needs; designing an information management system;

62 defining and capturing data and information; analyzing data and transforming it into information; maintaining the confidentiality and security of information; transmitting and reporting data and information; and integrating and using information. The principles of good information management apply to all methods, whether paper based or electronic. These standards are designed to be equally compatible with noncomputerized systems and future technologies. Standards, Intents, and Measurable Elements Planning Standard MOI.1 The transport organization plans and implements processes to meet information needs. Intent of MOI.1 For information and data to be available and useful for the clinical and/or management functions of a transport organization it must be planned. The resulting plan incorporates input from a variety of sources, including a) the process of dispatching emergency and nonemergency vehicles, planes, among others; b) the process of meeting patient medical and non-medical needs during transport; c) the needs of the organization s managers and leaders; d) those outside the organization who need or require data or information about the organization s operation and care processes; and e) the process of maintenance for the organization s air, land, and water vehicles. The priority information needs of these sources influence the organization s information management strategies and ability to implement those strategies. The strategies are appropriate for the organization s size, complexity of services, availability of trained staff, and other human and technical resources. The plan is comprehensive and includes all the units or divisions of the organization. Information management technology represents a major investment of resources for a health care organization. For this reason, technology is carefully matched to the organization s current and future needs and its resources. Available technology needs to be integrated with existing information management processes and helps integrate the activities of all the organization s units or divisions. This level of coordination requires that key clinical and managerial leaders participate in the selection process. Measurable Elements of MOI.1 1. The transport organization has a documented information management plan that is based at least on information sources a) through d) in the intent. 2. The information management plan is based on the mission, services, size and complexity of the transport organization. 3. The information management plan identifies implementation strategies. 4. The plan is implemented and supported by sufficient staff and other resources.

63 Standard MOI.1.1 The information plan includes how the confidentiality, security, and integrity of data and information will be maintained. Intent of MOI.1.1 The transport organization maintains the security and confidentiality of data and information and is especially careful about preserving the confidentiality of sensitive data and information. The balance between data sharing and data confidentiality is addressed. The organization determines the level of security and confidentiality maintained for different categories of information. Access to each category of information is based on need and defined by job title and function. An effective process defines who has access to information; the information to which an individual has access; the user s obligation to keep information confidential; and the process followed when confidentiality and security are violated. One aspect of maintaining security in emergency medical transport organizations relates to patient information. Patient information contained in a clinical record or on rosters or logs is considered confidential and protected from loss or misuse. The organization determines who is authorized to obtain a patient clinical record and make entries into the record. The organization develops a policy to authorize such individuals and identifies the content and format for entries into patient clinical records. There is a process to ensure that only authorized individuals make entries in a clinical record and that each entry identifies the author of the entry and the date. If required by the organization, the time of the entry is also noted (such as for timed treatments or medication orders). Measurable Elements of MOI The plan includes how the confidentiality, security and integrity of patient clinical records and other data and information will be maintained 2. The plan identifies the levels of security for each category of data and information and who has access to that level. 3. Those authorized to make entries in the record of a transported patient are identified in organization policy. 4. The format and location and content of entries are determined by organization policy. Standard MOI.1.2 The transport organization has a policy on the retention time of records, data, and information. Intent of MOI.1.2 The organization develops and implements a policy that guides the retention of records including those of dispatch, patient care and treatment, and other data and information. Data and information are retained for sufficient periods to comply with laws and regulations and to support patient care, management, legal documentation, research, and education. The retention policy is consistent with the confidentiality and security of such information. When the retention period is complete, data, and information are destroyed appropriately.

64 Measurable Elements of MOI The organization has a policy on the retention of data and information related to dispatch patient care and treatment, and other data and information. 2. The retention process provides expected confidentiality and security. 3. Records, data, and information are retained according to policy or laws and regulations. 4. Records, data, and information are destroyed appropriately. Standard MOI.1.3 The transport organization uses standardized abbreviations, codes, symbols, and definitions. Intent of MOI.1.3 Standardizing terminology, definitions, vocabulary, and nomenclature facilitates comparison of data and information within and among organizations. For emergency medical transport organizations this also includes the use of diagnosis and procedure codes. Standardization supports data aggregation, analysis, comparison and other uses. Such standardization is consistent with recognized local and national standards. Measurable Elements of MOI The transport organization has a list of all the abbreviation, codes, symbols, and their definitions, used within the organization. 2. The transport organization standardizes use by indicating what abbreviations, codes, and symbols are not to be used. 3. The transport organization monitors the use and corrects nonstandardized use. 4. The standardization is consistent with recognized local and national standards within health care and transport organizations. Standard MOI.1.4 The data and information needs of those within and outside the organization are met. Intent of MOI.1.4 The format and methods of disseminating data and information to the intended user are tailored to meet the user s expectations. Dissemination strategies include providing only the data and information the user requests or needs; formatting the report to aid use in the decision process; providing reports with the frequency needed by the user; linking sources of data and information; and providing interpretation or clarification of data. The information management process makes it possible to combine information from various sources and generate reports to support decision making. In particular, the combination of clinical and managerial information helps the leaders of the organization to plan collaboratively. The information management process supports leaders with integrated longitudinal data and comparative data. Patient records and other data and information are secured and protected at all times. For example, active patient records are kept in areas where only authorized professional staff have access, and records are stored in locations where heat, water, fire, or other damage is unlikely to occur. The organization also considers the risk of unauthorized access to electronically stored information and implements processes to prevent such access.

65 Measurable Elements of MOI Data and information dissemination meets user needs for timeliness and format. 2. Staff members have access to the level of information related to their needs and job responsibilities. 3. Linking and interpretation of data and information are provided as appropriate to user needs. 4. Clinical and managerial information is provided and, as appropriate, integrated to support the organization s governance and leadership. 5. Data and information are protected from loss, destruction, tampering, and unauthorized access/use at all levels of dissemination and use. Standard MOI.1.5 Decision-makers and other appropriate staff members are educated and trained in the principles of information management. Intent of MOI.1.5 Individuals in the organization who generate, collect, analyze, and use data and information are educated and trained to effectively participate in managing information. This education and training enable these individuals to a) understand security and confidentiality of data and information; b) use measurement instruments, statistical tools, and data analysis methods; c) assist in interpreting data; d) use data and information to help in decision making; e) educate and support the participation of patients and families in care processes; and f) use indicators to assess and improve care and work processes. Individuals are educated and trained as appropriate to their responsibilities, job descriptions, and data and information needs. Measurable Elements of MOI The organization identifies those leaders and staff to be educated on the principles of information management. 2. Those leaders and staff are provided education on the principles of information management as identified in a) through f) in the intent. 3. The education is appropriate to needs and job responsibilities and is updated as information management systems or processes change. Dispatch Records Note: This standard is for all transport organizations. Standard MOI.2 The organization initiates and maintains dispatch records for each request for service.

66 Intent of MOI.2 For emergency medical transport organizations, the record of requests for service is maintained and includes at least a) the location of the incident; b) call-back information; c) the type and nature of the request; and d) any pre-arrival information, when needed. For emergency and nonemergency transport, records are also maintained to e) identify the location and destination of the patient; f) identify the transport air, land or water vehicle providing the transport; g) record the time of the request for transport and departure; h) record the time of arrival at the origin of the patient; i) record the time of arrival at the destination of the patient; j) record the condition of the patient at arrival at the destination; and k) record any assistance received from any other agency. Measurable Elements of MOI.2 1. The organization maintains a dispatch record for each emergency and nonemergency request for service that includes at least a) through d) in the intent for emergency medical transport and e) through k) for nonemergency transport. 2. The record includes identification of the air, land or water transport vehicle responding to the request. 3. The record includes the identification of the driver or crew on board providing the transport as well as any family, others along during transport. Patient Records Note: These standards are for all transport organizations. Standard MOI.3 The organization initiates and maintains a standardized clinical record for every patient assessed or treated during emergency medical transport. Intent of MOI.3 Every patient assessed or treated has a clinical record. Each record is assigned an identifier unique to the patient, or some other mechanism links the patient with his or her clinical record. A single record and a single identifier enable the organization to easily locate patient clinical records and document the care of patients over time. The clinical record of each patient needs to present sufficient information to; a) Identify the patient, b) determine the patient s clinical needs, c) justify the care and treatment provided, d) document the course and results of the are and treatment, and e) document the patient s condition at the destination.

67 The clinical record content for each patient transported, or a walk in when possible, is standardized by organization policy. This also includes recording standardized information when the patient refuses transport and other unusual circumstances. Measurable Elements of MOI.3 1. A clinical record is initiated for every patient assessed or treated by the transport organization. 2. The clinical record includes a) through e) in the intent. 3. The content of clinical records is standardized by organization policy and identifies and includes exceptions for special circumstances. Standard MOI.3.1 Treat and release and nontreat, nontransport occurrences are documented. Intent of MOI.3.1 When a patient is treated and then released from the care of the emergency medical transport organization without being transported for further care, or the emergency medical transport organization declines to treat or transport a patient, there is documentation of the occurrence. The clinical record contains the following: a) A description of the patient s physical and clinical status; b) The criteria used to determine the patient s competence; c) A description of the treatment rendered; d) The risks of non-treatment e) A description of the follow-up care needed, if any; f) Options for follow-up care, including re-contacting the emergency medical transport organization; Verification and signature of the competent patient indicating that he or she understands his or her right to refuse treatment or transport, any treatment received, and any follow-up care needed; and the reason for nonor incomplete treatment and nontransport Measurable Elements of MOI Treat and release and nontreat, nontransport occurrences are documented and include at least a) through f) in the intent. 2. The clinical record contains verification and signature of the competent patient indicating that he or she understands his or her right to refuse treatment or transport, any treatment received, and any follow-up care needed. 3. The clinical record contains the reason for nontransport or incomplete treatment and nontransport. Standard MOI.3.2 As part of its performance improvement activities, the organization regularly assesses patient clinical record content and the completeness of records. Intent of MOI.3.2 Each organization determines the content and format of the patient record and has a process to assess record content and the completeness of records. That process is a part of the organization s performance improvement activities and is carried out regularly. Patient record review is based on a sample representing the number of patients served. The review process is conducted by relevant clinical professionals who are authorized to review the patient record. The review focuses on the timeliness, completeness, legibility, and so forth of the record and clinical information. Any content required by laws or regulations to be in the patient record is included in the review process.

68 Measurable Elements of MOI Patient clinical records are reviewed quarterly using a representative sample. 2. The review is conducted by clinical professionals authorized to make entries in clinical records or manage patient records. 3. The review focuses on the timeliness, legibility, and completeness of the clinical record. 4. Record contents required by law or regulation are included in the review process. 5. The record review results are used to improve the documentation process. Aggregate Data and Information Standard MOI.4 Aggregate data and information support patient transport processes, management of the transport organization, the information needs of outside agencies and the quality and patient safety program. Standard MOI.4.1 The security and confidentiality of patient-specific data and information are maintained when contributing to or using information from external databases as required by law or for comparative purposes. Intent of MOI.4 through MOI.4.1 The organization collects and analyzes aggregate data to support patient care and organization management. Aggregate data provide a profile of the organization over time and allow the comparison of the organization s performance with other organizations. Thus, aggregate data are an important part of the organization s performance improvement activities. In particular, aggregate data from risk management, utility system management, infection control, and utilization review can help the organization understand its current performance and identify opportunities for improvement. By participating in external performance databases, an organization can compare its performance to that of other similar organizations locally, nationally, and internationally. Performance comparison is an effective tool for identifying opportunities for improvement and documenting the organization s performance level. External databases vary widely from insurance databases to those maintained by professional societies. Measurable Elements of MOI.4 1. Aggregate data and information support patient care. 2. Aggregate data and information support organization management. 3. Aggregate data and information support the quality management program. 4. The organization has a process to aggregate data in response to identified user needs. 5. The organization provides needed data to agencies outside the organization. Measurable Elements of MOI The organization contributes data or information to external databases in accordance with laws or regulations. 2. The data is validated by the organization before contribution to the external database or release to the public. 3. The organization compares its performance using external reference databases. 4. The organization uses these comparisons when prioritizing improvement activities.

69 5. Security and confidentiality are maintained when reporting to or using external reference databases.

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71 Section IV: Patient- Centered Standards

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73 Access to Services and Continuity of Services (ACC) Changes to the ACC Chapter Standard Change Explanation Note: This table lists changes to requirements in this chapter only. Requirements that were in this chapter in the 1st edition of this manual and are now contained either in their entirety or in part in another chapter of this 2nd edition are listed in that chapter s Changes table. The following standards appeared in this chapter of the 1st edition standards but were deleted from this edition (listed with 1st edition numbers): None. Overview The goals achieved by meeting the standards in this chapter are the community s understanding of the organization s existence, purpose, catchment area or group, emergency and nonemergency transport services offered, and appropriate access point(s); the correct match of patient needs with the services available from the transport organization; the coordination of the services provided to the patient by the transport organization; and planning for the eventual disposition of the patient, including any required or recommended followup. If these goals are met, the result is improved patient outcomes and more efficient use of available resources.

74 Standards, Intents, and Measurable Elements Access to Services Standard ACC.1 Patients have access to transport services based on their identified needs and the transport service s mission, services and resources. Intent of ACC.1 Matching patient needs with the mission, services and resources of the transport organization depends on obtaining information on the patient s needs and condition through screening of the patient or the receipt of a request for transport. Screening can occur at the time services are requested, on-site at first contact with the patient, during transport, or when the patient arrives at the receiving organization. Screening will determine if the patient requires emergency medical transport or nonemergency transport. Screening can be done through a dispatch function or by pre-arranged transport, for example at discharge to home from acute care. Screening for nonemergency transport is an essential source of information on the condition of the patient, any special precautions such as for infection control, the need for any special equipment, and so forth. Guidelines are used for determining patient need and the correct transport. Use of the guidelines is monitored and failures to correctly determine patient need and the correct transport are investigated and any necessary changes made to the guidelines, staff training or the process of applying the guidelines. Measurable Elements of ACC.1 1. Screening to determine patient needs is initiated at the point of first contact with a dispatch function or the pre-arrangement for nonemergency transport. 2. Based on understanding the patient s needs, the type of transport (emergency or nonemergency) is selected. 3. Guidelines are used in screening patients and determining the correct transport. 4. Use of the guidelines is monitored and failures investigated as a component of quality improvement and patient safety. 5. Use of the guidelines is monitored and failures investigated as a component of quality improvement and patient safety. Standard ACC.1.1 The transport organization seeks to reduce physical, language, cultural, and other barriers to access and delivery of services. Intent of ACC.1.1 Transport organizations frequently serve communities with a diverse population. Patients may be aged, have disabilities, speak multiple languages or dialects, be culturally diverse, or present other barriers that make the process of accessing the transport organization s services more difficult. The organization is familiar with these barriers and has implemented processes to eliminate or reduce them during the entry process. The organization also seeks to reduce the impact of these barriers on the delivery of services. When significant financial barriers are present for patients in the community, the organization works with other community agencies to limit the impact of those barriers.

75 Measurable Elements of ACC The organization has identified the primary barriers to access in its patient population. 2. The organization has implemented measures to overcome or limit barriers to access. 3. The organization has implemented measures to overcome or limit the impact of barriers on the delivery of services. 4. There is a process for working with other community agencies to limit the impact of financial barriers on the delivery of services. Response and Deployment Plan Standard ACC.2 The transport organization has a comprehensive response and deployment plan consistent with its mission and resources. Intent of ACC.2 A transport organization s primary purpose is the timely and appropriate response to patients transportation needs. To do so requires a written plan that ensures that the proper levels of service arrive on scene on time. The organization s response and deployment plan (this may also be called a productivity management plan) needs to take into account the organization s mission, services, resources, terrain, environment, and demand to ensure optimal response to patient need, and includes a) coverage of peak periods including when there is a staff shortage; b) response to multiple-victim incidents or a surge in transport requests; c) on-time response to requests from the most remote portions of the organizations service area; and d) appropriate use of transport resources for land, water and air services. There is a process to review actual demand against the plan and make adjustments accordingly. Adjustments also come from testing the plan. For example, there may be a call to transport multiple burn patients to a receiving hospital s burn unit. Similarly, a hospital with contaminated water may need to transfer multiple patients to the dialysis unit of another hospital. Measurable Elements of ACC.2 1. The organization has a written response and deployment plan including the identification of response areas and availability of response units. 2. The plan includes a) through d) in the intent. 3. The plan is tested and adjusted accordingly. Standard ACC.2.1 The plan includes a process for prioritizing requests for transport services. Intent of ACC.2.1 Accepted guidelines determine the prioritization of requests for emergency and non-emergency transport services. The guidelines are developed with clinical input and include at least the following: Determination of the response level and urgency of a single request; Determination of the response level and urgency of multiple requests; and Determination of the availability, proximity, and appropriateness of available transport.

76 As resources are limited utilization requires a prioritization process. This process usually occurs with incomplete information, often provided by untrained observers. Prioritization should occur by the use of tested and clinically appropriate protocols that determine both response level and urgency based upon objective information about the patient(s) and the available services. Note: See list of monitors in QPS.2, item a) on the list for monitoring the prioritization process. Measurable Elements of ACC The organization has a prioritization process. 2. The prioritization process uses written guidelines that determine both response level and urgency. 3. The guidelines are used for each service request. 4. The guidelines are approved by the organization s clinical and managerial leaders. Standard ACC.2.2 The plan includes standards for response times and the monitoring of actual response times. Intent of ACC.2.2 Response times are important monitors for all types of transport services. Response times are particularly important for emergency medical transport services. The plan for emergency medical transport includes standards for the following response times: a) First contact to assignment of responding unit; b) Assignment of responding unit to start of transit; c) Start of transit to arrival on scene (wheels stop turning); d) Arrival on scene to patient-side (in emergency cases); and e) Departure from scene to arrival at destination if transported. The plan describes any difference in response times for geographic areas, population density, patient need, or other factors that are expected to influence total response time. The response times meet local, regional, or national laws and regulations. Single or synchronized clocks are used to monitor response times. Response times are monitored, reported as required, and incorporated into quality management and improvement activities. Note: See QPS.2 list of monitors (item j) for response times. Measurable Elements of ACC The response and deployment plan includes response time standards addressing at least a) through e) in the intent. 2. The response time standards meet local, regional, or national laws and regulations. 3. The response time standards are approved by the clinical and managerial leaders of the transport organization. 4. The response times are monitored (see QPS.2), using single or regularly synchronized clocks.

77 Dispatch and Communication Standard ACC.3 There is a process for obtaining and documenting transport service request information. Intent of ACC.3 Providing appropriate and timely emergency medical transport or nonemergency transport is contingent upon an efficient and accurate call taking process. The transport organization develops and implements a process for addressing service requests. The following information is obtained and documented for each emergency medical transport service request: a) Call-back telephone number; b) Address of the incident; c) Problem or nature of the request or complaint; d) Post-dispatch/pre-arrival instructions; and e) The need for assistance from other agencies The following information is obtained and documented for nonemergency transport service requests: f) Name of the individual requesting the transport and call-back telephone number; g) Clinical condition of patient and/or primary diagnosis; h) Any special considerations during transport such as special assistive equipment or infection precautions; and i) Destination and any arrival instructions. Measurable Elements of ACC.3 1. There is a process for obtaining and service request information. 2. The information obtained includes at least a) through e) for emergency medical transport services and f) through i) for nonemergency transport services. 3. The information obtained is documented. Standard ACC.3.1 There is direct communication capability between the caller and the dispatch system and the dispatch system and the transport/vehicle staff at all times. Intent of ACC.3.1 The dispatch system can maintain direct, immediate communication with the caller and the transport/vehicle staff any time the vehicle is in use. The system includes call routing (rapid transfer of medical calls to medical dispatch). Call waiting times are monitored (for example, "calls answered within 90 seconds"). There are processes to manage overflow or peak times and multiple calls for the same incident. Note: See QPS.2, item i) on the list of monitors for call waiting time. Measurable Elements of ACC Direct, immediate communication is maintained between the dispatch system and the caller at all times for emergency medical transport and is immediately available for nonemergency transport. 2. Direct, immediate communication is maintained between the dispatch system and the transport/vehicle staff at all times..

78 3. The system includes call routing capability. 4. Processes to manage overflow or peak times and multiple calls for the same incident are implemented. Standard ACC.3.2 The dispatch system has a plan for continued operation and communication in the event of service disruption. Intent of ACC.3.2 The organization plans for providing continued communication in the event of a service disruption. The plan addresses the following: a) Equipment failures at the dispatch system or in the vehicle; b) Power or telephone line (incoming/outbound) failures; c) Inaccessibility to the dispatch center; d) Vehicle failure; and e) Failure or closure of any facility that may house the dispatch system. The plan is tested at least annually, either in response to an actual failure or during scheduled drills. Measurable Elements of ACC The organization has a plan for providing continued communication in the event of a service disruption. 2. The plan addresses at least a) through e) in the intent. 3. The plan is tested at least annually. Transitions of Care Standard ACC.4 There is a process for the transfer of active patients between health care organizations and discharged patients to their home or place of discharge. Intent of ACC.4 Transferring patients between organizations is based on the patient s status and need for continuing health care services. Transfer may be in response to a patient s need for specialized consultation and treatment, urgent services, less intensive services such as subacute care or longer term rehabilitation, or home if the patient is fully discharged or will receive home care. A referral process is required to ensure that any continuing needs are met during transport and by the receiving organizations, staff, or family, if any. Such a process addresses a) how responsibility is transitioned between organizations and settings; b) criteria for when transfer is appropriate; c) who is responsible for the patient during transfer; d) how any continuing care needs are to be met during transport; and e) what is to be done when transfer to the desired source of care is not possible. Measurable Elements of ACC.4 1. There is a process to transfer patients between health care organizations or between organizations and the patient home or place of discharge. 2. The transfers are based on the patient s discharge or need for continuing care.

79 3. The process addresses a) through e) in the intent. 4. Patients are appropriately transferred to other organizations or home. Standard ACC.4.1 Information related to the patient s care is transferred with the patient. Intent of ACC.4.1 Continuity of patient care from one organization to another or transfer to the patient s home at discharge requires that essential information related to the patient is transferred with him or her. Thus, medications and other treatments can continue uninterrupted, and the status of the patient can be appropriately monitored during transport. To accomplish this information transfer with the patient, the patient s record is transferred or information from the patient s record is summarized at transfer or a discharge summary is provided. Such a summary should include the reason for transport, significant findings, diagnosis made, procedures performed, medications, and other treatments. The patient s condition at transfer is always noted in the record or summary. All parties involved in the transfer have access to the information. Measurable Elements of ACC The patient s record or a summary of patient care information is transferred with the patient. 2. The summary includes the reason for admission, significant findings, diagnosis made, procedures performed, medications, and other treatments. 3. The patient s condition at transfer or discharge is noted in the record or summary. Standard ACC.4.2 The receiving organization, during inter-facility transfer, is given a written summary of the patient s clinical condition and the interventions provided by the referring organization. Intent of ACC.4.2 An emergency medical transport organization can be either the receiving or referring organization and so should obtain clinical summary information on the patient when picking a patient up or provide it when delivering a patient to his/her destination. To ensure continuity of care, patient information is transferred with the patient. A copy of the discharge summary or other written clinical summary is provided to the receiving organization with the patient. The summary includes the patient s clinical condition or status, the procedures and other interventions provided, and the continuing patient needs. Measurable Elements of ACC Patient clinical information or a clinical summary is transferred with the patient. 2. The clinical summary includes patient status. 3. The clinical summary includes procedures and other interventions provided. 4. The clinical summary includes the patient s continuing care needs. Standard ACC.4.3 During transfer, a qualified staff member monitors the patient s condition.

80 Intent of ACC.4.3 Transferring a patient may be a brief process with the patient alert and talking, or transfer may involve the moving of a comatose patient who requires continuous nursing or medical oversight. In either case, the patient requires monitoring, but the qualifications of the individual providing the monitoring are significantly different. Thus, the condition and status of the patient determine the qualifications of the staff member monitoring the patient during transfer. The staff member may be the vehicle driver. Anyone responsible for monitoring the patient during transport has been trained to use guidelines when unanticipated emergencies occur during transport. Measurable Elements of ACC All patients are monitored during transfer. 2. The qualifications of the staff member are appropriate for the patient s condition. 3. The transport organization has clear guidelines for how to manage patients with an unanticipated emergency or urgent needs during transport. Standard ACC.4.4 The transfer process is documented in the patient s record. Intent of ACC.4.4 The record of each patient transferred to another health care organization contains documentation of the transfer. The name of the organization agreeing to receive the patient is noted, the reason(s) for the transfer is noted, and any special conditions for transfer (such as when space at the receiving organization is available, or the status of the patient). Also, it is noted if the patient s condition or status changed during transfer (for example, if the patient dies or requires resuscitation). Any other documentation required by organization policy (for example, a signature of the receiving nurse or physician, or the name of the individual who monitored the patient during transport) is included in the record. Measurable Elements of ACC The records of transferred patients note the health care organization agreeing to receive the patient. 2. The records of transferred patients contain other notes as required by the policy of the transferring organization. 3. The records of transferred patients note the reason(s) for transfer. 4. The records of transferred patients note any special conditions related to transfer. 5. The records of transferred patients note any change of patient condition or status during transfer. References 1. Cesta T. Managing length of stay using patient flow Part 1. Hosp Case Manag Feb;21(2): Cesta T. Managing length of stay using patient flow Part 2. Hosp Case Manag Mar;21(3): Litvak E, editor. Managing Patient Flow in Hospitals: Strategies and Solutions, 2nd ed. Oak Brook, IL: Joint Commission Resources, Amato-Vealey EJ, Fountain P, Coppola D. Perfecting patient flow in the surgical setting. AORN J Jul;96(1): Ardagh MW, Tonkin G, Possenniskie C. Improving acute patient flow and resolving emergency department overcrowding in New Zealand hospitals The major challenges and the promising initiatives. N Z Med J Oct 14;124(1344): Asplund K, et al. Triage Methods and Patient Flow Processes at Emergency Departments: A Systematic Review. Stockholm: Swedish Council on Health Technology Assessment, Hitchcock R. Speeding up the ED care process. Three hospital organizations mitigate overcrowding by improving patient flow, processes and documentation. Health Manag Technol Dec;33(12): Johnson M, Capasso V. Improving patient flow through the emergency department. J Healthc Manag Jul Aug;57(4):

81 9. Love RA, et al. The effectiveness of a provider in triage in the emergency department: A quality improvement initiative to improve patient flow. Adv Emerg Nurs J Jan Mar;34(1): Popovich MA, et al. Improving stable patient flow through the emergency department by utilizing evidence-based practice: One hospital's journey. J Emerg Nurs Sep;38(5): Resar R, et al. Using real-time demand capacity management to improve hospitalwide patient flow. Jt Comm J Qual Patient Saf May;37(5): Wong R, et al. Building hospital management capacity to improve patient flow for cardiac catheterization at a cardiovascular hospital in Egypt. Jt Comm J Qual Patient Saf Apr;38(4): Joint Commission Resources. Avoiding patient boarding: Enhancing flow through the emergency department. Joint Commission: The Source Jul;10(7):1, 4 5, ED boarding creates patient safety issues, increases risk of mortality. Hosp Case Manag Mar;21(3): Emeny R, Vincent C. Improved patient pathways can prevent overcrowding. Emerg Nurse Mar;20(10): Four-hour rule saves lives. Australian Nursing Journal Mar;19(8): Barrett L, Ford S, Ward-Smith P. A bed management strategy for overcrowding in the emergency department. Nurs Econ Mar Apr;30(2):82 85, Jones PG, Olsen S. Point prevalence of access block and overcrowding in New Zealand emergency departments in 2010 and their relationship to the Shorter Stays in ED target. Emerg Med Australas Oct;23(5): Taylor M. Rescuing the ED. Hosp Health Netw May;85(5): Alakeson V, Pande N, Ludwig M. A plan to reduce emergency room boarding of psychiatric patients. Health Aff (Millwood) Sep;29(9):

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83 Patient and Family Rights (PFR) Changes to the PFR Chapter Standard Change Explanation Note: This table lists changes to requirements in this chapter only. Requirements that were in this chapter in the 1st edition of this manual and are now contained either in their entirety or in part in another chapter of this 2nd edition are listed in that chapter s Changes table. The following standard appeared in this chapter of the 1st edition standards but was deleted from this edition (listed with 1st edition numbers): Overview Each patient is unique, with his or her own needs, strengths, values, and beliefs. Emergency medical transport organizations work to establish trust and open communication with patients and their families to understand and protect each patient s cultural, psychosocial, and spiritual values. To respect and protect patient rights in a transport organization, one starts by defining those rights and then educating patients and staff about those rights. Patients, and those who make decisions on their behalf, are informed of their rights and how to act on them. Staff are taught to understand and respect patients beliefs and values and to provide considerate and respectful care that protects patients dignity. This chapter addresses processes to identify, protect, and respect patient rights;

84 inform patients of their rights; include the patient s family, when appropriate, in decisions about the patient s care; obtain informed consent; educate staff about patient rights; and establish the organization s ethical framework. How these processes are carried out in an organization depends on its country s laws and regulations and any international conventions, treaties, or agreements on human rights endorsed by its country. Standards, Intents, and Measurable Elements Transport Organization Support for Patient Rights Standard PFR.1 The transport organization is responsible for providing processes that support patients and families rights during transport and care. Intent of PFR.1 An organization s leaders are primarily responsible for how an organization will treat its patients. Thus, the leaders need to know and understand patient and family rights and their organization s responsibilities as identified in laws and regulations. The leaders then provide direction to ensure that staff throughout the organization assume responsibility for protecting these rights. To effectively protect and advance patient rights, the leaders work collaboratively and seek to understand their responsibilities in relation to the community served by the organization. Patient and family rights are a fundamental element of all contacts among an organization, its staff, and patients and families. Thus, policies and procedures are developed and implemented to ensure that all staff are aware of and respond to patient and family rights issues when they interact with and care for patients throughout the organization. The organization used a collaborative and inclusive process to develop the policies and procedures, and, when appropriate, included patients and families. Emergency medical services and medical transport can be frightening and confusing for patients, making it difficult for them to understand and act on their rights. Thus, the organization prepares a statement of patient and family rights that is posted or printed and made available to patients. The statement is appropriate to the patient s age, understanding, and language. Measurable Elements of PFR.1 1. The organization s leaders identify, protect, and advance patient and family rights for the community they serve, including rights as identified in laws and regulations. 2. Policies and procedures guide and support patient and family rights in the organization. 3. Staff are knowledgeable about the policies and procedures and can explain their role and responsibility in protecting patient and family rights. 4. All patients are given information on their rights in a manner they can understand. Standard PFR.1.1 Care is considerate and respectful of the patient s personal values and beliefs.

85 Intent of PFR.1.1 Each patient brings his or her own set of values and beliefs to the care and transport process. This is true for the emergency medical transport and for nonemergency transport services. Some values and beliefs are commonly held by all patients and are frequently cultural and religious in origin. Other values and beliefs are those of the patient alone. All patients are encouraged to express their beliefs in ways that respect the beliefs of others. Strongly held values and beliefs can shape the care process and how patients respond to care. Thus, each care provider seeks to understand the care and services they provide within the context of the patient s values and beliefs. Patient privacy, during emergency procedures and examinations during transport, as well as during a nonemergency transport to a patient s home, is an important consideration. Patients may desire privacy from other staff, other patients, and even from family members. When possible, transport staff learn their patient s privacy needs and respect those needs. Measurable Elements of PFR There is a process to identify and respect patient values and beliefs. 2. Staff are educated on the process and provide care that is respectful of the patient s values and beliefs. 3. A patient s need for privacy is respected during transport. Standard PFR.1.2 The transport organization takes measures to protect patients from physical assault and their possessions from theft or loss. Intent of PFR.1.2 The transport organization takes responsibility for protecting patients from physical assault by strangers and staff. This responsibility is particularly relevant to infants and vulnerable children, the elderly, and others unable to protect themselves or signal for help. The transport organization communicates its responsibility, if any, for the patient s possessions to patients and families. When the organization takes responsibility for any or all of the patient s personal possessions on-site or transported with the patient, there is a process to account for the possessions and ensure that they will not be lost or stolen. This process takes into account those patients unable to make alternative safekeeping arrangements for their possessions, and those incapable of making decisions regarding their possessions. Measurable Elements of PFR The organization has a process to protect patients from assault. 2. Infants, vulnerable children, the elderly, and others less able or unable to protect themselves are addressed in the process. 3. The organization has determined its level of responsibility for the patient s possessions. 4. The patient s possessions are safeguarded when the organization assumes responsibility for them or when the patient is unable to assume responsibility.

86 Right to Participate in Care and Transport Decisions Standard PFR.2 The transport organization supports patients and families rights to participate in decisions regarding their care and transport. Intent of PFR.2 When there are decisions regarding the transport process or there are decisions regarding the care provided during transport, patients and families have a right to participate in those decisions. Such decisions may be regarding sources and types of care and even refusing care. The organization supports and promotes this patient and family involvement in all aspects of the care and transport process by developing and implementing related policies and procedures. Policies and procedures address issues such as treat and release and patient refusal for treatment and/or transport. Management, clinical staff, and others participate in developing such policies and procedures. All staff are trained on the policies and procedures and on their role in supporting patients and families rights to participate in the care process. To fully participate in decisions, the patient and their family are educated to equip them with the knowledge and skills needed to participate. Measurable Elements of PFR.2 1. Policies and procedures are developed to support and promote patient and family participation in care decisions and transport processes. 2. The development of the policies and procedures includes management and clinical staff. 3. Staff are trained on the policies and procedures and their role in supporting patient and family participation in care and transport decisions. 4. Patients and families are educated so that they have the knowledge and skills to participate in decisions regarding the transport processes and care. Standard PFR.2.1 The transport organization informs patients and families about their rights and responsibilities related to refusing or discontinuing treatment. Intent of PFR.2.1 Prior to nonemergency transport, or even during emergency transport, patients, or those making decisions on their behalf, may decide not to proceed with care or treatment or to continue care or treatment after it has been initiated. For example, a patient may be transported home after refusing treatment in the hospital and refuse to use the supportive measures provided during transport. Or a patient during transport home may refuse to be discharged at home and demand to go to another destination. The transport organization informs patients and families, in advance when possible, about their right to make these decisions, the potential outcomes that could result from these decisions, and their responsibilities related to such decisions. When competent patients are involved in the care process they need information in order to make knowledgeable informed decisions. Competent patients have a right to refuse treatment or transport. In some situations the transport organization may also decline to treat or transport patients. In all of these cases the emergency medical transport organization educates the patient about the risks, benefits, alternatives, physical, and financial implications for non or incomplete treatment and non-transport; any treatment that was rendered to that point; any follow-up care that will be needed; and

87 options for obtaining follow-up care. Measurable Elements of PFR The organization informs patients and families about their rights to refuse or discontinue treatment or transport. 2. The organization informs patients about the consequences of their decisions. 3. The organization informs patients and families about their responsibilities related to such decisions. 4. The transport organization educates patients when they refuse treatment or transport or the emergency medical transport organization declines to treat or transport them. Standard PFR.2.2 The transport organization has a policy on initiating resuscitative services. Standard PFR.2.3 Patients and families are informed about their right to donate organs and tissues. Intent of PFR.2.2 and PFR.2.3 Emergency response and intervention require clear guidelines for time-critical healthcare events. In addition, there may be emergent emergency situations during a routine nonemergency transport. Emergency and nonemergency transport organizations frequently encounter time-critical events in which immediate decisions about resuscitation are required. Medicine and patient care require an imperative to act on behalf of patients but healthcare providers frequently encounter events in which resuscitative care is futile or the patient has clearly expired. It is important that organizations develop clear and consistent policies regarding the initiation and termination of resuscitation. The organization also supports patient and family choices to donate organs or other tissues. Transport occurs within a time frame to keep organs and tissue viable. Policies and procedures guide the transport of potential organ donors without self-sustaining vital signs prior to arrival in the emergency department setting. Potential donors are identified prior to transport when possible All of these policies must be developed with participation from both clinical and managerial leaders and be consistent with laws, regulations, and community norms. Staff are trained in the policies and procedures. Measurable Elements of PFR The organization has policies and procedures guiding staff when to initiate and when to terminate resuscitation measures. 2. The organization has policies and procedures to guide staff encountering patients who choose to forego resuscitative or life-sustaining interventions. 3. Policies and procedures for initiating and terminating resuscitation are developed in conjunction with clinical and managerial staff. 4. Policies and procedures guide staff in the handling of and the legal and regulatory requirements for clearly expired patients. Measurable Elements of PFR Policies and procedures guide the transport of potential organ donors without self-sustaining vital signs prior to arrival in the emergency department setting. 2. Transport occurs within a time frame to keep organs and tissue viable.

88 3. The organization supports patient and family choices to donate organs or other tissues. 4. Staff are trained in the policies and procedures. Right to Comment or Complain Standard PFR.3 The transport organization informs patients and families about its process to receive and act on complaints, conflicts, and differences of opinion about patient care, and the patient s right to participate in these processes. Intent of PFR.3 Patients have a right to comment about or voice complaints about their care and the transport process. They also have a right to have those complaints reviewed and, when possible, resolved. Also, decisions regarding care sometime present questions, conflicts, or other dilemmas for the organization and the patient, family, or other decision-makers. These dilemmas may arise around issues of access, treatment, or discharge. They can be especially difficult to resolve when the issues involve, for example, withholding resuscitative services or forgoing or withdrawing life-sustaining treatment. The organization has established processes for seeking resolution of such dilemmas and complaints. The organization identifies in policies and procedures those who need to be involved in the processes and how the patient and family participate. Measurable Elements of PFR.3 1. Patients are aware of their right to voice a comment or complaint and the process to do so. 2. Complaints are reviewed according to the organization s mechanism. 3. Dilemmas that arise during the care and/or transport process are reviewed according to the organization s mechanism. 4. Policies and procedures identify participants in the process, including patients and families. Right to Give Consent Standard PFR.4 Patient informed consent is obtained through a process defined by the transport organization and carried out by trained staff. Intent of PFR.4 One of the main ways that patients are involved in their care decisions is by granting informed consent. For consent to be "informed", a patient must have information on factors related to the care that may be necessary to meet their needs. Informed consent may be obtained at several points in the care and transport process. For example, informed consent is obtained at the site of first contact, during transport, or before certain procedures or treatments for which the risk is high. For organizations that provide nonemergency transport services, consent may be covered by a "general" consent, or "implied" when the patient or hospital arranges for the transport. The consent process is clearly defined by the organization in policies and procedures. The policies and procedures include at least:

89 a) relevant laws and regulations;. b) when others can grant consent and the process for this; and c) the determination of when a patient does not have the legal right to make consent decision or does not have the physical or mental capacity to make consent decisions. d) the use of a general or implied consent for nonemergency transport. Patients and families are informed as to how they can give consent for example, verbally, by signing a consent form, or through some other mechanism. Patients and families understand who may, in addition to the patient, give consent. Designated staff are trained to inform patients and obtain and document patient consent. Measurable Elements of PFR.4 1. The organization has a clearly defined consent process described in policies and procedures that include a) through d) in the intent. 2. Designated staff are trained to implement the policies and procedures. 3. Patients give informed consent consistent with the policies and procedures. 4. The patient s signature or other indication of all types of consent is documented in the patient s record. Standard PFR.4.1 Informed consent is obtained before the use of blood and blood products, and other high-risk treatments and procedures. Intent of PFR.4.1 When the treatment during emergency medical transport includes the use of blood and blood products, or high-risk treatments or procedures, a separate consent is obtained. For nonemergency transport, high-risk procedures may, for example, include the use of physical restraint for disabled patients. This consent process provides the information on risks, benefits, and alternatives, and the identity of the individual providing the information is documented. Not all treatments and procedures require a specific, separate consent. Each organization identifies those highrisk, problem-prone, or other procedures and treatments for which consent must be obtained. The organization lists these procedures and treatments and educates staff to ensure that the process to obtain consent is consistent. The organization can decide the level of detail in the list. For example, each procedure and treatment can be listed separately, or categories or types of procedures and treatments can be identified on the list. The list is developed by those who provide the treatments or perform the procedures and is approved by the organization s clinical leaders. Measurable Elements of PFR The organization lists those categories or types of treatments and procedures that require specific informed consent. 2. Consent is obtained before the use of blood and blood products. 3. Consent is obtained before high-risk procedures and treatments. 4. The identity of the individual providing information on risks, benefits, and alternatives to the patient and family is noted in the patient s record.

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91 Assessment of Patients (AOP) Changes to the AOP Chapter Standard Change Explanation Note: This table lists changes to requirements in this chapter only. Requirements that were in this chapter in the 1st edition of this manual and are now contained either in their entirety or in part in another chapter of this 2nd edition are listed in that chapter s Changes table. The following standards appeared in this chapter of the 1st edition standards but were deleted from this edition (listed with 1st edition numbers): Overview An effective patient assessment and reassessment process is important for emergency medical transport and for nonemergency transport. The assessment and reassessment results in decisions about the patient s emergency or immediate treatment needs as well as decisions about the transport process. Patient assessment and reassessment is an ongoing, dynamic process that consists of three primary processes: 1) Collecting information and data on the patient s physical, psychological, and social status, and his or her health history; 2) Analyzing the data and information to identify the patient s immediate needs and transport considerations; and 3) Developing a plan to meet the patient s identified needs either on-site, during transport, or at the receiving organization.

92 Patient assessment and reassessment is appropriate when it considers the patient s condition, age, health needs, and his or her requests or preferences. These processes are most effectively carried out when the various clinical and management professionals responsible for patient transport work together. These processes may be carried out by qualified transport organization s staff, using approved guidelines. Standards, Intents, and Measurable Elements Standard AOP.1 All patients transported by the organization have their health care and transport needs identified through an established assessment and reassessment processes. Intent of AOP.1 The first contact with a patient may be on the scene of an accident, or at the patient s home or during transport for emergency medical transport, or may be at the arrival at a patient s home to transport them to a hospital appointment or at the hospital when transporting a patient home following a hospitalization or when transferring a patient from one facility to another such as from a nursing home to a hospital for a diagnostic test. Thus, the specific assessment information required at first contact, and the procedures for getting it, depend on the patient s needs and the setting in which care is to be provided.. Organization policy and procedures define how this assessment and reassessment process functions. The basis for these policies and procedures is the definition of acuity categories. The organization establishes a process to measure the accuracy of the definitions. The final selection of transport is based on the initial assessment of patient needs. The assessment and reassessment of patients are critical processes that require special education, training, knowledge, and skills. Thus, for each type of assessment those individuals qualified to perform the assessment in each setting are identified and their responsibilities are defined in writing. Measurable Elements of AOP.1 1. Organization policy and procedure define the information to be obtained and the timeframe for which it should be obtained for different types of patients. 2. Organization policy and procedure define assessment and reassessment responsibilities and who is qualified to perform the assessment or reassessment in each setting. 3. Acuity categories are defined and the accuracy of the definitions monitored. Standard AOP.1.1 The transport organization has determined the scope and content of assessments and reassessments, and who is qualified to conduct the assessments based on applicable laws and regulations. Intent of AOP.1.1 To consistently assess and reassess patient needs, the organization defines, in writing, the scope and content of assessments and reassessments to be performed by each clinical discipline or job category. For example, the scope of assessment and reassessment by an emergency or nonemergency transport driver or transport assistant, or by an emergency medical technician, or other emergency response team member are defined. Assessments and reassessments are performed by each discipline or job category within its scope of practice, licensure, applicable laws and regulations, or certification. The organization defines the assessment and reassessment activities in the different settings in which care is provided and who is qualified to conduct the assessment in that setting. For example, an emergency medical technician may be permitted to perform certain assessments at first contact with the patient or during transport however not reassessments at the receiving organization.

93 Measurable Elements of AOP The scope and content of assessments and reassessments by each discipline or job category are defined in writing. 2. Only those individuals permitted by licensure, applicable laws and regulations, or certification, perform the assessments or reassessments. 3. The assessment and reassessment activities that can be performed in different settings are defined in writing. Standard AOP.1.2 Clinical practice guidelines, when available and adopted by the emergency medical transport organization, or other standards of practice or guidelines for nonemergency transport organizations, are used to guide patient assessment and reassessment and reduce unwanted variation. Intent of AOP.1.2 Clinical practice guidelines are a means to improve quality and help practitioners and patients make clinical decisions. Similarly, nonclinical guidelines and other standards of practice help improve the quality and patient participation for important decisions in nonemergency transport organizations. A guideline is an effective way to improve processes by reducing variation. Clinical practice guidelines are found in the literature under many names: practice parameters, practice guidelines, patient care protocols, standards of practice, clinical pathways, and other names. The scientific basis of a guideline should be evaluated. Clinical and nonclinical guidelines may be adapted from external sources or created by staff within the organization. Regardless of the source, all clinical and non-clinical guidelines should be reviewed and approved by the organization s clinical and management leaders before implementation. This review and approval process ensures that the guidelines meet the selection criteria established by the leaders and are adapted to the community, patient needs, and organization resources. Once implemented, guidelines are reviewed on a regular basis to ensure their continued relevance to the patients served by the organization, and to ensure their continued scientific basis. Measurable Elements of AOP The transport organization s clinical and management leaders set criteria to select clinical and nonclinical guidelines. 2. The transport organization adopts and/or adapts guidelines as appropriate for the community, the patients served by the organization and the resources available within the organization. 3. When available and adopted, guidelines are used to guide the assessment of patients for which the guideline is applicable. 4. Guidelines are reviewed on a regular basis after implementation. Standard AOP.1.3 Assessment and reassessment findings are documented in the patient s record and are readily available to those responsible for the patient s subsequent or continuing care. Intent of AOP.1.3 Patient assessment and reassessment findings are valuable for emergency medical and nonemergency transport organizations. The finding may be used during the transport process as well as throughout any subsequent care process to evaluate patient progress and understand the need for reassessment. Nonemergency transport

94 organizations may use patient assessment to better plan appropriate transport, the need for assistive devices or the need for someone to accompany the patient and educate family on patient needs at home. It is therefore essential that assessments be documented well and can be quickly and easily retrieved from the patient s record and used by those caring for or transporting the patient. Assessments are completed at the time of care or transport or at the point of transfer of the patient. Measurable Elements of AOP Assessment and reassessment findings are documented in the patient s record. 2. Those caring for the patient can find and retrieve assessments and reassessment information as needed from the patient s record. 3. Assessments and reassessments are completed at the point of care, transport or transfer. Standard AOP.2 Each patient s initial assessment includes an evaluation of physical, emotional, and mental status, through a physical examination and health history. Intent of AOP.2 The initial assessment of a patient for which transport will be provided is critical to identifying the patient s needs and selecting appropriate transport. For emergency medical transport the initial assessment is needed to initiate the care process. The initial assessment provides information to understand the care the patient is seeking or needs; understand the best mode of transport consistent with patient needs; select the best care setting or destination; form an initial diagnosis; and understand the patient s response to initial care. To provide this information, the initial assessment includes an evaluation of the patient s physical, emotional, and mental status through a physical examination and health history. Gathering information on a patient is not intended to "classify" patients. Rather, a patient s cultural and family contexts are important factors that can influence his or her response to illness and treatment. Families can be of considerable help in these areas of assessment and in understanding the patient s wishes and preferences in the assessment process. The initial assessment of a patient for which nonemergency transport will be provided will help determine the type of transport, needed observations or treatments during transport and the appropriate monitoring of the patient during transport. This assessment of the nonemergency patients is conducted by staff at the discharging/sending organization or at the point of receipt of the patient such as from their home. Measurable Elements of AOP.2 1. Each patient has an initial assessment that meets organization policy. 2. The assessment is conducted by the transport organization or is available from the discharging organization and includes physical findings relevant to the patient s clinical condition and any relevant information on the patient s emotional and/or mental status. 3. The initial assessment results in understanding the transport the patient requires. 4. The initial assessment of emergency patients results in selecting the best setting and destination to meet the care needs of the patient (for example, burn unit or trauma unit).

95 Standard AOP.3 All patients are reassessed at defined intervals based on their clinical condition and transport conditions. Intent of AOP.3 Reassessment is key to understanding if care decisions and transport are appropriate and effective. Patients are reassessed throughout transport at defined intervals consistent with their clinical condition or applicable guidelines. For nonemergency transport, guidelines are used to monitor patients as indicated by the patient s condition. For example, a long transport journey or a journey interrupted by land, water or air adverse conditions may require the return of the patients to the discharging organization based on guidelines or the patient s condition. The results of these reassessments are noted in the patient s record for the information and use of all those who are or will be caring for the patient. Measurable Elements of AOP.3 1. Patients are reassessed to determine their response to treatment 2. Patients are reassessed to plan for continued treatment or release. 3. Patients are reassessed at defined intervals appropriate to their condition and transport conditions. Point-of-Care Testing Note: These standards are not applicable to nonemergency transport organizations. Standard AOP.4 The emergency medical transport organization identifies any point of care testing that will be conducted, and the extent to which such test results are used in patient care (definitive or used only as a screen). Intent of AOP.4 The emergency medical transport organization identifies the point of care tests that will be available (for example, glucose or hemoglobin tests and/or carbon dioxide detectors) and whether the results of testing will be considered definitive for purposes of care and diagnosis, or regarded as a screening tool. There is a quality control program for testing. Quality control procedures include testing of reagents; manufacturers recommendations; and documentation of results and corrective actions. Measurable Elements for AOP.4 1. The organization identifies any point of care tests to be conducted. 2. The organization identifies how the results will be used. 3. There is a quality control program for point of care testing procedures conducted by the organization that meets, or exceeds, the manufacturer s recommendations.

96 Standard AOP.4.1 Staff performing tests have adequate, specific training and orientation to perform the tests and demonstrate satisfactory levels of competence. Intent of AOP.4.1 Staff performing tests are qualified to do so. Staff have had specific training in the tests they perform. The training may be acquired through the organization or other training programs. Staff are oriented to the tests performed by the organization. Staff have shown current competence in performing those tests. Skills are assessed at defined intervals, determined by the director or supervisor, based on the frequency with which staff members perform tests, and their technical backgrounds. The organization also considers the complexity of the test methodology and the consequences of an inaccurate result. Methods to assess current skills can include performing a test on an unknown specimen; periodic observation of routine work by the supervisor or delegate; and monitoring each user s quality control performance. Measurable Elements of AOP Staff have had specific training in the tests they perform. 2. Staff are oriented to the tests performed by the organization. 3. Staff have shown current competence in performing tests. 4. Staff skills are assessed at defined intervals. 5. Training provided is documented. Planning and Prioritizing Care Needs Standard AOP.5 The transport organization has a process to review and integrate the assessment and reassessment information on patients to prioritize clinical care and transport services. Intent of AOP.5 A patient may undergo many kinds of assessments by many different assessors at the discharging organization or at the point of first contact or during transport. As a result, there may be a variety of information, test results, and other data available on patient clinical or transport needs. A patient benefits most when the qualified, responsible staff work together to review and analyze the assessment findings and to combine this information into a complete picture of his or her needs and condition. From this collaboration the order of importance is established, and care and transport decisions are made. When some patient s needs are identified as less critical and are not addressed during transport, this assessment information is included with the full assessment data and information that is provided upon arrival at the receiving organization, as applicable. The process for working together will be simple and informal when the patient s needs are not complex, and may be rapid and formal under critical conditions. The patient, his or her family, and others who make decisions on the patient s behalf are appropriately included in the decision process.

97 Measurable Elements of AOP.5 1. Patient assessment data and information are reviewed, analyzed and integrated through an appropriate process. 2. Those qualified individuals responsible for the patient s care and transport participate in the process. 3. Patient needs are prioritized based on assessment results. 4. The patient and his or her family participate in the decisions regarding the priority needs to be met. 5. Patient assessment data and information, including needs not addressed during transport, are provided upon arrival to the receiving organization for further follow up as needed. Standard AOP.6 The transport organization has processes to screen, assess, and manage pain appropriately. Intent of AOP.6 Pain can be a common part of the patient experience; unrelieved pain has adverse physical and psychological effects. Appropriate screening, assessment, and management of pain is respected and supported by the transport organization. Pain may be severe and debilitating during emergency medical transport or may be a factor in selecting assistive devices for transporting a patient home following hospitalization. Thus, transport organizations have processes to identify patients with pain during initial assessment and reassessments; and educate health care providers in pain assessment and management. Measurable Elements of AOP.6 1. All patients are screened for pain. 2. The organization has processes to provide appropriate assessment, reassessment and management of a patient s pain. 3. The organization identifies patients in pain or for which the transport process may be painful.. 4. The organization educates health professionals in assessing and managing pain. References 1. De Giusti M, et al. Occupational biological risk knowledge and perception: Results from a large survey in Rome, Italy. Ann Ist Super Sanita. 2012;48(2): Accessed Jun 22, scielo.php?script=sci_arttext&pid=s &lng=en&nrm=iso. 2. The Joint Commission Environment of Care Essentials for Health Care. Oak Brook, IL: Joint Commission Resources, Sharma J. Management of biohazards: An occupational need. J Sci Ind Res (India) Mar;70(3): World Health Organization. Waste from Health-Care Activities. Fact Sheet 253. Nov Accessed Jun 22, fs253/en/. 5. World Health Organization (WHO). Laboratory Biosafety Manual, 3rd ed. Geneva: WHO, Accessed Jun 22, publications/biosafety/biosafety7.pdf. 6. Blasi B, et al. Red blood cell storage and cell morphology. Transfus Med Apr;22(2): Improving blood safety worldwide. Lancet Aug 4;370(9585):361. Accessed Jun 22, ImprovingBloodSafetyWorldwide.pdf. 8. Grimm E, et al. Blood bank safety practices: Mislabeled samples and wrong blood in tube A Q-Probes analysis of 122 clinical laboratories. Arch Pathol Lab Med Aug;134(8): Heddle NM, et al. The effect of blood storage duration on in-hospital mortality: A randomized controlled pilot feasibility trial. Transfusion Jun;52(6): Klapper E, et al. Transfusion Practice: Toward extended phenotype matching: A new operational paradigm for the transfusion service. Transfusion Mar;50(3): Lindholm PF, Annen K, Ramsey G. Approaches to minimize infection risk in blood banking and

98 transfusion practice. Infect Disord Drug Targets Feb;11(1): Maskens C, et al. Hospital-based transfusion error tracking from 2005 to 2010: Identifying the key errors threatening patient transfusion safety. Transfusion. Epub 2013 May Puopolo M, et al. Transmission of sporadic Creutzfeldt-Jakob disease by blood transfusion: Risk factor or possible biases. Transfusion Jul;51(7): Stein J et al. Risk-based decision-making for blood safety: Preliminary report of a consensus conference. Vox Sang Nov;101(4): World Health Organization. Developing a National Blood System (Aide-Mémoire) Accessed Jun 22, am_developing_a_national_blood_system.pdf. 16. World Health Organization. Blood Transfusion Safety. Accessed Jun 22, en/index.html.

99 Care of Patients (COP) Changes to the COP Chapter Standard Change Explanation Note: This table lists changes to requirements in this chapter only. Requirements that were in this chapter in the 1st edition of this manual and are now contained either in their entirety or in part in another chapter of this 2nd edition are listed in that chapter s Changes table. The following standard appeared in this chapter of the 1st edition standards but was deleted from this edition (listed with 1st edition numbers): Overview Emergency medical transport organizations may be called upon to provide many types of patient care in many different settings such as in a home, at the site of an accident or disaster, or even at the organization home base when a patient with a medical need walks in. Providing appropriate care in many settings and in a manner that supports and responds to each patient s unique needs requires a high level of planning and coordination. Certain activities are basic to patient care. These activities, based on the assessment of patients (see AOP.1), include planning and prioritizing care (see AOP.5) and delivering care to each patient, monitoring the patient to understand the results of the care, modifying the care when necessary, completing the care when appropriate, and determining the need for follow-up. These activities are basic to the treating and releasing of a patient, as well as the treating and transporting of a patient to a receiving organization.

100 Standards, Intents, and Measurable Elements Care Delivery for All Patients Note: This standard applies to those organizations that provide only emergency medical transport or provide both emergency and nonemergency transport services. Standard COP.1 Policies and procedures and applicable laws and regulations guide the uniform care of all patients. Intent of COP.1 Patients with the same health problems and care needs have a right to receive the same quality of care. Carrying out the principle of "one level of quality of care" requires that the clinical and management leaders plan and coordinate the care provided to patients during the transport process. In particular, services provided to similar patient populations in multiple settings are guided by policies and procedures that result in their uniform delivery. Those policies and procedures respect applicable laws and regulations that shape the care process. Uniform patient care is reflected in the following: Access to and appropriateness of care and treatment do not depend on the patient s ability to pay or the source of payment, as guided by the organization s mission. Acuity of the patient s condition determines the resources allocated to meet the patient s transport needs The level of care provided to patients with similar needs is the same for all the different settings in which care takes place. Uniform patient care results when the planning and delivery of care use similar integrated processes. The result is the efficient use of resources and permits the evaluation of outcomes of similar care throughout the transport organization. Measurable Elements of COP.1 1. The organization s clinical and managerial leaders work together to provide uniform care processes. 2. Similar care is provided in the same way in all patient care settings. 3. Policies and procedures guide uniform care and reflect relevant laws and regulations.

101 Standard COP.2 Transport organizations implement guidelines, pathways, protocols and other tools, to guide care and/or patient monitoring during transport. Intent of COP.2 The goals of a transport organization are to standardize clinical care and transport processes; standardize patient monitoring to reduce risks during care and transport; and provide clinical care and transport services in a timely, effective manner using available resources efficiently. Transport organizations use a variety of tools and approaches to reach these goals. For example, care providers seek to develop clinical care processes and make clinical care decisions based on the best available scientific evidence. Similarly, nonemergency transport organizations make decisions using protocols, professional standards and similar tools. Thus protocols, pathways, guidelines and other defined processes are useful in this effort. When such guidelines and other related tools are available and relevant to the organization s patient population and mission, there is a process to evaluate the guideline or protocol, adapt it to the organization s communities, patient needs and resources, and train staff to use the guideline or protocol. Note: See AOP.1.2 for the use of guidelines in the patient s assessment and reassessment process. Measurable Element of COP.2 1. Guidelines, protocols, and pathways, when available and relevant to the organization s community, patient needs and services, are adapted or adopted and approved by the clinical and managerial leaders of the organization. 2. Guidelines, protocols pathways and other tools are selected and implemented for critical transport processes. 3. Transport organization leaders can demonstrate how the use of guidelines, pathways, protocols and other tools have reduced variation in processes and improved outcomes. The Transport of High-Risk Patients and Provision of High- Risk Services Standard COP.3 Policies and procedures identify and guide the care and transport of high-risk patients and the provision of high-risk clinical and nonclinical services. Intent of COP.3 Some patients are considered "high risk" because of their age, their condition, or the critical nature of their needs. Children and the elderly are commonly placed in this group as they frequently cannot speak for themselves, do not understand the care and/or transport process, and cannot participate in decisions regarding their care and transport. Similarly, the frightened, confused, or comatose emergency patient is unable to understand the care process when the care needs to be provided efficiently and rapidly.

102 Transport organizations also provide a variety of services, some of which are considered "high risk" because of the complex equipment needed to treat a life-threatening condition (for example, cardiac decompensation), the nature of the treatment (for example, use of blood and blood products or an invasive procedure), or the potential for harm to the patient (for example, restraint). Policies and procedures are important tools for staff to understand these patients and services and to respond in a thorough, competent, and uniform manner. The clinical and managerial leaders take responsibility for identifying the patients and services considered high risk in the organization; using a process to develop relevant policies and procedures; and training staff in implementing the policies and procedures. High-risk patients and services include: a) emergency patients; b) comatose patients; c) patients on life support; d) care and/or transport of patients with a communicable disease; e) care and/or transport of immunosuppressed patients; f) care and/or transport of patients receiving dialysis; g) care and/or transport of patients in restraints; h) care and/or transport of patients receiving chemotherapy; i) care and/or transport of vulnerable patient populations, including frail elderly, dependent children, and patients at risk for abuse and/or neglect; and j) prisoners and those under police protection or supervision Additional patients and services are included when represented in the organization s patient population and services. Policies and procedures must be tailored to the particular at-risk patient population or high-risk service to be appropriate and effective in reducing the related risk. Of particular concern is that the policy or procedure identify how planning will occur; the documentation required for the care and transport teams to work effectively; special consent considerations; monitoring requirements; special qualifications or skills of staff involved in the care and transport process; and the availability and use of specialized equipment. Guidelines, pathways, protocols and other tools are frequently helpful in developing the policies and procedures and may be incorporated into them. Monitoring provides the information needed to ensure that the policies and procedures are adequately implemented and followed for all relevant patients and services. Measurable Elements of COP.3 1. The organization s clinical and managerial leaders have identified high-risk patients and services including patients and services identified in a) through j) in the intent that are provided by the transport organization. 2. Applicable policies and procedures are developed and implemented. 3. Staff have been trained and use the policies and procedures to guide care and transport.

103 Sedation and Paralyzation Note: The standards in this section only apply to those organizations that provide emergency medical transport services. Proper use of medications (including those for pain, seizure control, and muscle relaxation, such as narcotics, benzodiazepines, and/or nitrous oxide) can often have the intended or unintended side effect of sedating a patient. Sedation can result in the loss of protective reflexes such as gag or pain withdrawal. Four levels of sedation are identified: minimal (no loss of normal function), moderate (conscious sedation), deep (with potential loss of spontaneous ventilation), and anesthesia (with potential cardiovascular instability). Additionally, rapid sequence intubation often calls for complete paralysis. Because the depressive side effects of these medications are often individual and unpredictable, the standards call for staff to be able to manage a patient who is sedated at one level deeper than intended. The standards for sedation apply when patients receive, in any setting, for any purpose, by any route, any sedatives or paralytics. For the purposes of this chapter, the words sedative and sedation are intended to include paralyzation and paralytics. Note that paralyzation should never be a substitute for sedation, and the use of paralytics should be coupled with extra quality monitoring. Definitions of the levels of sedation include the following: Minimal sedation: A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected. Moderate sedation/analgesia ("conscious sedation"): A drug-induced level of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patient airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Deep sedation/analgesia: A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. Anesthesia and/or paralysis: The administration to an individual, in any setting, for any purpose, by any route (general, spinal, or other), of major regional anesthesia or sedation (with or without analgesia) for which there is a reasonable expectation that, in the manner used, the analgesia or sedation will result in the loss of protective reflexes. Standard COP.4 Procedural sedation is standardized and provided by qualified individuals. Intent of COP.4 Procedural sedation, which includes moderate and deep sedation, involves any sedation administered intravenously, regardless of the dosage. Procedural sedation can be performed during transport. Because procedural sedation, like anesthesia, poses significant potential risks to patients, the administration of sedation is guided by policies and procedures to reduce variation in practice. The qualifications of staff participating in the procedure, the medical technology, the supplies, and the monitoring must be the same wherever and whenever procedural sedation is provided.

104 Standardization of procedural sedation is supported by policies and procedures and identifies a) areas or types of emergency medical transport where procedural sedation may occur; b) special qualifications or skills of staff involved in the procedural sedation process; c) the differences between pediatric, adult, and geriatric populations or other special considerations; d) availability and use of specialized medical technology; and e) obtaining informed consent for both the procedure and sedation. The qualifications of the physician, EMT, or other individual responsible for the patient receiving procedural sedation are important. Understanding the methods for sedation as they relate to the patient and the type of procedure performed improves the patient s tolerance of an uncomfortable or painful procedure and decreases the risks of complications. Complications related to procedural sedation primarily include cardiac or respiratory depression. Thus, certification in at least basic life support is essential. In addition, knowledge of the pharmacology of the sedation agents used, as well as reversal agents, decreases the risks of adverse outcomes. As such, the individual responsible for procedural sedation must be competent in f) techniques and various modes of sedation; g) pharmacology of sedation drugs and the use of reversal agents; h) monitoring requirements; and i) response to complications. The health care practitioner performing the procedure should not be responsible for providing continuous monitoring of the patient. A separate, qualified individual should assume responsibility for providing uninterrupted monitoring of the patient s physiological parameters and assistance in supportive or resuscitative measures. The individual responsible for providing the monitoring must be competent in j) monitoring requirements; k) response to complications; l) use of reversal agents; and m) recovery criteria. It is not always possible to predict how an individual patient receiving sedation will respond. Qualified individuals are trained to administer pharmacological agents to predictably achieve desired levels of analgesia or sedation, and to monitor patients carefully in order to maintain them at the desired level of sedation. When one individual is both administering the sedation and monitoring the patient they are quality to do both as defined above. Measurable Elements of COP.4 1. Procedural sedation is standardized throughout the transport organization and includes a) through e) in the intent. 2. Individuals administering procedural sedation are qualified including f) through i) in the intent. 3. Individuals monitoring the patient are qualified including j) through m) in the intent. Standard COP.5 Each patient s physiological status is monitored during and following administration of procedural sedation. Intent of COP.5 Physiological monitoring is often the only reliable source of assessment for patients who undergo sedation. The patient s physiological status is measured and assessed throughout sedation to ensure appropriate physiological support. Appropriate equipment for care and resuscitation is available for monitoring vital signs, including heart and respiratory rates and pulse oximetry (for all but minimal sedation). Heart rate and rhythm and pulse oximetry

105 (for all but minimal sedation) are continuously monitored. Respiratory frequency and adequacy of pulmonary ventilation are continually monitored. Blood pressure is measured at regular intervals. The monitoring is documented in the patient s record. Measurable Elements of COP.5 1. Each patient s physiological status is monitored during and following sedation. 2. Appropriate equipment for care and resuscitation is available for monitoring vital signs, including heart rate and rhythm, respiratory rate, capnography, and/or pulse oximetry. 3. Heart rate and rhythm and pulse oximetry (for all but minimal sedation) are continuously monitored. 4. Respiratory frequency and adequacy of pulmonary ventilation are continually monitored. 5. Blood pressure is measured at intervals appropriate to the patient s condition. 6. The results of monitoring are documented. Invasive Procedures Note: The standards in this section only apply to those organizations that provide emergency medical transport services. Standard COP.6 Invasive procedures are based on the results of a patient s assessment. Intent of COP.6 The care of patients, at times, may require that an invasive procedure be performed to treat or facilitate treatment. Because invasive procedures carry a level of risk, their use is carefully planned. Patient assessment is the basis for determining when an invasive procedure is necessary and in selecting the appropriate procedure. Assessment provides information necessary to select the appropriate procedure and the optimal time; perform procedures safely; and interpret findings of patient monitoring. Procedure selection depends on the patient s history, physical status, and diagnostic data as well as the risks and benefits of the procedure for the patient. Procedure selection considers the information from the assessment, test results, and other available information. The assessment process is carried out in a shortened time frame for emergency patients. The assessment also helps in the determination of when an invasive procedure should be deferred to the receiving organization. A patient s continuing care may depend on the events and findings of the invasive procedure. Thus, the patient s record includes any diagnosis, a description of the procedure and any findings, and the names of the individual performing or assisting in the procedure. The patient s physiological status is monitored during the invasive procedure and immediately after. The monitoring is appropriate to the patient s condition and the procedure performed. Results of monitoring trigger key decisions during the procedure as well as decisions regarding post-procedure follow-up. Monitoring findings are entered into the patient s record.

106 It is necessary to plan for any post-procedure care, including the level of care, the care setting, follow-up monitoring or treatment, and the need for medication. The required post-procedure care is documented in the patient s record to ensure continuity of services during the recovery or rehabilitative period. Measurable Element of COP.6 1. Patient assessment information is the basis for determining the need for invasive procedures. 2. A description of the invasive procedure and any findings are recorded. 3. The patient s physiological status is monitored continuously during the procedure and is recorded. 4. Any necessary post-procedure care is planned and recorded. Medication Use Standard COP.7 Medication management and use in the transport organization meet patient needs and comply with laws and regulations and standards of practice. Intent of COP.7 Medications are frequently used in treating and transporting emergency patients and many nonemergency patients may be taking medications regularly or at discharge. As an important resource in patient care, medication use must be organized effectively and efficiently. Medication management is a joint responsibility of the clinical and management leaders of the transport organization.. How this responsibility is shared depends on the organization s structure and staffing. Medications may be managed from one central supply in the organization, through the pharmacy of a health care organization, or from a supply on each transport vehicle. Applicable laws and regulations are incorporated into the organizational structure and the operations of the medication management system used in the organization. Every organization must decide which medications to make available for use by care providers. This decision is based on the organization s mission, patient needs, and the types of services provided. The organization develops a list of all the medications it stocks or that are readily available from outside sources. In some cases, laws or regulations may determine the medications on the list or the source of those medications. Measurable Element of COP.7 1. Medication management and use is organized so that patient medication needs are met. 2. Medication management and use complies with applicable laws and regulations. 3. Medications available are appropriate to the organization s mission, patient needs, and services provided. 4. There is a method for oversight of medication use within the organization, under the shared responsibility of clinical and managerial leaders.

107 Standard COP.7.1 There is a list of medications stored and available for use in the transport organization s base or transport vehicles and the medications are protected from loss, theft, damage or abuse. Intent of COP.7.1 Medication selection is a joint process, overseen by clinical and management leaders. They consider patient need and safety as well as economic factors. The organization has a method, such as a committee, to maintain and monitor this medication list and to monitor the use of medications within the organization. To ensure access to emergency medications when needed, the organization establishes a procedure or process to prevent abuse, theft, or loss of the medications and to ensure that medications are replaced when used or when damaged or out-of-date. The medication list for nonemergency transport organizations will be very different from that of emergency medical transport organizations. The list may include medications that do not require authorization (prescribing) or that the patient can self-administer, such as an analgesic for a headache. Measurable Elements of COP A process, managed by clinical and management leaders, is used to develop the list of medications to be stored and used in the context of laws and regulations. 2. The transport organization establishes and implements a process for how medications are stored and maintained. 3. Medications are protected from loss, theft, damage or abuse. 4. Accountability for tracking medications is assigned to one or more individuals by the clinical leaders. 5. Medications are monitored and replaced in a timely manner after use or when expired or damaged. Standard COP.7.2 The transport organization, through its clinical leaders, identifies those qualified individuals permitted to authorize medications and those permitted to administer medications. Intent of COP.7.2 Selecting a medication to treat a patient requires specific knowledge and experience. Clinical leaders within each organization are responsible for identifying those individuals with the requisite knowledge and experience and who are also permitted by licensure, certification, laws, or regulations to authorize medications. The administration of medication requires knowledge, skills, and experience. Each organization is responsible for identifying those trained and experienced individuals permitted by the organization and by licensure, certification, laws, or regulations to administer medications. For nonemergency transport organizations individual drivers or those accompanying a patient may be permitted to assist a patient in self-administration of a medication, or provide an analgesic for a patient with pain. All medications are written in the patient s record. Measurable Elements of COP Only those permitted by the organization and by relevant licensure, laws, and regulations authorize medications. 2. Only those permitted by the organization and by relevant licensure, certification, laws, or regulations administer medications. 3. The process is directed and monitored by the clinical leaders of the transport organization..

108 4. Medications authorized and administered are written in the patient s record. Standard COP.7.3 Medications are labeled and stored in a safe and clean environment. Intent of COP.7.3 The emergency medical transport organization provides a clean and safe environment for medication storage that complies with laws, regulations, and professional practice standards. In particular, medications are clearly labeled, stored properly, and protected from heat and light when necessary. Medications stored and dispensed from areas outside the organization (for example in transport vehicle) comply with the same safety measures. Measurable Elements of COP Medications are labeled according to organization policy. 2. Medications are stored according to organization policy. 3. Medication management and storage complies with laws, regulations, and professional standards of practice. Standard COP The transport organization has a medication recall system. Intent of COP The transport organization has a process for identifying, retrieving, and returning or destroying medications recalled by the manufacturer or supplier. There is a policy or procedure that addresses any use of or the destruction of any known expired or outdated medications. Measurable Elements of COP There is a medication recall system in place. 2. Policies and procedures address any use of any known expired or outdated medications. 3. Policies and procedures address the destruction of any known expired or outdated medications. 4. Policies and procedures are implemented. Standard COP.7.4 Medication effects on patients are monitored and adverse effects recorded. Intent of COP.7.4 The purposes of monitoring are to evaluate the medication s effect on the patient s symptoms or illness, adjust the dosage or type of medication when needed, and evaluate the patient for adverse effects. Monitoring medication effects includes observing and documenting any adverse effects. Through clinical leaders, the organization identifies all those adverse effects that are to be recorded and those adverse effects that must be reported. The organization establishes the mechanism for reporting adverse events when required and the time frame for reporting. Measurable Element of COP Medication effects on patients are monitored and recorded.

109 2. The organization has identified those adverse effects that are to be recorded in the patient s record and those that must be reported to the transport organization and/or outside agencies or organizations. 3. Adverse effects are reported as required. Standard COP.7.5 Medication errors and near misses are reported through a process and time frame defined by the transport organization. Intent of COP.7.5 The transport organization has a process to identify and report medication errors. The process is developed jointly by the clinical and managerial leaders.. The process includes defining a medication error, using a standardized format for reporting, and educating staff on the process and importance of reporting. The reporting process is part of the organization s performance improvement program. The program is focused on the prevention of medication errors through understanding the types of errors that occur in the organization and in other organizations. Improvements in medication processes and staff training are used to prevent errors in the future. The pharmacy or pharmacist associated with the transport program participates in such staff training. Measurable Elements of COP Medication errors are defined. 2. Medication errors are reported in a timely manner using an established process. 3. The organization uses medication error reporting information to improve medication use processes. 4. Near misses are defined. 5. Near misses are reported in a timely manner using an established process. 6. The organization uses medication error reporting information to improve processes. Nontreatment and Nontransport Note: The standards in this section only apply to those organizations that provide emergency medical transport services. Standards COP.8 and COP.8.1 There is a process to treat and release patients. Standard COP.8.1 Criteria are used to determine when a patient will not be treated or transported. Intent of COP.8 and COP.8.1 There are treat and release situations in which the emergency medical transport organization may be involved.

110 The transport organization might treat a patient but not transport him or her, the patient might refuse treatment or transport, or the organization might decline to treat or transport a patient. The emergency medical transport organization has a written process for managing these situations. The process addresses determination of whether the individual has a legal right to make care decisions; verification of the patient s physical and mental competence; and criteria for transporting a patient against his or her will. Written criteria are used to determine when the emergency medical transport organization can decline to treat or transport a patient. When screening criteria are met and the emergency medical transport organization decides not to treat or transport a patient, there is a process to ensure that the patient is physically and clinically safe; and verify that the patient is competent and mentally capable of understanding his or her care needs, if any. Treat and release and protocols for not treating or transporting are developed jointly by clinical and managerial leaders.. Staff are trained in all protocols and can verbalize the process to follow when these situations arise. The process is implemented and situations are appropriately documented. Measurable Elements of COP.8 1. There is a process to treat and release patients. 2. Treat and release procedures are developed and approved jointly by clinical and managerial leaders.. 3. The process addresses verification of the patient s clinical competency, 4. The process addresses criteria for transporting a patient against his or her will. 5. Staff are trained in all protocols and can verbalize the process to follow when these situations arise. 6. The process is implemented and situations encountered documented. Measurable Elements of COP Written criteria are used to determine when the emergency medical transport organization can decline to treat or transport a patient. 2. When the emergency medical transport organization decides not to treat or transport a patient, there is a process to ensure that the patient is physically and clinically safe. 3. When the emergency medical transport organization decides not to treat or transport a patient, there is a process to verify that the patient is competent and mentally capable of understanding his or her care needs, if any. 4. Protocols not to treat or transport are developed and approved by clinical and managerial leaders. 5. Staff are trained in all protocols and can verbalize the process to follow when these situations arise. 6. The process is implemented and situations encountered documented. References 1. Dykes PC, et al. Leveraging standards to support patient-centric interdisciplinary plans of care. AMIA Annu Symp Proc. 2011;2011: Lamoure J, et al. The Collaborative Patient/Person- Centric Care Model (CPCCM): Introducing a new paradigm in patient care involving an evidenceinformed approach. Canadian Healthcare Network. Epub 2011 Mar O Leary KJ, et al. Patterns of nurse-physician communication and agreement on the plan of care. Qual Saf Health Care Jun;19(3): Schwartz JM, et al. The daily goals communication sheet: A simple and novel tool for improved communication and care. Jt Comm J Qual Patient Saf Oct;34(10): O Leary KJ, et al. Hospitalized patients understanding of their plan of care. Mayo Clin Proc. 2010;85(1): Bonnell S, Macauley K, Nolan S. Management and handoff of a deteriorating patient from primary to acute care settings: A nursing academic and acute care collaborative case. Simul Healthc Jun;8(3):

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