OAR 333-250-0320: Quality Assessment and Performance Improvement

(1) The licensed ambulance service shall establish and maintain an effective quality assessment and performance improvement program that is approved by the emergency medical services (EMS) medical director and ambulance service administrator and may include: (a) A method to monitor, evaluate and improve organizational efficiency and care delivery; (b) A method to select and track performance improvement indicators which may include, but are not limited to: (A) Accurate patient assessment; (B) Medical intervention delivered in accordance with established standing orders; (C) Success of skills; (D) Quality of clinical documentation; and (E) Clinical outcome data; and (c) A process for investigating and addressing patient safety issues raised by means other than measured indicators. (2) The ambulance service must implement a defined quarterly reporting process for performance improvement activities and issues including: (a) Documenting and reporting individual issues and clinical indicator results; and (b) Documenting and reporting aggregate data of clinical indicators and other activities to staff. (3) To assist the licensed ambulance service and the EMS medical director in determining if appropriate and timely emergency medical care was rendered to a patient, the ambulance service designated official may request the following information from the receiving hospital as authorized by ORS 682.056: (a) Patient admit status and unit admitted to; (b) Any procedure listed in the National Highway Transportation Safety Administration, National EMS Information System (NEMSIS) data dictionary, using a version determined by the Oregon Health Authority, and performed on the patient within the first hour of being admitted; (c) Any medication administered to the patient within the first hour of being admitted; and (d) Trauma system entry by emergency department staff. (4) Information provided under section (3) of this rule is considered confidential pursuant to ORS 682.056. Any employee or volunteer participating in a quality improvement session must have a signed confidentiality statement in their personnel file.