Spreadsheet: 40ed0973-b7c7-4369-a004-02efd475028b
Sheet: Sheet1

EMS Operational Program QA/QI Quarterly Aggregation of Data Reporting Form | Unnamed: 1 | Unnamed: 2
(Required by COMAR 30.03.04.02)
If you need assistance with this form,  please contact [NAME], Chief Compliance Officer, at (410) 706-2339 or (410) 446-5102. Reports are due 14 days after the end of each period ª to MIEMSS Compliance Office and the State EMS Medical Director's Office via e-mail ([EMAIL], and [EMAIL]).
Reporting Period: | Enter Reporting Period
Report Due Date: |  | Enter Date
Name of EMS Operational Program (EMSOP)/Jurisdiction: | Enter Your EMSOP
QA Officer Name: | Name
QA Officer Phone Number: | Contact Info
QA Officer E-mail Address: | Contact Info
ª  Fiscal Year Reporting Periods - July-Sept, Oct-Dec, Jan-Mar, Apr-June | Cases Reviewed by QA Officer's) | Cases Reviewed by Medical Review Committee *
Types of Cases          ( Select Single Most Significant Indicator ) |  | ( Part "A")
- Protocol Variation (e.g., Potentially Harmful Medication or Patient Care Error) *
- Prohibited Conduct (e.g., Criminal Offense, Substance Abuse) *
- Skills Issue (e.g., [NAME], beyond scope of practice, potentially harmful) *
- Documentation Issue     (e.g., Incomplete/Improper documentation of patient care or refusal)
- Transport Issue              (e.g., prolonged transport time, incorrect destination hospital)
- Dispatch Issue                (e.g., ALS not dispatched)
- Communication Issue    (e.g. misunderstanding in relay of information)
- Conduct Issue                 (e.g., unprofessional behavior on call - consider *)
- Routine Patient Care Review        (Specify - space provided on page 2)
- Other                                               (Specify - space provided on page 2)
Total                      ( "Types of Cases" )                                (Part "A")
Origin of Cases   ( Select Single Most Significant Indicator )
- EMSOP/Jurisdictional Medical Director
- EMSOP/Jurisdictional QA Officer
- Provider directly involved in case (self-reported)
- Other provider
- Hospital
- Nursing home/extended care facility
- Patient/Family
- Police/other agency                        (Specify - Space provided on page 2)
- Media
- Routine Patient Care Review        (Specify - Space provided on page 2)
- Other                                                 (Specify - Space provided on page 2)
- MIEMSS Medical Director/QA Officer
Total                        ( "Origin of Cases" )                             (Part "B")
* Requires 5- and 35-day report
Outcome of Cases    (Report Single Highest Action Taken)
- EMS Provider's Credentials Limited or Suspended (Medical Director) **
- Termination * (Notify MIEMSS Compliance Office ASAP)
- EMSOP sanctions / discipline * (e.g., Probation, Field Internship)
- Remediation / Re-training *
- Referral to MIEMSS for Action *
- Provision of additional resources  (e.g., New equipment added to ambulance stock)
- Change in jurisdictional procedures   (e.g., New local QA/SOP developed)
- Recommended change in State Protocol
- Unfounded
- Case Pending          (Specify Reason - Space provided on page 2)
- Routine Patient Care Review (Specify - Space provided on page 2)
- No action required
Total                             ( "Outcome of Cases" )                 (Part " C ")
** Requires immediate notification of State EMS Medical Director
Total # of patient encounters in period for EMSOP/Jurisdiction
Total # of QA Cases reported above for this period | (Totals - Part "A" = "B" = "C" )
Disposition of Cases                ( # of total cases, # in each category ) | MIEMSS COMPLIANCE OFFICE USE
- Resolved by EMS Operational Program
- Referred to State requesting Closure
- Referred to State recommending additional Action
I. Quality Assurance
a. Did you observe any trends within your program during this reporting period (e.g., problems with use of a particular medicine, problems with pediatric cases, etc.)?
b. Have you been able to address these issues within your jurisdiction or do you need assistance from the State (if so, please specify)?
II. Quality Improvement
Please list and describe jurisdictional QI projects (only new or updated information is  required, e.g., new projects, results of projects previously reported):
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