N.H. Admin. Code § Saf-C 5921.02

Current through Register No. 36, September 5, 2024

Section Saf-C 5921.02 - Quality Management Program Requirements

(a) Units shall be accredited by the Commission on the Accreditation of Ambulance Services (CAAS).

(b) If the unit is not accredited by the CAAS, then the unit shall establish a written plan, in collaboration with the MRH that conforms to the following:

(1) A written QM plan shall outline operational and clinical care performance measures that the EMS unit and the MRH agree to monitor;

(2) The written plan shall include, at minimum, the following:

a. A mission statement;

b. Goals and objectives;

c. Methods for addressing:

1. New employee training and orientation;

2. Employee training and certification;

3. Review of EMSIRs; and

4. Complaints and adverse or near-miss events;

d. Identification of benchmarks and issues to monitor;

e. A communication plan, including:

1. Confidentiality of information;

2. Feedback loop for providers, the QM committee, and the MRH; and

3. Periodic reporting to stakeholders; and

f. Key dates and authorizations, including:

1. Authorized and dated signatures of stakeholders;

2. Effective dates; and

3. Date of last review;

(3) The QM program shall include a QM committee;

(4) The QM committee shall include, at minimum, the following members who shall meet no less than 2 times per year:

a. A head of unit, or designee;

b. A training officer;

c. Two EMS providers, one which shall be the highest level provider on the unit roster; and

d. The medical director, or designee; and

(5) The QM written plan shall be kept on file and updated yearly.

(c) The written plan shall be made available for review by the division upon request.

(d) All programs set forth or defined by the division, the coordinating board, or medical control board that make use of EMSIR data benchmarks or standards for evaluation, measurement, or reporting of the quality of EMS care shall be considered a quality management program, including any reporting at the aggregate level.

(e) All quality management program requirements included in this section shall be protected from discovery in accordance with RSA 153-A:34, II.

N.H. Admin. Code § Saf-C 5921.02

(See Revision Note at chapter heading for Saf-C 5900) #7690, eff 5-21-02; ss by #8630, INTERIM, eff 5-19-06, EXPIRED: 11-15-06

New. #9779-A, eff 9-8-10 (from Saf-C 5921.01 )

Amended by Volume XXXIX Number 24, Filed June 13, 2019, Proposed by #12790, Effective 5/24/2019, Expires 5/24/2029.