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To determine or to assist in developing an indicator using the eight (8) categories <br />above, the Manager of QAtQI will present to Quality Review Committee the information <br />from the following: <br />Manager, Director, Corporate Board or Strategic Planning <br />Information or issues during a meeting of Company Managers, Directors or Corporate <br />Board members that are forward to the Quality Review Committee for consideration of <br />tracking as an indictor. <br />Incidents and bion -Indicator Tracking/Fallout Log <br />Incident reports may be used for a variety of circumstances, and not only for negative <br />situations. An incident report may be initiated to simply identify a situation that warrants <br />attention. The report creates a "paper trail" that can allow a situation to be monitored <br />and tracked. Below are some examples of when an incident report might be Initiated: <br />Unexpected Clinical Event <br />: Equipment Failure <br />Delayed Response <br />• Protocol Variance <br />• Extenuating Circumstances <br />« Vehicle Accidents <br />• Customer Dissatisfaction <br />• Deviation of Destination Guidelines <br />» Exceptional Performance <br />Incident reports are normally routed through the Division Manager or Operations <br />Manager. The Operations Manager will forward to Quality Improvement any situations <br />with patient care implications. These may be positive or negative. The Quality <br />Improvement Department will document the incident in the non -indictor tracking log and <br />present the findings to Quality Review Committee, <br />Quality Review Committee Development of Standardized EMS Indicators <br />The Process <br />The primary QI tool Is the standardized EMS quality indicator. Methods for developing <br />and using the indicators to measure EMS system performance are described in the <br />following steps: <br />STEP 1, Asking the Questions <br />Gather all committee members together and have the Manager of QAfQI <br />present feedback from the management meetings and the incident tracking <br />logs. Use a brainstorming session with the group find out what questions they <br />have regarding the issues. Clearly state the purpose of the brainstorming <br />