Quality Assurance and Reporting

Section 518 Section 518.1800  Quality Assurance and Reporting a)         The freestanding emergency center shall develop and implement a quality assessment and improvement program designed to meet at least the following: 1)         Ongoing monitoring and evaluation of the quality and accessibility of care and services provided, including, but not limited to: A)        Infection control, B)        Patient satisfaction, C)        Compliance with EMS System protocols, and D)        Timely patient transfers to hospitals; 2)         Identification and analysis of problems; and 3)         Identification and implementation of corrective action or changes in response to problems. b)         The freestanding emergency center shall report the following to the Department: 1) Reports of any patient transfers from the FEC to a hospital shall be faxed to the Chief, Division of Health Care Facilities and Programs at (217)782-0382 within 48 hours after the transfer . (Section 32.5(a)(10) of the Act) Reports shall list the patient's name, diagnosis, date and time of arrival at the FEC, and date, time, destination and mechanism of transfer from the FEC. 2)         Reports of morbidity and mortality rates for patients treated at the FEC shall be submitted on a quarterly basis .  (Section 32.5(a)(11) of the Act) 3)         Reports of all patients transferred to trauma centers shall be submitted on a quarterly basis. 4)         Reports of injuries allegedly caused by a violent act shall be reported in accordance with Section 55.80 of the Civil Administrative Code of Illinois and the Violent Injury Reporting Code. c)         Each freestanding emergency center shall submit a data report, completed by each vehicle service provider for every emergency pre-hospital or inter-hospital transport, to the Department's Division of Emergency Medical Services and Highway Safety on March 1, June 1, September 1 and December 1 of each year, covering run report data from the preceding quarter.  The report shall be in one of the following formats: 1)         Copies of the Department-issued scannable run report form, or 2)         A data diskette containing the prescribed data elements. A)        The data elements shall be in a format compatible with the Department's database input specifications, and B)        Department review and approval of data format compatibility is required prior to submission. d)         Each FEC shall develop and implement a mechanism for linking run reports with emergency department, trauma center and admission records from the hospitals that receive emergency patients within the System.  This mechanism shall facilitate tracking of case outcomes for purposes of internal quality control, medical study and improvement of both adult and pediatric patients. e)         The FEC shall use the single form designated or approved by the Resource Hospital. f)         The FEC shall report any injury resulting from the discharge of a firearm or any injury sustained in the commission of or as a victim of a criminal offense. (Section 3.2 of the Criminal Identification Act)