Achieving electronic data-driven QA/QI results

The Monroe Fire Department’s Continuous Quality Improvement Plan provides an effective tool for evaluating and improving the quality of prehospital care

By Joseph Locke, EMT-P

The city of Monroe (Ohio) Fire Department annually responds to approximately 2,000 EMS calls. Historically, there was not a universally objective way of evaluating any of our EMS providers.

The fire department established a formal QA/QI process in July of 2019. This QA/QI process will showcase how electronic EMS data collected at the point of care can be harnessed to increase patient safety and reduce EMS provider errors, and improve patient outcomes while increasing EMS billing revenue.

The purpose of the Monroe Fire Department’s Continuous Quality Improvement Plan (CQIP) was to establish a department-wide process and provide an effective tool for evaluating and improving the quality of prehospital care within the department. This tool will focus on improvement efforts to identify root causes of errors and identify a remedial plan. The CQIP will also recognize excellence in performance and service to the community. The intent of this process is not be punitive, but to be educational.


Quality assurance: Every EMS call is reviewed using a standard process of assessing all aspects of the electronic patient care report, including, but not limited to:

  • Billing and documentation, including incident number, signatures, date, patient name and patient medications; as well as the entire crew on scene – including the engine crew, hospital selection, delays and the hospital-provided electronic patient tracking number
  • Treatment, accurately documenting all treatments and interventions, medications administered, DNR status, a minimum of two complete sets of vital signs, ECG attached to the PCR, specialty cases (e.g., RSI, stroke, traumas, cardiac alerts, etc.), glucose check when indicated (e.g., altered GCS), and assessing for CHART narrative style

Once the EMS report is reviewed, it is tracked in each EMS providers’ electronic file. When an error occurs, a quality improvement form is generated. This QI form will identify the errors made, utilizing protocol language or department policy as a guide. The QI form will provide insight to the error made and identify the appropriate action that should occur in that particular situation. This form is delivered to the EMS provider for review. At that time, the QI form is signed by the EMS provider and then the QI form is filed in the EMS provider’s individual electronic folder.

Tracking this data electronically allows for real-time statistics to be generated on an individual EMS provider, crew, shift and department basis. This analyzed data is utilized to identify specific errors and provide insight into why the error occurred, the statistical rate of errors made, and to identify individual or department remediation needs.

We classify each error on a tiered rating system. Tier 1 is a minor documentation or protocol error that had no effect on patient care (e.g., an inaccurate run number).

A Tier 2 error is a moderate treatment or protocol error that possibly had a negative impact on patient care or patient outcome. An example of a Tier 2 would be failure to obtain a 12 lead ECG in the presence of chest pain.

A Tier 3 error is a major treatment or protocol error deemed to be dangerous and/or that had a direct negative effect on patient outcome. An example of a Tier 3 would be administering 1 mg 1:1,000 epi IVP during a cardiac arrest, when section 2005 of the GMVEMSC section of the protocol states to administer 1 mg 1:10,000 epi IVP.


At the launch of the QA/QI system in July of 2019, the Monroe Fire Department recorded 46 errors. In September of 2022, we recorded 6 errors. Interestingly, sharp increases in errors are directly correlated to newly hired EMS providers (click here to see the chart full size. ).

Figure 1: Errors per month
This table represents the quantity of errors/tiers per month since July 2019 to September 2022.

In July 2019, 72% of the EMS runs were without a documented issue (28% had issues). In September of 2022, 96% of the EMS runs were without a documented issue (4% had issues).

Figure 2: Department accuracy
This table represents the runs, tiers and the department accuracy percentage for the month.

In 2019, the highest rated EMS provider had an accuracy rating of 99.04% and 5 providers were rated above 98% (click here to see the chart full size). In 2020, the top EMS provider had an accuracy rating of 99.3% and 10 providers were rated above 98%. In 2021, there were 7 providers who had an accuracy rating of 100% and 30 providers who were rated above 98%.

Since the implementation of the QA/QI program, our department has seen a vast increase in EMS provider accuracy, a stark decrease in EMS provider errors, increased EMS provider protocol compliance and an increase in EMS billing revenue.

Revenue growth

Another impact of our improved EMS quality is an increase in EMS billing revenue. In 2017, the department transported 1,630 patients and recovered $387,000 through EMS billing. In 2021, the department transported 1,815 patients and recovered $517,000 through EMS billing.

About the author

Joseph Locke, EMT-P, is the City of Monroe Fire Department EMS coordinator. He is certified as a Safety Officer; EMS Instructor; Fire Instructor; Fire Officer I, II and III; Ohio Firefighter II; Ohio Paramedic; HAZMAT Tech; and ACLS/PALS/BLS Instructor. He holds an Associates of Applied Scienced degree. 

He also implemented the department’s current version of EMS QA/QI, which analyzes all aspects of data, protocol and billing requirements. This system has improved recent statistics to an area best 99% accuracy.

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