Self-Assessment Survey: Emergency Healthcare Systems (EHS) Plan

CATRAC has organized the DSHS Self-Assessment tool by four categories:
1. Emergency Healthcare Systems Plan
2. Research & Data
3. System Requirements
4. RAC Administrative requirements 
 
The Self-Assessment tool has been broken into four surveys. You are currently taking the Emergency Healthcare Systems Plan portion of the Self-Assessment Survey.
 
The following survey is the exact language from the Self-Assessment tool presented by each category. My apologies. Please score each element according to service line using the 0-5 scale to the best of your ability. The accuracy of identifying gaps in the region relies on the accuracy of this survey. 

The Element number corresponds directly to the RAC Self-Assessment Scoring Tool.
Taking this survey on a mobile device is not recommended.
First and last name(Required.)
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What service line are you representing? (check all that apply)(Required.)
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Element 8: SYSTEM PLAN

The trauma and emergency health care system plan has defined methods of assisting in sharing the regional and state all-hazard emergency response and preparedness plans with stakeholders.

Be sure to read each rating description as they vary for each question.

0. Not known or N/A

1. There is no evidence that the regional trauma and emergency health care system plan has defined processes to assist in sharing the regional and state all-hazard, emergency response preparedness plans.

2. There is an established regional trauma and emergency health care system plan but there is no linkage or assistance from the region that addresses the sharing of the regional or state all-hazard emergency response and preparedness plans.

3. The regional trauma and emergency health care system plan addresses the regional role in assisting in sharing the regional health care coalition all-hazard, emergency response and preparedness plan with stakeholders.

4. In addition to #3, RAC leaders foster regional stakeholder integration with exercising planning, and public health initiatives.

5. In addition to #4, regional stakeholders have opportunities to integrate with the regional medical operation center through an inclusive process, as well as participation in all response after-reviews.

Please rate each service line below. 
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Element 10: SYSTEM PLAN

The regional trauma and emergency health care system plan includes the identification of resources (both staffing and equipment) necessary to respond to system needs.

Be sure to read each rating description as they vary for each question.

0. Not known or N/A

1. The regional trauma and emergency healthcare system plan does not include processes to assist in the identification of additional resources.

2. The regional trauma and emergency health care system plan addresses system needs but does not have measures to assist in identifying additional resource needs for all areas of the region.

3. The regional trauma and emergency health care system plan identifies both equipment and staffing resources available currently and can assist in identifying when additional resources are needed.

4. In addition to #3, this monitoring of equipment and resources includes all geographic areas of the region for continual operations. (Example: pediatric transport capabilities in the very rural areas of the region are needed.)

5. In addition to #4, the regional leaders and stakeholders collectively work on strategies to address the additional resource needs and share the strategies with the regional stakeholders, public health, local officials, local business community stakeholders, and the department.

Please rate each service line below. 
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Element 12: SYSTEM INTEGRATION

The RAC utilizes the recommendations from the trauma, prehospital, perinatal, stroke, and cardiac medical directors, medical advisory collaboration that fosters the integration of the specialty needs of the regional trauma and emergency health care system are addressed.

Be sure to read each rating description as they vary for each question.

0. Not known or N/A

1. Medical oversight for the region is not defined.

2. Regional medical advisory collaboration that fosters the specialty needs within the regional trauma and emergency health care system is not in place

3. The region has a defined structure to ensure medical oversight advisory responsibilities for trauma, prehospital, perinatal, stroke, cardiac and other emergency healthcare needs in the region are established.

4. In addition to #3, guidelines for field triage and destination criteria, regional standards of care and evidence-based practice guidelines, hospital communication, EMS time-out during patient hand-off at the hospital, and transfer coordination. The region routinely evaluates the compliance to established regional standards of care through its performance improvement processes.

5. In addition to #4, the system stakeholders are included in the development of medical advisory guidelines. Performance improvement monitoring and outcomes are shared with stakeholders, public heath, local officials, business community stakeholders, and the department.

Please rate each service line below. 
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Element 14: SYSTEM INTEGRATION

The regional trauma and emergency health care system plan integrates the designated trauma, perinatal, stroke, and non-designated chest pain centers, with other acute care facilities, extended care facilities, and rehabilitation facilities along with the prehospital providers into the various regional committees. This includes facilities for specialty care such as burn care and prehospital providers.

Be sure to read each rating description as they vary for each question.

0. Not known or N/A

1. The regional trauma and emergency health care system plan does not include the designated facilities or prehospital providers in the region.

2. There is a regional trauma and emergency health care system plan that does integrate all designated facilities and prehospital providers but does not include others.

3. The regional trauma and emergency health care system plan integrates the designated trauma, perinatal, stroke, and non-designated cardiac chest pain centers with other non-designated acute care facilities, extended care facilities, and rehabilitation facilities as well as all 911 prehospital providers from the urban, suburban, and rural communities into the various regional committees and identified projects.

4. In addition to #3, defined roles, responsibilities, and expectations of participation in the regional committees are outlined in the regional bylaws.

5. In addition to #4, the committee outcomes are monitored, analyzed, and shared with the regional stakeholders, public health, local officials, business community, and the department.

Please rate each service line below. 
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Element 17: PREHOSPITAL

The regional trauma and emergency health care system EMS medical director committee is actively involved with the local and state advisory council initiatives focusing on the development, implementation, and ongoing evaluation of prehospital system guidelines. These guidelines include, but are not limited to, which resources to dispatch, for example, Advanced Life Support (ALS) versus Basic Life Support (BLS), air-ground coordination, early notification of the health care facility, pre-arrival instructions, and other procedures necessary.

Be sure to read each rating description as they vary for each question.

0. Not known or N/A

1. There are no regional trauma and emergency health care system recommended prehospital protocols.

2. Regional trauma and emergency health care system protocols have been developed but without regard to the national standards.

3. Regional trauma and emergency health care system guidelines have been developed and adopted and are congruent with national standards, but there is no evidence of a coordinated implementation process with the regional prehospital providers and other stakeholders.

4. In addition to #3, a documented regional implementation plan that includes the regional prehospital providers and other stakeholders with minimal outcome data.

5. In addition to #4, these guidelines are integrated with the system performance improvement process to evaluate the compliance to the guidelines and outcome data.

Please rate each service line below. 
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Element 20: DEFINITIVE CARE FACILITIES

The regional trauma and emergency health care system plan has measures in place to assist facilities in understanding the designation requirements and to ensure the facilities understand the data requirements specific to their level of designation and type of designation and the processes of data validation. This is coordinated through the various committees utilizing mentorship and education.

Be sure to read each rating description as they vary for each question.

0. Not known or N/A

1. The current regional trauma and emergency healthcare plan does not address designation assistance.

2. There is a regional trauma and emergency health care system plan, and it addresses data but does not focus on designation assistance or data validation.

3. The regional trauma and emergency health care system plan integrates the designation process and for trauma, maternal, neonatal, and stroke into the appropriate regional committees to assist with mentorship and measures to ensure data quality and data validation for all types of designation.

4. In addition to #3, the RAC and its various committees ensure participants are aware of the courses available to assist them in understanding the designation requirements and data requirements to include data validation.

5. In addition to #4, data, identified by the RAC, is reviewed to define improvements or ongoing needs through the system performance improvement process.

Please rate each service line below. 
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Element 24: PREVENTION, COALITION, OUTREACH

A written injury and disease prevention plan is developed and coordinated with other agencies and community partners. The prevention programs are data-driven and target high-risk injury and time-sensitive disease based on regional data. Specific goals with measurable objectives are incorporated into the prevention plan.

Be sure to read each rating description as they vary for each question.

0. Not known or N/A

1. There is no written plan for a coordinated injury and disease prevention program.

2. There are multiple injury prevention and disease programs that may conflict with resources available or with the goals of the regional trauma and emergency health care system, or lack of regional coordination.

3. The regional trauma and emergency healthcare system plan includes written guidelines for targeted, coordinated, injury and time-sensitive disease prevention programs which are based on regional data with defined goals and measurable outcomes.

4. In addition to #3, the written injury and time-sensitive disease prevention plan is implemented with regional and community stakeholder participation. These programs have regional support and may be integrated with established coalitions.

5. In addition to #4, these programs have documented evaluation processes to define the effectiveness of the programs. The program outcomes are shared with regional stakeholders, public health, local officials, the business community stakeholders, and the department through the regional annual report. If coalitions are not in place for high risk injury or time-sensitive disease the RAC may consider developing a coalition to integrate with the community partners and other interested stakeholders.

Please rate each service line below. 
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Element 26: REHABILITATION

The regional system has incorporated rehabilitation resources into the system plan.

Be sure to read each rating description as they vary for each question.

0. Not known or N/A

1. The regional stakeholders have not integrated rehabilitation resources into the trauma and emergency healthcare system plan.

2. The regional plan has incorporated rehabilitation programs, but rehabilitation specialists are not participating in the regional activities, only in the designated facilities.

3. The regional plan has incorporated opportunities for rehabilitation facilities to participate in regional activities.

4. In addition to #3, a regional rehabilitation specialist(s) is participating in the various committees.

5. In addition to #4, there is evidence of a well-integrated system plan to include rehabilitation facilities in the regional system planning efforts and rehabilitation facilities provide data on patient discharge functional outcomes for the regional annual report. Rehabilitation facilities participate in the system performance improvement process.

Please rate each service line below. 
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Element 30: REGIONAL SYSTEM PERFORMANCE IMPROVEMENT

The regional trauma and emergency healthcare system plan has defined processes to support a regional system performance improvement plan that is supported by regional stakeholders through committee participation, sharing of requested data, and review of specific regional referrals. The system performance improvement plan defines the review process, level of harm, and level of review to include the identified opportunities for improvement. All regional opportunities for improvement have a defined action plan and the action plan is implemented and monitored to reach event resolution. An annual summary of the regional performance improvement process is shared with the regional stakeholders. The retrospective regional medical advisory process review of the established patient field triage and destination, communication, treatment, and transport are integrated with the regional performance improvement process.

Be sure to read each rating description as they vary for each question.

0. Not known or N/A

1. The region does not have a defined structure or procedures to support a regional performance improvement process.

2. Elements of a regional system performance improvement process are established but there are no formal procedures established.

3. The regional leadership and stakeholders have developed and implemented a regional system performance plan that is supported by the stakeholders, committee activities, sharing of requested data, and referral of specific events for regional review. The system performance improvement plan defines the review process, level of harm, and level of review to include the identified opportunities for improvement. All regional opportunities for improvement have a defined action plan and the action plan is implemented and monitored to reach event resolution.

4. In addition to #3, The regional performance improvement process reviews data and events specific to prehospital field triage and destination, communication, treatment, and appropriateness of transport mode; diversion hours, transfer process, out-of-RAC transfers, double transfers, transfer delays due to transport agency or facility acceptance, compliance to established regional evidence-based practice guidelines, patient outcomes, and membership participation criteria defined in the bylaw.

5. In addition to #4, Annual reports of the performance improvement activities are developed and shared with stakeholders, public health, local officials, community stakeholders, and the department.

Please rate each service line below. 
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Element 31: REGIONAL SYSTEM PERFORMANCE IMPROVEMENT

The regional system performance improvement plan has standardized guidelines for the review of trauma, prehospital, perinatal, stroke, cardiac, and other time-sensitive disease process patient outcomes for all ages and all areas of the region. These outcomes are compared and measured against known national outcomes.

Be sure to read each rating description as they vary for each question.

0. Not known or N/A

1. The regional system does not have processes established to engage in performance review of patient care outcome data to evaluate its performance against national norms.

2. There is some standardized measurement of outcomes data for the region, but formalized processes are not in place

3. The regional system performance improvement plan outlines standardized processes for the review of trauma, prehospital, perinatal, stroke, cardiac, and other time-sensitive disease process outcomes, and shares reports with appropriate committees.

4. In addition to #3, these system reports are used by the stakeholders to identify opportunities for regional improvement and develop actions plans which are then implemented and monitored for the effectiveness of creating the needed change for system improvements.

5. In addition to #4, the system improvements are monitored and reported through the regional annual performance improvement report and shared with stakeholders, public health, local government, community business stakeholders, and the department.

Please rate each service line below. 
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