MDOC Case Investigations

These guidelines will be used to evaluate events requiring medical review by the Medical Direction Committee (MDOC) for the City of Pittsburgh EMS. The members of the Medical Direction Committee include MDs number 1-5, Devon Davis and the EMS Fellows.

Our overall goal for incident evaluation is to identify ways to improve the individuals and the system. The focus should be remediation not discipline by the medical directors

• An event may be referred to the MDOC or identified by the MDOC as requiring Medical Review
  
• The event will be logged into the MDOC Continuous Quality Improvement (CQI) computer data base and assigned an initial Level of Concern

Levels of Concern:

Level A - ("atta" person), recognizing outstanding performance by a unit or individual; 

Level 0 - a nonevent; 

Level 1 - natural or predictable occurring event; 

Level 2 - event related to slight deviation from protocol or accepted standard of care; 

Level 3 - event related to a moderate deviation from protocol or accepted standard of care;

Level 4 - event related to significant deviation from protocol or accepted standard of care;

• Concerns brought to the attention of the MDOC may also result in discipline being issued by the Bureau of Emergency Medical Services.
  
• The event will be assigned to specific member MDOC for investigation. If you were the Command MD or MDOC on the day of the event then you should be the investigator. (MD2 does investigations that involve the EOC and Fire.) In a timely fashion, the MDOC will review all of the pertinent documentation and with a representative from Administration will seek input from the parties involved.
• If the evaluation may lead to administrative discipline, you must have an EMS supervisor with you when you speak with the paramedics. It is often difficult to know if an investigation will lead to disciplinary action. Therefore, if you are at all unsure, run the case by Deputy Chief Garretson.
• Although burdensome, this procedure helps administration participate in the process. 
• The medics may ask for Union representation at meetings. This is their right. However, I would strongly recommend that the MDOC set ground rules at the beginning of the meeting, i.e., the union representative will speak only at end and will not answer questions for the paramedic. 
• Because of shifts and schedules, meeting up with the paramedics is often challenging. If possible, try to meet the medics at their station while they are on duty. If this can not happen in a timely fashion or if the issue is particularly sensitive, send a letter to the medic (to be delivered by an EMS Supervisor) requesting a meeting with the medic. (We have a template letter on file) Deputy Chief Garretson has authorized overtime for the medics to meet with us. Try to meet at a place with easy parking such as medic 9.

• After completing the investigation the MDOC will, if necessary, prescribe a remediation plan for the personnel involved. System wide issues will be addressed through EMS Administration, EMS Training, the MDOC Newsletter, and/or changes in MDOC policies or protocols.
  
• With respect to a paramedic's ability to practice under the license of the Command Physicians and to maintain Command Authorization, the MDOCS have the following options: (These are not necessarily invoked in a step wise fashion.)
• No Change in Command Status 
• Provisional/Limited Command Status 
• Provisional Command status may limit the paramedics to perform specific skills or tasks. In general, Provisional Command status will be invoked for a specific time period during which the paramedic undergoes a remediation process. Failure to remediate may lead to withdrawal of Command Status. 
• Withdrawal of Command Status 

-Withdrawal of Command status means that the paramedic may not practice as an ALS provider in the Pittsburgh EMS system as per the Rules and Regulations of the State of Pennsylvania. We must submit paper work to EMSI.

• The paramedics involved in any event should receive written documentation from the MDOC based on their investigation. Any change in the paramedics Command Status will be clearly identified. In addition, steps required for remediation and return of command status, if appropriate, will be defined. EMS administration will receive a copy of the MDOCs findings. A copy of all of this documentation should go in the Pittsburgh EMS CQI database that is kept in the division office.
  
• The overall goal of the Pittsburgh EMS Continuous Quality Improvement process is to raise the level of medical care provided by the City of Pittsburgh EMS System. This will be accomplished by improving the performance of the individual paramedic and the overall system. 

October 22, 1999