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Accreditation/Re-accreditation

20 points of Accreditation/ReAccreditation (for Medical Dispatch Centers*)

The 20 points of Accreditation requirements are presented as a guide for EMS agencies to become officially recognized as an Accredited Center of Excellence. To apply for Accreditation, an agency must submit an ACE application form along with a self study document based on the twenty points of accreditation.

Click here to download the Medical Twenty Points Brochure

Click here to download the Medical Twenty Points Application

1. Communication center overview and description.

a) Document the total number of stations that are active (calltaking and dispatching) versus supervisory or standby (enter on line 9 of the application).
b) Include a floor plan showing the placement of each workstation.
c) List any current accreditations and the accrediting body.

2. Medical Priority Dispatch System® (MPDS) version and licensing confirmation.

a) Provide the following as applicable:

  • i. MPDS® version number
  • ii. ProQA® version number
  • iii. AQUA™ version number
  • iv. ED-Qâ„¢ Scoring Standards version

b) Include documentation (or policy) stating that the most recent versions of the Protocols (ProQA and/or cardsets) and the Scoring Standards will be implemented within one year of their release.

3. Current Academy EMD certification of all personnel authorized to process emergency calls.

a) Provide a list of all EMDs, indicating their name, hire date, last certification date, next recertification date, and Academy EMD certification number.

4. All EMD certification courses are conducted by Academy-certified instructors, and all case review is conducted by Academy-certified ED-Qs.

a) If you have an in-house or contracted instructor, include their name, next recertification date, and certification number.
b) List all ED-Qs, indicating their name, next recertification date, and Academy ED-Q certification number.

5. Full activity of quality improvement (QI) committee processes.

a) Include copies of agendas and minutes of all Dispatch Review Committee (DRC) and Dispatch Steering Committee (DSC) meetings (minimum of three required in the six months immediately preceding the application).
b) List the names and titles of all committee members for:

  • i. Quality Improvement Unit
  • ii. Dispatch Review Committee
  • iii. Dispatch Steering Committee

c) List the tasks and objectives of each committee.

6. NAED quality assurance and improvement methodology.

a) Attach a complete description of the methods used to evaluate EMD performance in using all elements of the MPDS correctly as outlined in the ED-Q Course Manual (consistent reviewing practices). The document should outline the following:

  • i. How cases are randomly selected.
  • ii. The minimum number of cases reviewed monthly.
  • iii. Any special case review practices employed. This can include cases identified by the agency that warrant additional reviews. Examples are cardiac arrest, choking, and childbirth.

b) Attach a detailed description of how EMD performance is checked, tabulated, and tracked.
c) Include details and dates of when case review began and how scores were shared with each employee.
d) Include details and dates of when shift and center scores were posted.

7. Consistent case evaluation that meets or exceeds the Academy's minimum performance expectations.

a) Based on agency size, one of the following will apply:

  • i. For agencies with less than 43,334 cases per year, the minimum is 25 cases per week.
  • ii. For agencies with greater than 43,333 cases per year but less than 500,000, the minimum is 3% of the volume.
  • iii. For agencies with greater than 500,000 cases per year, the minimum will vary from 1% to 3% based on the volume. (Use the Academy's calculator available on the ACE website. Provide a screen shot printout of the calculation and total).

b) List the total number of emergency medical calls received by the center in the six months immediately prior to the accreditation application.
c) List the total number of cases reviewed in the same time period.

8. Historical Baseline QA data from initial implementation of structured Academy QA processes (first QI summary report, if available).

a) A Baseline QI Summary Report (or equivalent) that includes the following:

  • i. Case Entry compliance
  • ii. Key Question compliance
  • iii. DLS compliance
    1. PDI compliance
    2. PAI compliance
  • iv. Chief Complaint selection compliance
  • v. Final Coding compliance
  • vi. Total compliance score

b) Determinant Drift Reports (or equivalent) for the center.
c) If these are not available, please indicate on cover letter.

9. Monthly average case evaluation compliance scores for the dispatch center for six months immediately preceding the accreditation application at or above accreditation levels.

a) Include a QI Summary report showing the agency has reached the following expected minimum performance levels for at least the three months preceding the application:

  • 95% Case Entry
  • 90% Key Questions
  • 90% PDIs
  • 95% PAIs
  • 95% Chief Complaint accuracy
  • 90% Final coding accuracy
  • 90% Total compliance scores

b) Include a Center Drift Report showing that both risk and waste responses are 5% or less for the last three months prior to the application.

10. Verification of correct case evaluation and QI techniques, validated through independent Academy review.

a) Include copies of 25 example case review audio files and completed case evaluation records for Academy assessment.

  • i. 22 of these must be from the one-month period immediately preceding the application and must be selected purely at random, not cases specifically marked for feedback or other review.
  • ii. State the process for random selection of these calls.
  • iii. Include an additional 3 cases involving Pre-Arrival Instructions (the first Pre-Arrival case taken for each month in the three months immediately preceding this application).

11. Implementation and/or maintenance of MPDS orientation and dispatch case feedback methodology for all field personnel.

a) Describe your MPDS field orientation process.

  • i. Include copies of handouts, presentations, and any other materials used.
  • ii. List the number of Field Responder Guides distributed, along with the dates these were given out.

b) Describe your EMD case feedback methodology.
c) Include a blank copy of the field feedback form utilized by your agency.

  • i. Include documentation of the dates these were distributed to all field stations.

12. Verification of local policies and procedures for implementation and maintenance of EMD. Include all policies relating to EMD practices, which must include the following:

a) Implementation and application of MPDS.
b) Medical Director approval of all MPDS protocols, including those requiring local approval, to include:

  • i. Obvious / Expected Death
  • ii. OMEGA referrals (if applicable)
  • iii. High-Risk Birth Situations
  • iv. Protocol 33 Acuity levels (if applicable)

c) Protocol compliance.

  • i. Quality improvement
  • ii. CDE requirements
  • iii. Performance management and remediation
  • iv. Customer service skills (how customer service scores are addressed by your agency)
  • v. Language translation processes
  • vi. Include a policy stating that all emergency medical calls are only processed by EMD-certified personnel, and that employees are removed from their calltaking duties if their certification is expired, suspended, or revoked.

13. Copies of all documents pertaining to your Continuing Dispatch Education (CDE) Program.

a) Submit past six months' CDE schedules and topics.
b) Submit EMD attendance records.
c) Submit a CDE schedule draft for the next six months.
  Check this box if utilizing the CDE EMD Advancement Series.

14. Secondary Emergency Notification of Dispatch (SEND) orientation.

a) Include documentation of the distribution of SEND Protocol information to all police and fire dispatchers and to other agencies routinely forwarding emergency calls.

  • i. List others as appropriate.

b) Include documentation of agencies trained, copies of attendance records, and any training materials used for this process.

  Check this box if utilizing the Special Procedures Briefing CD on SEND.

15. Established local response assignments for each MPDS Determinant Code.

a) Include a description of the process for developing response configurations.
b) Include a list of all MPDS Determinant Codes and the response configuration locally assigned for each.
c) Include copies of the specific Dispatch Steering Committee (DSC) minutes with verification that all response configurations are approved.

16. Maintenance and modification processes for local response assignments to MPDS Determinant Codes.

a) Provide documentation about how MPDS local response assignments are regularly reviewed and how recommended changes are approved.

17. Documentation for the call center's incidence (numbers) of all MPDS codes and levels.

a) Each Chief Complaint (1–33).
b) Each individual Determinant Descriptor code (approximately 300).
c) Each Determinant Level (Ω, A, B, C, D, and E).

18. Appointment and appropriate involvement of the Medical Director to provide oversight of the center's EMD activities.

a) List the name, address, license number, and country/state/province (or equivalent) in which the Medical Director is licensed to practice.
b) Include a copy of the documentation appointing the Medical Director.
c) List the approved roles and responsibilities of the Medical Director within the dispatch system.

19. Agreement to share nonconfidential EMD data with the Academy and others for the improvement of the MPDS and the enhancement of EMD in general.

a) Include written verification, signed by the agency's senior executive, agreeing to the above requirement.
b) Include written verification, signed by the agency’s senior executive, agreeing to submit the semiannual
compliance summary reports to the Academy (submitted electronically through the Academy’s website).

20. Agreement to abide by the Academy's Code of Ethics and the standards set forth for an Accredited Center of Excellence.

a) Include written verification, signed by the agency's senior executive, agreeing to the above requirement.
b) Provide verification and date of the prominent posting of the Code of Ethics and its location.