GUIDELINE FOR THE DEVELOPMENT OF PROTOCOLS FOR
ONGOING ASSESSMENT OF MEDICAL CONTROL PHYSICIAN COMPLIANCE WITH
STATEWIDE TREATMENT PROTOCOLS

Purpose:  To assist hospitals in developing comprehensive written protocols to ensure physician on-line medical direction is in conformance with Statewide Treatment Protocols.

Regulation:  Hospital Licensure Regulation 130.1503(B) 
Ensure that all on-line medical direction is in conformance with the Statewide Treatment Protocols.

Regulation:  Hospital Licensure Regulation 130.1504(A)(2) 
Each hospital that operates a medical control service shall ensure that each physician who provides on-line medical direction is currently credentialed to practice as a physician in the hospital emergency department and the physician demonstrates proficiency in the clinical application of the current Statewide Treatment Protocols.

Guideline:  physician compliance reviews, for adherence to Statewide Treatment Protocols and hospital policies and procedures, include but are not limited to the following:

Review of real time medical direction
Review of audiotapes 
Review of ED medical direction records/forms
Review of EMS trip records
Review of treatments which deviate from Statewide Treatment Protocols, are not approved, or are not permitted under the Statewide Treatment Protocols
Incidents, complaints, EMS/EMT referred cases  
Competency examination
Conferences/staff meeting reviews of protocols and nuances