Massachusetts Department of Public Health
Office of Emergency Medical Services
Affiliation Agreement Review		

Please fill out the following form for review. Please review 105 CMR 170.300 with respect to affiliation agreements. These regulations have been modified and affiliation agreements should reflect those new requirements. The ambulance regulation program inspector will be reviewing these new requirements during the licensure process.

Name of Service		___________________________________________________________________

Inspector		___________________________________________________________________

Name of Hospital		______________________________________________________________

Yes   No    
1.	Is there an affiliation agreement in place with a hospital(s) licensed by the Department to provide medical control?        			
2.	Is the affiliation agreement(s) current?				
3.	What is the expiration date on the agreement?     (                                     )			
4.	Are the signatories in the agreement still the same as when the agreement was signed?			
5.	Does the agreement address the requirement to abide by Statewide Treatment Protocols?			
6.	Does the agreement provide for the hospital to designate an affiliate hospital medical director, who meets the requirements of 105 CMR 130.1504, to perform all the duties of 105 CMR 130.1503, including but not limited to authorization to practice of ALS-level EMTs?			
7.	Who is this medical director designated by your affiliate hospital?

8.	Does the agreement provide for 24-hour on-line medical direction, by physicians who meet the requirements of 105 CMR 130.1504?			
9.	Does the agreement provide for monthly review of trip records for ALS calls?			
10.	Does the agreement provide for the hospital to operate a QA/QI program that includes regular review of trip records and other statistical data pertinent to the EMS service’s operations, in accordance with the hospital’s QA/QI processes?			
11.	Are these trip record reviews and other QA/QI activities being conducted in accordance with what is described in the agreement?			
12.	Does the agreement provide for regular consultation between medical and nursing staff and EMTs providing ALS? 			
13.	Does the agreement set out, at a minimum, how many M&M rounds the hospital makes available to EMTs providing ALS?  
Min Amount____________________________________________

1.	
14.	Do M&M rounds for ALS-level EMTs occur as called for in the agreement, and are ALS-level EMTs attending in accordance with the requirements in the agreement?			
15.	Does the agreement provide for procedures for obtaining medications from the hospital pharmacy?			
16.	Are there limits to what the hospital agrees to exchange/provide to the service?			
17.	Does the agreement have provisions for quality assurance, quality improvement (i.e., min. skills/year)?			
18.	Are trip records signed by a hospital physician or his/her designee?			
19.	Does the agreement provide for the hospital to ensure EMS personnel have access to remediation, training and retraining as necessary under the oversight of the medical director?			
20.	Does the agreement provide for skill maintenance and review for EMS personnel?			
21.	Does skill maintenance and review occur as called for in the agreement?			
22.	With which other hospital(s) does this service have affiliation agreements?

			

	Yes   No    
									
				OEMS Form 512-9 (9/10)

Comments: