Peninsulas EMS Council has a strong focus on improving the EMS provided within our region.  We accomplish this focus through several activities and programs:

Regional Performance Improvement Plan - Through the efforts of the PEMS Performance Improvement (PI) Committee and the Performance Improvement Coordinator, PEMS produces a regional plan each three years to guide the process of improving EMS in areas other than trauma.  This plan is reviewed annually and revised when necessary.

 Click here to download the PEMS Regional Performance Improvement Plan (General EMS).

Regional QA/QI and Performance Improvement guidance - PEMS provides education and advice to regional agencies with regard to establishing internal QA/QI and performance improvement plans and programs.  The templates used in production of these plans and programs fully meet the requirements of 12VAC5-31, Virginia EMS Regulations.

    Click here to download the General EMS Quality Management Template .

Statistical Reviews and Reports - PEMS provides reports to authorized agencies and organizations who do not have their own capability to do so, providing statistical information regarding provision of EMS in the PEMS region.  


Medical Incident Review (MIR) - PEMS provides a system whereby any member of an agency, the healthcare system or the general public can make known their concerns regarding specific patient care incidents.  Each of these incidents is investigated and referred to the agency having authority for accomplishment of corrective action where necessary.  Information obtained through this process is handled with all due regard for HIPAA/PHI considerations.  Sanitized and aggregate results of MIRs are reviewed by the PI Committee to determine whether flaws in systemic processes contributed to the circumstances requiring the review.

Click here to submit a Medical Incident Review or   download a form here and send to our secure fax at 804-302-6073.


Regional coordination - The PEMS PI Coordinator communicates regularly with PI counterparts in our sister Councils to determine where we can coordinate to reduce duplication of effort in performance improvement activities throughout Virginia.

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PEMS Performance Improvement (PI) Committee

The PEMS Performance Improvement Committee consists of representatives across the entire spectrum of emergency medical services in our region. The committee meets quarterly to plan and review data on special projects and MIRs (Medical Incident Reports). Our goal is to ensure that our region meets or exceeds the EMS standards of care established by our Protocols, Policies & Procedures as well as the Commonwealth of Virginia.

The PI Committee serves the data and information needs of the Trauma Triage, STEMI, and Stroke Task Forces as well as the Medical Advisory Committee and other PEMS committees and stakeholders.  The PI Committee also supports the needs of our hospital partners in accomplishing their accreditation goals for their various specialty teams.

Performance improvement is a never-ending process in which all healthcare workers are encouraged to work together, without fear of repercussion, to develop and enhance the system in which they work. Based on EMS community collaboration and a shared commitment to excellence, performance improvement reveals potential areas for improvement of the EMS system, identifies training opportunities, highlights outstanding clinical performance, audits compliance with treatment protocols, and reviews specific illnesses or injuries and their associated treatments. These efforts contribute to the continued success of our emergency medical services through a systematic process of review, analysis, and systemic improvement.

Each quarter the PI Committee focuses on a specific project. Reports from these studies are reported through PI Committee meeting minutes and reports and are available here.

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