17.3 Policies, Quality Improvement & Budgeting
Key Takeaways
- NATA 2024 (Scarneo-Miller et al., Journal of Athletic Training 59(6):570–583): an EAP is not a policies-and-procedures manual. The EAP is the common initial response to any catastrophic injury; P&Ps are the detailed, often condition-specific documents.
- Written P&Ps cover infection control, lightning, concussion, exertional heat, mental health, referral, supervision, documentation/privacy, and name an EAP coordinator. BOC Guiding Principles for AT Policy and Procedure Development (updated 2025) is the mapping tool.
- Quality improvement uses Donabedian structure, process, and outcome plus the Plan-Do-Study-Act cycle. Injury surveillance (Domain I) should feed QI rather than sit in a disconnected spreadsheet.
- Budgets split capital (durable assets) from operational (consumables and recurring costs). Justify line items with injury, outcome, and inventory data—not with “we have always bought this.”
- Risk is managed by avoidance, transference (insurance/contracts), reduction, and retention. OSHA 300/300A/301 logs record work-related employee injuries, not the athlete medical record. Trap: copying another school’s EAP and calling the QI program done.
Quick Answer: Policies and procedures (P&Ps) are not the emergency action plan (EAP). NATA 2024 (Scarneo-Miller et al., Journal of Athletic Training 59(6):570–583) says the EAP is the common initial steps for any catastrophic injury; P&Ps are the detailed, often condition-specific playbook (sudden cardiac arrest, heat, concussion, lightning, infection control, mental health). Quality improvement (QI) uses Donabedian structure/process/outcome and Plan-Do-Study-Act (PDSA), fed by injury surveillance. Capital versus operational budgets, OSHA employee logs, and risk avoidance / transference / reduction / retention are the administrative toolkit. Trap: copying another school’s EAP and calling the QI program done.
PA8 Domain V task 0501 is assess organizational and individual outcomes using quality improvement analyses. Task 0502 is develop policies, procedures, and plans to address organizational needs. Task 0504 (17.1) supplies the standardized data those analyses need. Domain I surveillance without Domain V QI is a spreadsheet that never changes practice.
EAP versus policies and procedures (NATA 2024)
The 2024 position statement is blunt: do not mistake the EAP for policies and procedures (sometimes called a protocol). The EAP is a written, venue- and sport-specific summary of preparations and on-site response to catastrophic or potentially catastrophic injury in the prehospital setting—activate, communicate, retrieve equipment, direct EMS, provide emergency care. It is not injury- or illness-specific. A mental-health policy may outline prevention, recognition, and the clinical response; the EAP still says who calls, where to take the person, and how crisis teams enter.
Designate an EAP coordinator (NATA 2024 rec. 4) who owns development, training, distribution, and at least annual review—not a PDF orphan in a shared drive. Condition-specific P&Ps sit beside the EAP. High-yield manuals the exam expects you to name:
| Policy / procedure | What it must actually do |
|---|---|
| Infection control / bloodborne pathogens | OSHA-aligned exposure plan, PPE, sharps, cleaning, post-exposure follow-up |
| Lightning / severe weather | Weather watcher, safer locations, suspend-and-30-minute restart (see Chapter 4/9 addenda) |
| Concussion | Recognition, removal, no same-day return, graduated RTP with physician direction as required |
| Exertional heat | WBGT thresholds, cooling (full-body immersion), return-to-activity |
| Mental health | Screening, referral, emergency/crisis pathway, 988/911 when there is danger |
| Referral and physician direction | Standing orders, when to send, documentation of the hand-off |
| Supervision | AT coverage, students/aides, coach-only events, minors |
| Documentation and privacy | SOAP/EHR, HIPAA/FERPA, retention, media |
| Medication storage | If within state scope and physician protocol |
BOC Guiding Principles for AT Policy and Procedure Development (origin 2016; updated 2022 and 2025) maps employee safety, facility management, patient care, information governance, and risk management, with templates that include PHI communication, concussion, crisis communication, medical documentation, mental health, sudden cardiac arrest, and workplace injury. Write them for this organization, have physician and administration approval, train the people who must use them, date the review, and retire last year’s copy. A binder that no coach has seen is not implementation.
Quality improvement: Donabedian, PDSA, surveillance, benchmarking
Avedis Donabedian’s triad is the exam’s QI vocabulary:
- Structure — what you have: AT full-time equivalents, physician access, AEDs within the 3-minute retrieve window, cold-water immersion tubs, EHR, locked records, credentials posted.
- Process — what you do: percentage of concussions removed and not returned the same day; same-day documentation rate; WBGT logged before practice; EAP rehearsal attendance; influenza-vaccine clinic uptake.
- Outcome — what happens to patients or the program: time-loss, infection after wound care, PRO change (FAAM, KOOS), recurrent ankle-sprain rate, days from ACL reconstruction to passing hop tests, employee needlesticks.
Owning six AEDs is structure. Using them in under 3 minutes in a rehearsal is process. Neurologically intact survival after SCA is an outcome. Do not call a shopping list “outcomes.”
Plan-Do-Study-Act (PDSA) (Shewhart/Deming cycle) is how you test a change without pretending a poster is improvement:
- Plan — name a gap from data (recurrent lateral ankle sprains in soccer; 40% of SOAP notes entered after 72 hours). Set a small, measurable aim.
- Do — try the change on a limited scale (bracing plus a 3-month neuromuscular program for last year’s sprains; a same-day charting block after practice).
- Study — compare new counts, PROs, and compliance with the baseline. Include unintended effects (athletes skipping rehab).
- Act — adopt, adapt, or abandon, then run the cycle again. QI is continuous, not a spring in-service.
Injury surveillance feeds QI and closes the loop to Domain I (task 0101). An electronic system that codes body part, mechanism, event type, and time-loss is useless if nobody plots ankle sprains per 1,000 athlete-exposures or compares this season with last. Benchmarking means comparing your rates and processes with a relevant peer group (NCAA Injury Surveillance Program-style data, similar-size high schools, your own 3-year baseline)—not with a professional club that has 24-hour physician coverage. PA8 is explicit: collect injury documentation, surveillance, and health-related outcome measures, then use them for organizational decisions.
Exam trap: photocopying the neighboring school’s EAP, changing the header, skipping rehearsal, collecting no sprain data, and labeling the folder “QI program.” That is neither an EAP, nor a P&P, nor QI.
Budget, inventory, OSHA logs, and risk management
Operational (expense) budget: recurring costs in the fiscal year—tape, gloves, wound-care, modalities consumables, ice, ambulance stand-by if you buy it, NATA/BOC fees, CEUs, copier contracts, EHR subscriptions. Capital budget: durable assets above the organization’s dollar threshold that last multiple years—treatment tables, a new immersion tub, an isokinetic dynamometer, ultrasound/stim units, a medication refrigerator, sometimes the EHR implementation itself. Do not hide a $12,000 tub inside the tape line.
Supply inventory: par levels, expiration dates (medications, wound products, AED pads and batteries), lot numbers for recalls, and a count after away trips. Stockouts of SAM splints during a Friday doubleheader are a process failure. Justify requests with injury and outcome data: “12 time-loss ankle sprains, mean FAAM sport 48% at week 2, $X for functional braces plus a documented 11+ fidelity plan” beats “we need more stuff.” Administrators fund risk reduced per dollar, not nostalgia.
OSHA recordkeeping (29 CFR 1904) — Log of Work-Related Injuries and Illnesses (Form 300), Summary (300A), and Injury and Illness Incident Report (301) — tracks work-related employee injuries and illnesses (the AT’s needlestick, the coach’s fall from a ladder), with posting and retention rules for the employer. These logs are not the student-athlete medical record, not a SOAP template, and not a substitute for FERPA/HIPAA charts. Bloodborne-pathogen exposures still launch the exposure-control plan (needlestick protocol, source testing, employee follow-up) and an OSHA record when the case meets 1904 criteria.
Risk management uses four classic treatments:
| Strategy | Meaning in athletic training |
|---|---|
| Avoidance | Do not hold the 5K on an open ridge in a thunderstorm; cancel when WBGT is above the policy stop |
| Transference | Insurance, indemnification, facility-use contracts, certificates of insurance from visiting teams |
| Reduction (loss control) | EAPs, P&Ps, supervision, equipment standards, documentation, rehearsal, education |
| Retention | Accept residual risk (deductibles, rare events you cannot transfer); budget for it honestly |
Professional liability insurance is transference, not a reason to skip reduction. Waiver forms do not waive gross negligence in most jurisdictions and never replace a working immersion tub.
Put the loop together: surveillance finds a cluster of exertional heat collapses → QI (structure: tubs and WBGT monitors; process: delayed practice start; outcome: zero heat-stroke transfers) → budget line for a second tub → written heat P&P beside the venue EAP → rehearsal in August → documentation of the rehearsal. That is Domain V serving Domain I and Domain III. Copying another school’s EAP and filing it under “QI” is the failure mode the exam will hand you.
A secondary school keeps one document titled “Athletics EAP / Policies / QI.” It was copied from a neighboring district, never rehearsed, and is also used as the concussion, heat, and mental-health manual. What does NATA 2024 require you to separate?
Which description correctly applies Donabedian’s triad and PDSA to an athletic training QI problem such as recurrent ankle sprains?
The athletic director asks how to fund a second cold-water immersion tub, more tape, and whether OSHA 300 logs replace athlete SOAP notes. Which statement is accurate?