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Since the enactment of the National Highway Safety Act of 1966, and the formal beginning of emergency medical services (EMS), the common goal of EMS systems has been to reduce unnecessary death and disability. While this goal remains constant, the authors are confronted more than ever by the public with the demand that EMS provide the highest quality service at the lowest possible cost. There are clear expectations for improved health, improved quality and improved efficiency. This manual provies a useful guide for EMS system leaders to use to improve quality within their organizations. This manual encourages EMS leaders to integrate continuous quality improvement (QI) practices into EMS operations to the extent that those practices become an essential and seamless part of normal EMS routines.