Emergency Management Services (EMS) Quality Improvement is the intentional process of making something better in EMS. Quality Improvement (QI) focuses on making system-level changes in clinical processes. This differs from quality assurance, which is more consistent with protocol, process, or policy compliance. EMS QI programs work best in a just culture environment that implements change through a robust education program. Effective QI programs are transparent; both administration and clinical staff know the goals and methods of any improvement effort. Quality improvement programs often use Key Performance Indicators (KPIs) to measure ongoing clinical performance, identify areas for improvement, and assess the impact of process changes. EMS systems should build their KPIs on clinical evidence, a perceived system deficit, or an operational need.
Quality improvement practices vary significantly among EMS agencies across the United States; however, a survey of EMS agencies nationwide in 2015 revealed that 71% of agencies surveyed report having dedicated quality improvement personnel. Examples of quality improvement projects include improving prehospital aspirin administration rates in patients with acute coronary syndromes, improving paramedic identification of STEMI, and decreasing peri-intubation hypoxia, among others. Each of these projects began with identifying the need for improvement. They developed a plan that included a process change and a means for assessing the impact of that change. Many EMS organizations elect to use the Institute of Healthcare Improvement Model of improvement: the Plan-Do-Study-Act (PDSA) cycle. Effective PDSA cycles should be organized with groups of people involved in all aspects of the process being improved. For example, a PDSA cycle looking to improve cardiac arrest survival should include field paramedics as well as staff from the medical director's office, administration, and logistics personnel.
The purpose of the “plan step” is to clearly and concisely define the problem or need for improvement. It should include a definition of what improvement. This step should also brainstorm solutions, pick one solution to try, and generate a plan to test and implement the proposed solution. The committee should define the problem using as much objective data as possible. They should be clear about how they will measure both the extent of the problem and how they will determine if their change is an improvement. For example, if a system is attempting to improve aspirin administration rates, a successful change could be “aspirin administration, or the presence of an aspirin allergy is documented in 95% of patient encounters with a chief complaint of chest pain.” The “plan” step also includes brainstorming as many ideas as possible to answer the question “what intervention could lead to improvement?” The next part is the selection of a specific intervention, such as employee education, and a plan for reevaluation. The plan should answer several questions, including “What is the problem?" “What is the intervention?” “How will we measure the problem, the change, and the outcome?” and “How do we know a change is an improvement?”
This is perhaps the least complex, but often the most difficult step to accomplish. Once a plan is made, the "Do" step is simply executing the plan. Pick a specific day in the immediate future to implement the plan. Instead of implementing the plan across the entire system all at once, first, perform a small trial of the change. This small step, known as a "test of change" allows the team to see if their change has the desired effect. Often, this small test identifies unexpected areas that should be addressed before wider implementation of the change. For example, if the change being tested is a checklist to improve intubation success, the checklist could be developed and trialed with one shift at a single ambulance station before deploying it for an entire system.
The purpose of the “study” step is to determine if the plan that was designed and implemented caused a change that was an improvement. This determination should use the definition developed in the “plan” step. During this step, participants in the project should also look for any unintended outcomes. The team should discuss what aspects of the plan were functional and what parts of the plan didn’t work as intended. As with defining the problem, objective data is helpful in the “study” step. For the above intubation checklist example, this step could include evaluating success rates of intubations before and after the checklist, compliance with or use of the checklist. They should also get feedback on the checklist itself from the end-user. Other data, such as time on-scene, cardiac arrest rates, or other data that may be impacted by a change in intubation practices should be considered in this step as well. The most common tool for measuring the effects of these tests of change is the process control chart. These charts plot the proportion of cases that met the definition of success over time. They also include a marker demonstrating the point in time at which the change was implemented.
The “Act” step is designed to take action on items found in the “study” step. Following the prior example, this might include improving an airway checklist based on the feedback provided by end users or providing additional training. Once the “Act” step is complete, the cycle begins again with planning: re-deploy an improved checklist, evaluate success rates, deploy the idea to an entire system, or receive additional feedback.
This PDSA cycle is continued in an iterative process until the desired improvement is achieved.
Key Components of QI Program
A QI program must use a non-punitive approach. A “Just Culture” strategy is a common example of this approach. Just culture is an organizational method that emphasizes accountability of both the individual and the organization in the prevention of errors and improvement. Just culture also acknowledges that errors are often caused by a combination of factors, including system factors. It considers “near misses” to be as significant as actual errors. A just culture approach encourages self-reporting of both near-misses and actual errors. It promotes accountability for one’s actions and education, an intolerance of ignorance, and a desire to improve the system for improved safety and outcomes constantly.
Many quality improvement projects, especially clinical quality improvement projects, will require education of some form to propagate the information regarding the intervention. An individual or team with an educational focus is likely to be beneficial in achieving the desired improvement outcomes.
A quality improvement project should involve representatives from any part of an organization that may be affected by the changes as a part or result of an improvement project. Additionally, involving individuals with many perspectives will increase the pool of unique ideas. The more ideas, the more likely the group is to find a successful change.
There are several concerns specific to prehospital quality improvement programs. One common misunderstanding is that quality improvement is the same as quality assurance. Quality improvement, by nature, is designed to improve a problem or process; quality assurance functions to ensure compliance with protocols or policies. Quality assurance and quality improvement, however, can be intertwined through the use of key performance indicators and quality metrics. For example, EMS systems may set a goal to use evidence-based interventions, such as aspirin in acute coronary syndromes, or bronchodilators in reactive airway disease patients. Through the quality assurance process, the system may discover that their medics are not using these interventions effectively or documenting them appropriately. A concurrent quality improvement program would evaluate the cause of these shortcomings from multiple perspectives and develop a plan for addressing them.
Another concern is selecting quality indicators and improvement projects that are meaningful for the patient and the EMS system. Clinically, this means quality indicators should be evidence-based as much as possible, with a specific focus on areas where EMS can make a difference in patient outcomes. Some of these areas include high-quality CPR with early defibrillation for out-of-hospital cardiac arrest, administration of aspirin to patients with acute coronary syndromes, and use of bronchodilators in bronchoconstrictive disease, among many others. EMS improvement projects may also focus on non-clinical outcomes, such as on-scene time, cost-related concerns, public health outcomes, or even workforce safety and wellness.
Quality improvement projects often come with significant volumes of data, almost all of which require interpretation. Clinical data often comes from patient care records, but improvement data may also come from dispatch information, hospital records, system financial records, surveys, and other sources, depending on the project. This data is typically plotted over time in control charts. While it is tempting to jump to conclusions based on early changes, the team should look for sustained change. A small variation in the process is natural and does not likely represent a real change. Fortunately, there are several rules to help identify true changes instead of these normal variations. The QI team should include individuals with experience interpreting and managing data.
EMS-specific quality improvement projects face unique challenges, including difficulty obtaining desired data from healthcare records, both EMS records as well as follow-up data from the hospital. Such data can be time- and labor-intensive to obtain or may not be available at all due to privacy concerns. Some challenges are unique to the unpredictable nature of EMS. For example, a system may want to evaluate a way to improve the outcomes of critical trauma patients, but may not be able to collect data due to the relatively rare occurrence of these events in their system. EMS systems must also consider the operational aspect of EMS delivery; if attempting to minimize the time from 911-call to CPR in cardiac arrest patients, systems must not only consider the EMTs and paramedics on the ambulance but must also consider the 911-call takers and dispatchers when approaching solutions.
Legal requirements for medical directors vary by state. In most states, however, EMS medical directors are required to ensure EMT and paramedic compliance with system clinical guidelines or quality assurance. While this can be achieved in different ways, each should pair quality assurance with quality improvement to impact clinical outcomes.
Some organizations have organized large-scale databases that can be used for both research and larger-scale quality improvement. One example is the Cardiac Arrest Registry to Enhance Survival (CARES). This database is designed to collect data regarding cardiac arrest for improving cardiac arrest survival. Larger scale quality improvement in EMS can occur at a state level, through an integrated QI program, leading to much larger improvements in EMS system quality of care.
Quality improvement may also result in better integration of care from the prehospital to the hospital environment by ensuring that appropriate treatments begin in appropriate patients and that the treatments are evidence-based. Operational improvement projects may also result in improved response times, improved on-scene times when appropriate, and safer work environment for medics.
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