Administration and Leadership, Columns

Engage Your Medical Director to Ensure High Clinical Standards

Issue 7 and Volume 39.

EMS delivers patient care through delegated medical acts similar to the way doctors practice medicine—providers conduct a subjective evaluation, perform a detailed physical examination, develop a working field impression, then create and implement a treatment plan for every patient they see. Patients aren’t diagnosed and treated in the truest sense of the words, but the practical outcome is the same.

Unlike doctors, EMS providers haven’t gone to medical school and therefore can’t function outside their scope of practice. Typically, providers are licensed to work with patients by state regulatory agencies under the oversight of a local medical director. This physician plays an integral role in developing protocols and ensuring high-quality patient care, so it’s important the EMS manager or administrator encourage them to be engaged and involved at all levels.

Clinical Protocols
The medical director establishes protocols and procedures for EMS providers. Working with a manager if necessary, they must develop an understanding of community expectations and determine how best to meet them: Will the service function at a BLS or ALS level? Is the staff capable of providing service at the desired level? Can the agency afford any additional costs associated with higher levels of care?

The competency of providers is more than a certification or license. To meet the medical director’s expectations, clinicians must be educated and tested to the agency’s standard.

Encouraging your medical director to help develop rigorous pre-hire testing and evaluation is a good first step to ensure you have skilled, competent employees. In Washington’s King County Medic One service, for example, all new hires must attend the University of Washington Paramedic Training Program even though they’re already certified paramedics. This retraining ensconces the expectations of both the system administrators and the medical director. An extensive field training and evaluation program can help ensure every new hire is ready to perform procedures, but the medical director must retain clinical oversight and ultimately decides the level of care the patient receives.

An ongoing quality assurance/improvement program is necessary to monitor protocol compliance and evaluate a medic’s day-to-day performance. This often occurs through a retrospective patient care record (PCR) review. The advent of electronic PCRs has made it easier for medical directors to stay on top of this. Feedback provided months after the call limits learning and opportunities to improve. Make sure your medical director understands the importance of near real-time feedback and commits the necessary time to deliver it.

Medical director ride-alongs present another opportunity for real-time evaluation and feedback. An administrator may see significant engagement when the medical director is provided a uniform and the capability to respond with a crew. Policies and procedures should be adopted to guide the ride-along program and establish the responsibilities of the medical director on scene. Remember the intent of these programs is to provide support and clinical oversight to assure quality, not to allow medical directors to play doctor by making house calls in an emergency vehicle.

As part of the University of Pittsburg medical school, residents have regular rotations in the field with Pittsburgh EMS and provide this level of support. It’s no coincidence many of the physicians who are actively engaged in EMS across the country came from this program.

The engaged medical director is an advocate for their agency. The medical community is large and often disparate. Employees in other areas of healthcare rarely understand how EMS functions and what its capabilities are. The medical director helps break these barriers, allowing EMS a seat at the healthcare table. This engagement has so far proved valuable in helping develop and promote community paramedicine/mobile integrated healthcare programs.

Encourage your medical director to engage with other medical directors. Organizations like the National Association of EMS Physicians and the American College of Emergency Physicians encourage medical directors to step up their game and promote EMS through quality medicine, even creating an EMS subspecialty of emergency medicine. Preparing for and taking this exam will help physicians better understand the intricacies of EMS.

The clinical component of any EMS system is integral to success, but it’s not just about clinical decision making. To optimize the effectiveness of EMS, agencies need both strong administrative and clinical leadership. The EMS administrator will provide support services and establish functional policies, staffing procedures and a budget, leaving the medical director to focus on the clinical protocols and procedures. A truly engaged medical director is necessary to design and implement the collective vision of an agency. Together, these leaders are an incredible team that can produce extraordinary care and service. Engage your medical director today.

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