Richmond, Va., Ambulance Authority (RAA) is well known for being a high-performance EMS system and for its community education efforts and implementation of a culture of safety.
But the agency has also recently taken a huge leap forward in the areas of quality assurance (QA) and quality improvement (QI).
RAA, which serves as the sole provider of emergency ambulance services for the Virginia capital, has implemented a “Total Quality Management” (TQM) system. The system links quality management efforts in the clinical, operations and billing arenas in order to comprehensively improve RAA’s service and efficiency.
Each month, RAA’s TQM committee meets to discuss any potential areas for improvement. The director of reimbursement might mention a specific documentation issue that’s causing delays in billing or collections. The chief clinical officer may discuss intubation rates and educational programs being implemented to improve them.
The idea behind TQM is that everything is interconnected. Dispatch and operations impact clinical care, clinical documentation impacts reimbursement, reimbursement impacts operations, and so on. Like many agencies, RAA has a clinical services committee that focuses solely on clinical issues, where the medical director is joined by the clinical officer, the QA/QI coordinator, the training staff and other paramedics. But the TQM meeting adds another layer.
Attendees at the TQM meetings include the chief operating officer, the director of operations, the chief clinical officer, the quality manager, the director of reimbursement and the compliance director.
Believing that each aspect of agency performance is connected and part of the cycle of providing high-quality services, RAA uses its TQM approach to measure and analyze outcomes and processes and make adjustments to training and policies to achieve its desired outcomes.
Using Technology to Fill the Gaps
Previously, RAA’s clinical and documentation QI process focused on reviewing specific types of patient care reports (PCRs), such as all cardiac arrests; specific high-risk, low-frequency procedures (e.g., cricothyrotomy); and a certain percentage of other calls. The agency also would choose to review specific topics or themes during certain months—perhaps looking at reports written by new hires one month and field training officers the next. The billing team would then review the report to identify documentation issues related to reimbursement.
Like most departments, RAA used to perform these focused PCR reviews because, as a high-volume agency, trying to review every PCR provides a limited return on a significant investment of manpower and resources. Either several reviewers read the reports with little consistency or guidance on what to look for, or one person attempts to review every PCR but eventually gets so far behind he or she scrambles to catch up and can’t provide effective feedback to providers or correct documentation errors in time to impact billing. Practitioners may not receive the feedback until several weeks after the call, when they might not even remember the patient.
RAA readers felt the process wasn’t as effective as it could be. They began searching for other solutions, and found one right in their own headquarters.
In the dispatch center, supervisors had already seen how technology could provide real-time feedback and lead to improvements. At any time, dispatchers can look at a monitor that shows whether they’re meeting certain performance standards. RAA uses FirstWatch, a California-based data and technology firm, as one method to monitor computer-aided dispatch (CAD) data and provide almost instant analysis.
In the dispatch center, that has helped drive improvements in areas like call processing times, where live feedback via the dispatch performance dashboard helps provide focus to the system status controllers on duty.
On the clinical side, RAA recently began using FirstPass, a tool developed by FirstWatch to automatically evaluate PCRs for adherence to protocols. FirstPass works by running each PCR through a series of tests based on certain criteria as soon as the data is available. The tests are based on treatment bundles and tailored to the agency’s protocols.
The software also compares each PCR to a universal protocol that checks reports for certain demographic and basic clinical data, such as baseline vital signs, signatures and other information RAA wants to collect for every patient.
Certain types of reports are screened further. For example, if the patient complaint is for chest pain or another cardiac-related problem, FirstPass will look for documentation of a 12-lead ECG. If none is documented, the incident is flagged. For chest pain patients, FirstPass will also look for appropriate documentation of specific treatments, such as aspirin or nitroglycerine administration.
FirstPass’s clinical care bundles are evidence-based but also tailored to RAA’s protocols and training. RAA is also working with the FirstPass team to develop even more sophisticated analysis and reporting tools.
The TQM Process
Now, when paramedic and RAA’s QA/QI Director of Operations Tom Ludin arrives each morning, he checks to see which reports were flagged by the FirstPass system. He can immediately review the PCR to determine if it was a documentation error, an omission in patient care or if there was a reasonable deviation from protocol. If the answer isn’t clear, he can talk to the crew who treated the patient first to help make his decision while the crew still recalls the details of the call.
“It gives a lot of opportunity to look through and see where improvements are needed,” says Ludin. “We can’t fix it if we don’t know it’s a problem.”
FirstPass enhances RAA’s TQM system by notifying the QA/QI director when the care documented in a PCR doesn’t comply with the agency’s protocols, therefore identifying areas for improvement. Photo courtesy FirstWatch
FirstPass not only allows for every PCR to be reviewed for minimal criteria, it also creates a system for measuring overall performance of the agency and individual providers. In many systems, simple database searches and spreadsheet computations can determine how often 12-lead ECGs are documented as having been performed on chest pain patients. But FirstPass creates an easy way to then track why that happened. On a continuous basis, supervisors can determine whether providers require re-education in clinical areas, documentation, or both.
“Ninety-nine percent of the calls pass the criteria. I never look at most of those,” says Ludin.
After Ludin reviews a PCR that failed a FirstPass test, he decides whether there was a deviation from protocol or a documentation error and emails the provider who wrote the report within one business day. That provider then has a chance to review the call and explain what happened, or correct the PCR, and Ludin and his colleagues determine whether any further action—such as remedial training—is required.
But while FirstPass allows RAA to check each PCR for certain criteria, it doesn’t replace having a real person dedicated to QA/QI.
“FirstPass is a tool,” Ludin says, explaining that he still uses his own database queries and other methods for other aspects of the quality management process.
For example, Ludin reads a random selection of PCRs each month so he can look for any issues the computer might not catch. As an accredited dispatch center, RAA already reviews the 9-1-1 calls for critical cases and a random selection of other calls each month—Ludin uses the same list to determine which PCRs he will review.
Having a TQM system means that when issues are discovered by one department, the entire agency helps find a solution. This will become even more critical for EMS agencies when the next revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) is adopted by payers later this year.
With ICD-10, the number of billing codes will greatly expand, and the importance of good documentation will increase. Having a TQM program is helping RAA prepare for these changes by bringing billing and clinical services to the table together. When the billers find an issue with documentation, they can ask the clinical supervisors about it and determine if it’s a documentation error or a misunderstanding by the billers over what service was actually provided. If systemic problems are discovered, the clinical department can conduct training or change the minimum required information to complete a PCR.
Closing the QI Loop
RAA keeps its quality management as nonpunitive as possible, focusing instead on finding ways to motivate its staff to make corrections and solve problems. Just publicly displaying some performance measures, either at the individual level or system-wide level, has led to improvements. Clinical lapses aren’t necessarily tied to performance evaluations, unless supervisors feel there are no efforts made to improve.
“You’re not evaluated on your QA/QI results,” Ludin says. “Instead it’s your responsiveness to training.”
When it was recently discovered that intubation rates were slipping after an influx of newly qualified paramedics, RAA’s training coordinators instituted a system-wide effort to improve—even though they knew not every single paramedic had unsuccessful intubations. In the crew Login Room, they set up intubation manikins and equipment, as well as some literature and videos on airway management. At the beginning of each shift, every ALS provider took time to practice intubation before heading out on the ambulance to run calls.
After the recent intubation refresher stations, RAA’s training staff received positive feedback from the providers, including one paramedic who credited the training with helping make his first live intubation successful.
RAA was also an early EMS adopter of self-reporting. Several years ago, operational medical director Joseph Ornato, MD, signed off on a self-reporting protocol that encourages providers to come forward when they make an error or omission.
But this isn’t to say that RAA doesn’t let providers know they value high performance. Each year when employees submit preferences for which shifts they want to work, RAA ranks them using a combination of seniority and performance. With FirstPass now in effect, that might include compliance to clinical protocols and PCR documentation in the future.
The Future of QA/QI
Technology adds one more tool to the TQM process, allowing personnel to spend more time doing what they do best—analyzing the problems and finding solutions—instead of spending hours determining whether the right boxes were checked. Software can’t replace having dedicated providers and educators, but it can make the system more efficient and more robust, allowing agencies to focus on areas where improvement is necessary and ultimately provide better care for their patients.