The modern concept of quality improvement (QI) evolved from the field of engineering.1 Instead of simply performing quality assurance–where defective products were discovered and removed through an inspection process–QI programs strive to figure out why errors occurred and design systems to prevent them. The motivation was to improve production, which would translate to better quality at a lower cost-and thus higher profits.
In healthcare, the less successful a treatment or procedure was, the more it would usually cost-patients would stay longer in the hospital or be forced to undergo further treatments and procedures. At the same time, the evidence base for much of medicine hardly existed, making it unclear whether you were paying for something that was proven to be effective. And there was little incentive for making the delivery of healthcare more efficient, eliminating errors or developing quality control processes.
In this legacy model, there’s no incentive to improve patient care. A hospital that invests in quality, providing top-notch, evidence-based care on a cardiac patient will receive the same reimbursement (and possibly less) than another hospital that provides inferior care. And there’s little transparency on how effective or efficient those hospitals are.
Today, with consumers demanding better care, it only makes sense that quality measures be used to achieve that goal and demonstrate value to the community.
The Triple Aim
This move to quality in healthcare is based in part on the Institute for Healthcare Improvement’s (IHI) Triple Aim that “describes an approach to optimizing health system performance.”2,3 The three dimensions that comprise the Triple Aim are:
- Improving the patient experience of care (including quality and satisfaction);
- Improving the health of populations; and
- Reducing the per capita cost of healthcare.
EMS exists now where healthcare was a decade ago, before QI and measures became part of the culture. Perhaps it has lagged behind because it benefited from its reputation of providing public safety. Rarely has the public demanded proof that EMS was effective-the public was happy as long as EMTs and paramedics showed up, spoke confidently and took patients to the hospital.
But just as the cost of healthcare overall has skyrocketed, so has the cost of EMS. Several recent reports by the U.S. Health and Human Services (HHS) Office of the Inspector General and the U.S. General Accounting Office detail how the cost of providing EMS care to Medicare recipients has grown exponentially and far faster than the overall cost of providing medical care.4,5 This is an unsustainable model.
At the same time, EMS across the country is evolving as innovative programs try to provide more appropriate care, treatment and transport options. These programs aim to reduce costs while at the same time keeping patients healthier.
The reimbursement model for EMS, however, has always been almost entirely based on transportation, not the provision of healthcare. The U.S. Centers for Medicare and Medicaid Services (CMS) pays for ambulance transports, but not the assessment or treatment provided by prehospital personnel-and most other payors do the same.6 The EMS community has long argued against this model, dating back at least as far as the 1996 EMS Agenda for the Future, which strongly recommended changing it.7
The focus on reducing costs and keeping patients out of the hospital presents a window of opportunity, when policymakers and the public may be more supportive than ever of recognizing EMS as an integral partner in the healthcare continuum. As that happens, though, it only makes sense that those who pay for EMS care-patients, taxpayers, local officials, insurers-want to know what they’re getting for their money.
Quality Measure in EMS
EMS, unfortunately, has few metrics to measure itself by to show value or quality. There are no universally agreed-upon metrics for the industry to benchmark against.
Just as quality programs are taking hold in healthcare and hospitals, there will likely soon be an expectation that EMS systems will adopt quality programs as well. Many of the measurements used to assess the quality of inpatient hospital care are directly applicable to the out-of-hospital environment, such as the time it takes to acquire an ECG on a patient with chest pain or a heart attack patient to get from the scene to the cardiac catheterization lab.
Beyond the clinical care domains, patient experience isn’t routinely measured for the out-of-hospital patient. However, it wouldn’t be difficult to translate the inpatient measures to the out-of-hospital setting by asking such things as:
- Was your pain relieved?
- Did the provider communicate with you?
- How clean was the ambulance?
EMS is a perfect laboratory for looking at quality. By and large, EMS controls the delivery of health for emergency care and the transport for entire populations and geographic areas with limited or no competition. This is good and bad for different reasons. It’s good because it means that the delivery of this care can be centralized and organized. Records are maintained using a standardized system, making data extraction and comparison easier. All of the healthcare providers are trained to a certain level and all follow common protocols. Because of all these things, it’s more straightforward to develop quality control measures and to impact the delivery of care because it’s an organized “system.” The same can’t be said about the rest of healthcare.
In many EMS systems, data to measure quality is bountiful (e.g., in dispatch and patient care reporting software). What’s key is capturing the data and then measuring it. The reality is that this can be done without changing any of the systems already in place in an EMS agency.
EMS systems that understand the need for quality to improve efficiencies and demonstrate value are investing in data analytics and information to improve the quality of care delivered to the populations they serve and are well positioned for the EMS of the future.
The Path Forward
As EMS continues to evolve, investing in quality and measuring value will become a requirement. This shouldn’t be seen as a threat to the industry, but really as the maturation of EMS as a true partner in the healthcare community.
EMS has a unique opportunity to develop instruments to show how what we do matters and further professionalize this discipline of medical care. Whether those instruments or measures are used by individual agencies internally to assess quality, taxpayers to know what they’re getting for their investment, or insurers to determine reimbursement levels, the same rule applies: Measures need to be evidence-based, understood and supported by the EMS community, and focused on processes and outcomes that EMS agencies and providers can influence.
The push to measure quality and demonstrate value in healthcare isn’t going away, and the EMS profession has an opportunity to steer the effort to ensure it truly does improve the care patients receive and the critical service we deliver to our communities.
1. Colton D. Quality improvement in health care. Conceptual and historical foundations. Eval Health Prof. 2000;23(1):7-42.
2. Institute for Healthcare Improvement. (2015.) The triple aim. Retrieved March 6, 2016, from www.ihi.org/Engage/Initiatives/TripleAim/pages/default.aspx.
3. Berwick DM, Nolan TW, Whittington J. (2008). The triple aim: Care, health, and cost. Health Aff (Millwood). 2008;27(3):759-769.
4. U.S. Government Accountability Office. (October 2012.) Ambulance providers: Costs and Medicare margins have varied widely; transports of beneficiaries have increased. Retrieved March 6, 2016, from www.gao.gov/assets/650/649018.pdf.
5. U.S. Department of Health and Human Services Office of the Inspector General. (September 2015.) Inappropriate payments and questionable billing for Medicare Part B ambulance transports. Retrieved March 6, 2016, from http://oig.hhs.gov/oei/reports/oei-09-12-00351.pdf.
6. Munjal K, Carr B. Realigning reimbursement policy and financial incentives to support patient-centered out-of-hospital care. JAMA. 2013;309(7):667-668.
7. National Highway Traffic Safety Administration. (1996.) Emergency medical services agenda for the future. Retrieved March 6, 2016, from www.ems.gov/pdf/2010/EMSAgendaWeb_7-06-10.pdf.