Although many agencies have begun measuring performance, few have truly figured out how to use that data to make improvements. They struggle deciding which measures matter, interpreting the numbers and figuring out ways to improve. The process can at times be overwhelming.
If you feel that way, the good news is that you’re not alone. There are agencies out there that have used their data to support improvement efforts that are making a difference in patients’ lives.
Decide What to Measure
One of the very first steps is to decide what to measure. It might be that you know there’s a specific area of care you’d like to focus on, either because it’s a high-risk event, such as airway management; other times, partnering with a hospital ST elevation myocardial infarction (STEMI) or stroke team might lead you to start in those areas.
Measures, however, should be chosen carefully. They should be evidence-based and as patient-centered as possible. That’s where the EMS Compass initiative will help-experts in EMS and measurement, along with a wide range of EMS stakeholders, are coming together to ensure that the EMS Compass measures meet those criteria. But your agency still may want to choose which measures to focus on first, and there may be times when other measures are still appropriate.
In some cases, measures will help determine what areas you want to focus your improvement efforts on. In other cases, implementing a new program might then influence what you want to measure. Either way, many experts recommend focusing on one or two areas to try to improve. For example, Allina Health EMS in Minnesota picks one clinical area each year and focuses on improvements in that specific condition, such as treatment of stroke or sepsis.1 While they continue to measure the quality of care in other areas to look for serious deficiencies and to ensure that previous gains do not backslide, most of their efforts through the year revolve around that one clinical topic and the measures that support evidence-based care.
System-Wide Issues & Solutions
In Sioux Falls, S.D., the EMS system, like many others, tracks intubation success rates. But instead of focusing on individual statistics, the agency noticed that across the board, the rate of successfully securing an endotracheal tube decreased as the number of attempts increased.
“The first attempt was the most important because the second and third attempts had much lower success rates,” said Julie Charbonneau, the Sioux Falls quality assurance coordinator. “Because the rate of complications increases with each intubation attempt, we wanted to make sure the first attempt was the best attempt.”
“After reviewing the data … we added tools to the airway kit and changed policy to give the medics the best chance at first attempt success,” she explained.
They also made rapid sequence induction a standing order if needed to make that first attempt successful. Since implementing the new policies and adding tools to the airway kits, first attempt success has increased by 10-15% overall.
Focusing on a measure of individual skill performance could potentially result in creating improvements on the measures but not in patient care. For example, had they solely focused on improving first-pass rates without providing the tools and system-level changes to do so, it’s possible that the outcome would have been providers spending more time struggling to intubate on the first attempt-resulting in decreased oxygen saturations for the patient. For this reason, EMS Compass is focusing on even more patient-centered measures that are more directly linked to patient outcomes.
Measure to Evaluate Changes
In addition to identifying areas for improvement, performance measures should also be implemented when significant changes are made in protocols or policies. Measures can let you know if those protocols are being followed and also whether the changes have the intended impact. Even the process of deciding what to measure helps an agency gain clarity around what the goal is of any change in practice, whether operational or clinical.
In Snohomish County, Wash., Fire District One Deputy Chief Shaughn Maxwell introduced checklists for several different clinical conditions, such as stroke, congestive heart failure (CHF), asthma and STEMI. These checklists included critical items in the protocols, such as checking blood sugar for potential stroke patients or using end-tidal carbon dioxide monitoring on CHF and other respiratory patients. But only by measuring would the agency know if the checklists made a difference in patient care.
In 2011, they had a documented rate of checking blood sugar 57% of the time for potential stroke patients. Three years later, after implementing the checklists, that rate was 91%. They saw similar improvements across the board.
Sometimes measures show an agency that a change didn’t have the intended effect. Meds-1 EMS in Grand Rapids, Minn., added an ALS non-transport vehicle to respond to high-acuity calls along with an ALS transport unit in Grand Rapids because the city had no first responders. But they noticed that when the additional paramedic was dispatched on calls, on-scene times were increasing-which could detrimentally impact patients with certain time-sensitive conditions such as STEMI, stroke and trauma. There could be many reasons for this, including that the paramedics on scene were waiting for the additional provider to arrive, or the hand-off in care from one paramedic to the other caused delays. In the rural areas, where community first responders assisted the Meds-1 transport units, on-scene times had remained consistent, and lower than in the city. Based on the information gleaned from those measures, Meds-1 instead worked with the Grand Rapids Police Department to develop a first responder program.
“Ongoing data assessment has indicated improved procedure times and overall scene time reduction,” said Timothy George, director of EMS and community health outreach for Meds-1.
Any EMS quality improvement plan needs measurement in order to know where to focus efforts and whether those efforts are succeeding. The measures serve as both a map and a guide that lets the agency know where it is, and in which direction it should travel. Performance measurement can be daunting, but it’s critical that every agency takes small steps toward using measures to guide improvement plans-otherwise, we’re doing a disservice to our patients, our communities and our profession.
1. Heightman AJ. Focused & forward-thinking: A close look at Alina Health EMS & 10 things every EMS system should be doing (even if they’re too busy). JEMS. 2016;41(2):44-53.