EMS agencies continue to be characterized by the speed of response, when in fact the speed of ambulance response rarely makes a difference in patient outcomes.1,2 To shift focus away from response times and toward quality of care and outcomes, Allina Health Emergency Medical Services (AHEMS) implemented the concept of an annual Care Goal as part of its suite of yearly organizational goals in 2007.
The purpose of the annual Care Goal is to bring targeted focus to a patient condition or protocol where there is opportunity for system-level improvement or where we would like to “hardwire” proper clinical procedures or documentation practices. The Care Goal is a formalized 12-month initiative designed to ensure that appropriate recognition, treatment and documentation occurs during each and every encounter with a specific patient population. Our clinicians appreciate the intentional focus on patients and the feedback they receive as a part of the Care Goal process, and there is great pride in being able to measure and document successes.
“I love our Care Goals and look forward to what’s coming next each year,” says AHEMS paramedic Jessica Holm. “The follow-up after each Care Goal-specific call we respond to enhances our knowledge and increases performance, making the organization and the clinicians stronger year after year.”
Components of a Care Goal: A Learned Process
To support the achievement of the goal, a comprehensive plan for education, measurement and feedback is developed. Many challenges and solutions have been encountered during our eight years of Care Goal work at AHEMS and this has resulted in a refined and standardized process that includes the following key components:
- Review and research current trends;
- Selection of a patient population or condition for focus;
- Development of appropriate metrics, assessment of current performance, and goal setting;
- Establishment of surveillance and measurement process;
- Clinician education; and
- Clinician communications and feedback.
The process begins by researching what is happening inside the EMS industry and examining healthcare quality measures from agencies such as the Joint Commission that are garnering attention within the profession. Protocols or conditions where we struggle with inconsistencies or have added new procedures or equipment are also common targets. Then, AHEMS’ physicians, quality risk manager and clinical director make a recommendation for a Care Goal, and our senior leadership decides on the final goal.
A simple scoring algorithm that reflects performance relative to the goal is then formulated, preferably using data elements readily available in patient charts. For example, if the goal is to obtain a complete assessment of vital signs on each eligible patient, patient charts are reviewed and scored based on the presence of documented blood pressure, pulse, respirations and oxygen saturation. Once a metric is devised, it is applied to historical data to explore volumes and understand current performance.
Establishing this baseline performance is crucial for setting reasonable goals for the organization, and the examination of historical data allows medical direction and senior leadership to identify what it will take to improve performance. Prospective data collection involves creating reports that flag incidents related to the goal and abstracting or extracting data elements required for scoring. Mechanisms for tracking eligible encounters and data collection can take a variety of forms, and while an electronic patient care (ePCR) record system makes the process simpler, the Care Goal model can certainly be implemented in systems using paper records.
Education & Communication
During the first and fourth quarters, the background, objectives and metrics of the Care Goal are presented to all clinicians as a component of system-wide mandatory education sessions. We use the marketing concept that it takes seven “touches” before someone will internalize and/or act upon a call to action, and thus encourage field training officers (FTOs) to reinforce messages and education elements throughout the year. We have observed that performance improves in proximity to training rounds and thus a second round of training is conducted during the fourth quarter.
Care Goal communications occur regularly through messages from the EMS president, posters in bases, hang tags, weekly video segments and monthly case reviews. Crews typically receive individual feedback on their performance within seven days of each Care Goal-related incident, and organizational progress reports are shared monthly.
Suggestions for Success
Since 2008, AHEMS has succeeded in meeting or exceeding its Care Goal every year, and our experience has yielded the following helpful principles:
- Understand the required resources. For example, if your goal will involve time-intensive chart reviews, select a patient population with a volume you can manage.
- Build a data collection tool that works for your organization. ePCRs are not a necessity. Even hash marks on a sheet of paper can get you headed in the right direction.
- Engage your physicians. Staff will be more engaged if they believe their efforts have a champion and will have a meaningful impact on patient care.
- Education is key and must be ongoing. Make a plan for refresher education.
- Regular reporting is powerful. Let leaders and clinicians know how they are doing, as individuals and as a system.
- Celebrate progress. It helps maintain momentum.
Healthcare reform is a certainty in the U.S., and it is no longer a question of “if” but “when” the pay-for-performance paradigm will impact EMS. By measuring and managing the quality of care delivered in your service, you will be better prepared to address the changes ahead. As AHEMS paramedic John Zahn notes, “Our Care Goals have proven the effectiveness of focused quality improvement efforts. Through just-in-time individual feedback as well as retooled education, we have successfully raised the bar.”
Indeed, EMS quality can and should be more than how fast you can arrive on scene.
1. Pons P, Haukoos J, Bludworth W, et. al. Paramedic response time: does it affect patient survival?. Acad Emerg Med. 2005;12(7):594–600.
2. Pons P, Markovchick V. Eight minutes or less: does the ambulance response time guideline impact trauma patient outcome? J Emerg Med. 2002;23(1):43.
Susan Long, MA, BA, AS, NRP, is director of clinical services with Allina Health EMS in St. Paul, Minn. She has 35 years of EMS experience, working as an EMT, paramedic and educator. She is the current president of The Savvik Foundation, and can be reached at [email protected].
Lori Boland, MPH, is a clinical epidemiologist who collaborates with prehospital clinicians, emergency medicine physicians and intensivists in support of investigator-initiated research in the areas of emergency services and critical care at Allina Health. She can be reached at [email protected].