Building a More Effective and Efficient EMS Quality Improvement System

At Community Ambulance, we’ve always felt that we provide high-quality medical care to our communities across several counties in Georgia. I certainly felt that way during my time here as a paramedic and field supervisor: We took education seriously, and we had quality compliance managers who were tasked with keeping an eye on our patient care reports (PCRs) to ensure we completed them properly and provided appropriate care.

I’m sure most EMS organizations are currently in the same boat we were in a few years ago: We thought we were doing a great job, but did we really know whether we were, or how we could get better? The reality was, we had no real way of tracking performance, or any idea of what areas we needed to improve. After realizing that we lacked an efficient system for evaluating data we were collecting, even for critical emergencies like cardiac arrest, acute coronary syndrome (ACS) and major trauma, our leadership decided something needed to change.

I was approached by my boss and asked if I would be interested in transitioning to a new quality improvement (QI) position. Like many others across EMS who are asked the same question, I had extensive experience in the field, but little training in QI. So obviously, I said yes.

That was two and a half years ago.

How We Got Started

In order to do this right, we had to find a way to organize and analyze our data–and we were also coming to the realization that having myself, or even a team of people, review thousands of PCRs to find errors or inconsistencies is not the best use of time. A 100% chart review of our 40,000-plus PCRs each year would mean reading more than 100 charts each day, seven days a week; in reality, it would mean rushing through chart review and still having unread PCRs pile up every day.

When looking for solutions, we recognized that automating some of these processes to focus on systemwide issues and patterns gathered from our data could vastly improve our efficiency and the quality of our patient care. We turned to the team at FirstWatch, led by Mike Taigman, who’s been teaching QI to EMS professionals for decades. With their help, our QI program has taken off.

How We Use the Data

One of our first steps was to choose what really mattered and focus on that. For example, we participated in the American Heart Association’s Mission: Lifeline program and wanted to ensure we met the performance standards for STEMI care. Instead of reading every chest pain report–and possibly missing ones not classified properly–we used software that performs an immediate initial review looking for critical items, such as documentation of 12-lead ECGs and administration of nitroglycerine or aspirin for appropriate patients.

What we saw was that aspirin wasn’t being given even when it should have been. (See Figure 1.) Our medical director took it upon himself to educate our personnel on why aspirin is so vital for these patients. We reviewed our policies and protocols to ensure they were in alignment with the treatments our patients needed.

Figure 1: Aspirin administration for ACS/STEMI patients

Taigman had me ready to take a new approach when he said, “We think about these things all the time, but do we really think about it?” He was right–education was only part of the solution. Our next step was creating pocket cards with checklists and reminders on them and making a few posters that our personnel would see every day to make sure we met or exceeded our patient care standards.

We also shared the information derived through the QI process with our clinicians. If the software flagged a PCR, I could then review and track whether there was a documentation error, a protocol deviation or another reason. Our paramedics knew when this happened, and also gained a better understanding of their overall performance in complying with the entire bundle of care for ACS patients. They were intrinsically motivated to do better immediately. Human nature, after all, will intuitively want you to push that 86% or 92% closer to 100%.

And last year, with performance in this area improving, we were recognized with the Mission: Lifeline Gold Award. It was truly the culmination of an effort that began with our leadership recognizing the importance of investing in a QI program, through the creation of my position, the use of technology and, most important, the steps we took to make systemwide improvements. The technology didn’t replace the need for people; instead, it helped us find the areas where we needed to do better, so we could focus on the changes necessary to improve care for our patients.

Although our initial efforts surrounded treatment of ACS, we now report and review much more than that, including treatment of cardiac arrest; pediatric patients and use of ambulance child restraint systems; naloxone administraion, on-scene time for suspected stroke/cerebrovascular accident (CVA) and much more. (See Figure 2.) We’re confident that we’re on the right path now to continually improve and provide the best care to our communities.

Figure 2: On-scene time of less than 10 minutes for suspected CVA

Lessons Learned

  1. It’s hard to get a lot of people at once to change their thinking. Having evidence-based guidelines is helpful, but having the data show the discrepancies between what should be happening and what is actually happening is what will help those mindsets shift;
  2. Technology isn’t going to replace the human job of quality assurance/QI. It’s meant to make the job more efficient and more effective, allowing for more improvement across the entire system; and
  3. Showing employees their own personal data doesn’t just help keep employees accountable–it drives them to be better, even if they are already the best.

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