Create Sustainable Change

Smaller is better for learning and improvement

Few would argue that quality improvement is important in EMS, but for smaller systems with cash-strapped budgets and time-pressed managers, it can feel like a daunting undertaking. David M. Williams, PhD, says the best quality improvement can come in small packages without the cost of expensive experts or large projects.


Williams is a former paramedic who earned undergraduate and graduate degrees in EMS and studied EMS systems for his doctorate. Today, he’s a quality improvement consultant, advising healthcare organizations, school systems, and businesses on process improvement and measurement for learning. He serves on the faculty at The Institute for Healthcare Improvement (IHI) and is an improvement advisor supporting using IHI’s methodologies on large patient safety collaboratives in the U.S. and Europe.


Although many EMS agencies strive to make improvements, Williams has noticed that most of these efforts fall flat. He sees several reasons for this. First, he says, EMS is inexperienced at using data for learning and improvement. Most systems don’t measure the right data or plot it in the right way to understand the change, making it difficult to know what change resulted in improvement.


Second, it’s the processes. “We tend to think about improving performance as compliance to process–that the performance issues are the fault of the individual,” he says. “Nobody looks at the process to see if it might be flawed.” In 95% of cases, it’s the process that needs to be improved–not the people, Williams says.


Finally, the process is often designed by a leader. “A lot of the challenges people encounter is that the process is not designed by the people who will use it in the environment in which it will be used,” Williams says.


The traditional EMS approach to changing a process involves gathering representatives from all of the stakeholders, developing a change and implementing it. Some may trial the change over a short time period, but usually on too large of a scale. More often than not, this is monumentally cumbersome and leaves no clear way to manage the learning. “The reality is that you can’t learn that way. There are too many variables to control,” Williams says. “By starting small, you can iron out the majority of the issues.”

Model for improvement

Williams favors the Model for Improvement (MFI), a process based on the scientific method that allows a process to be designed, tested and refined by the end-user on a very small scale before it’s rolled out to the rest of the agency or department. It has the advantage of involving those who will use the process, thus building the all-important will, and it’s tested to work out the details before it’s released, giving it a better chance at both acceptance and success.


Moreover, the MFI is a simple tool that can be used to accelerate improvement. “It’s used everywhere, but nobody ever used it in EMS,” Williams says. “If you do it well, it gets very detailed.” By comparing the predictions to the results, you can either adapt or adopt the change or abandon it.


Developed by Associates in Process Improvement, the MFI is based on three questions:

  1. What are we trying to accomplish?
  2. How will we know that a change is an improvement?
  3. What changes can we make that will result in improvement?

These questions guide the improvement work going forward.

The process

One of the biggest mistakes EMS tends to make when conducting in-house improvement is failing to understand the aim of the project. Without a clear focus on what you are trying to accomplish with your improvement, it’s tough to develop meaningful measurement. Good design will set clear aims and measure specific data over time to both understand its behavior and determine if changes to the process result in improvement.


“That’s something very foreign to EMS. We tend to start with the data,” Williams says. “It’s not about the value of the work or the effort. We have to find what moves the dot. The answer is a process issue.”


According to the IHI, the following improvement projects are included:

  • Setting Aims: The aim should be time-specific and measurable. “This puts greater attention on achieving a result,” Williams says.
  • Establishing Measures: Quantitative and qualitative measures must be used to determine if changes actually led to an improvement.
  • Selecting Changes: Identify the changes that are most likely to result in improvement, remembering that all improvements require making changes, but not all changes result in improvements.
  • Testing Changes: The testing process, called the Plan-Do-Study-Act cycle, developed by W. Edwards Deming, begins with testing on a small scale. A change is tried out one time on one call with one crew on one ambulance with one patient at time. “You learn a ton instantly,” Williams says.
  • Implementing Changes: By continuing to work at the smallest scale possible, modifications are made until the process improves and is measurably reliable. The next step is to try the change under additional conditions. Additional knowledge is gathered by adding other variables (e.g., day vs. night shift, weekends vs. week days).
  • Spreading Changes: By the time a process is ready to implement, it’s reliable, and a spread plan will enable the improvement to be rolled out system-wide.

The beauty of this system is that people become acutely knowledgeable about the thing they are trying to improve. “They learn rapidly and deeply,” Williams says. The key is to involve people who are closest to the process.


One of the biggest benefits of the MFI is that “unlike other improvement systems, it doesn’t require an expert to guide you through it,” he says. “It’s accessible to anybody and focuses on learning and improving through action.”

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