The world is obsessed with quality. In every corner of the globe, people seek to provide consistent products or services that completely fulfill customer expectations. What is “quality” in the field of”žEMS? Can we achieve a definition by understanding what quality is not?
Someone in your”žEMS organization is responsible for System Administration and Quality Improvement (QI). That individual (or group of individuals) has a critical role in the organization, in the community that allows it to stay in existence and in each of the patient care providers. This individual will give specific suggestions regarding system administration, performance and emergency care QI.”ž
Every EMT working to care for patients should understand how this process occurs, and why it’s important.
A case study
The “in basket” contains two letters of significance today. The first compliments one of your paramedics for their management of a difficult interaction at a nursing home. The nursing home staff was particularly impressed with how the paramedic managed a patient that had choked on a piece of meat in the cafeteria. The paramedic arrived, attempted to talk the patient through coughing the object out and, when that failed,”ž”ž used an instrument to remove the piece of meat. The patient was checked at the emergency department (ED) and came back to the nursing home in an hour in great shape.
The second note was from a neighboring”žEMS agency, that had a very positive interaction on a difficult multiple-casualty motor vehicle accident — with the same paramedic! They described how he triaged a group of patients in one of the vehicles, then managed the critical patient by intubating the patient, getting a difficult IV line, and infusing fluid in a tight space by warming and pressurizing the fluid up under his bunker coat. They suggested some recognition of the paramedic for outstanding work!
You seek out the patient care reports on both of these incidents, and find both. The incidents were weeks apart in the last couple months. The first report contains the run times and patient identifiers, a narrative report that says, Ë™The patient coughed the object out,à“ and no mention of any airway intervention. There was no initial assessment or patient re-evaluation. The second incident had a unit report that contained the incident times, no patient identifiers and the dreaded words “no patient contact.”
The conflicting life of the”žEMS QI director“žWhat do you do about these incidents? Write a complimentary note, a reprimand or both? This is an experienced paramedic with a clean record. He has done “minimal” care reports in the past, doesn’t complain about documentation requirements or the department’s “clunky” computer system”žand is consistently upper tier on all department training and testing. There has never been a department member that didn’t want to serve on his crew.
Is there a trend? This opportunity for praise needs to include an honest review of the paramedic’s work. So you check through the stack of run reports for other incidents run by the paramedic. You go back through several months of reports and discover a consistent trend toward minimal documentation and a disproportionate number of incidents documented as “no patient contact.” The only procedures documented for the past six months are spinal immobilization and initiation of an IV line.
This is a trend. Now, you need to use comparative statistics to identify how this paramedic differs in documentation of incidents from the rest of the department. This is an opportunity to review the entire department numbers to evaluate the profile of runs and how they would compare to this paramedic’s run profile. For example, the department overall logs 10% of runs with “no patient contact” where the unit is cancelled enroute or a false call has occurred. This paramedic logs 30% of those call types. On average, the paramedics perform one “significant procedure” a week with this busy service. That would include managing an airway, delivering a baby, decompressing a chest, delivering electricity (defib/cardiovert/pace), or special splinting or bandaging. This paramedic has documented none of these procedures in 26 weeks. Further, a cursory review of the incident type and patient assessment indicates the paramedic would have performed some of these procedures.
How to approach the paramedic“žOne leadership approach suggests asking questions first, rather than making assumptions and taking action first. You have two complimentary letters on hand to base a discussion on.
There is another rule of thumb for leaders that perform quality review in service organizations:
Compliments should outnumber suggestion letters by a ratio of three to one.”žEMS”žinterpretation: Good runs are always worth noting. You should provide three times as many compliments for good runs as runs with causes for constructive criticism or suggestions.
So, you ask to meet the paramedic privately and introduce the topic by handing him his copies of the compliment letters. Genuinely, you have the opportunity to say “thank you” on behalf of the department and the patients he served. But then you need to initiate a discussion about incident and patient care documentation that begins by showing him copies of the patient care reports he had written. Allow an opportunity for him to discuss the incomplete documentation, provide counseling on that lack of performance and initiate a follow-up plan.”žThat plan will include a review of all run reports on that paramedic’s shift, verification that the reports are complete and accurate (spot check by verification with other crew members involved in care of that patient), and focused review of all procedures performed. If necessary, discuss the ramifications — including any disciplinary actions — if the next set of reviews continues to indicate documentation shortfalls. You need to have a corrective plan in place should any incident with falsified documentation occur, such as “no patient contact.””ž
A reasonable concluding statement is: “Thank you for the wonderful patient care you provide.”ž
Because of the quality care you provide to patients, we look forward to placing many more complimentary notes in your file, but these two notes cannot be part of that process because the work necessary to complete those incident reports is not on file or not accurate.”
The EMS quality improvement program has many facets. It includes performance measurement of the department as a whole and then the individual components that make up the organization, whether that is a shift, a company or an individual. The QI program must have raw material, and those elements are the reports from the communication center and the patient care reports. A few incidents will have supplementary reports, and one would include notes that praise the management of the incident or raise issues about care or competence.”ž
Typical items in the QI Director’s in-basket include:
- Incident reports — a missing wallet from a patient.
- A patient complaint — “The medics were cruel to me”
- Communication center issues — a citizen complaint about response time, scene time or time at hospital.
- Mutual aid run reports.
- Hospital interface reports — ED staff complain about patient care
- Mutual aid interface reports — another jurisdiction complains about your medics’unprofessional behavior.
- Documentation of failures and shortcomings — a high-profile incident without a run report (or an adequate one).”ž”ž”ž”ž”ž
Take advantage of the compliment letters to praise the individuals and crews involved. Use a reward program to highlight individuals’and the department’s great work. Credibility exists in the Quality Improvement program when department personnel manage the issues they are presented with. You don’t want the members of your service to dread seeing you in the station or cringe at the sight of an envelope from you!
Complaints hit the basket. Log every one of them using a standardized form. Ensure the EMTs working in the system understand that the patient care report they fill out on every patient encounter is the foundation for identifying the system’s strengths and weaknesses.
Manage minor complaints immediately. (A best practice: Manage compliments the same shift you receive them. No need to delay relating good news!). Study more significant complaints completely. Of particular concern are any adverse patient outcomes or injuries to department personnel. Capture the case’s important elements on paper. Discuss the case with the medics and the ED crew, and create a “time line” of the case. Often, the system proves unfair to medics by not completing the process of gathering further information from them. If necessary and appropriate, interview those involved. Make sure to get the medic’s views in a fair, non-intimidating way. In a few cases, you will benefit by having some objective people review the patient care report and run record.
In most cases, the process will end with the completion of a file and note to the provider(s) involved. Occasionally, notes on the disciplinary process are necessary, as is passing the file to department’s legal counsel. The patient care elements of a complaint are protected from discovery by “peer review” elements of health law. But other elements are open to public reporting, so the process must be fair and objective.
It is then a great opportunity to report to the department chief and jurisdictional officials a quality report, produced on a regular basis (quarterly or annually, depending on size of department). The quality report gives elements of department performance, and again highlights compliments and positive reviews of the agency_s activities. It is appropriate to report that complaints are received and managed to improve”ž”ž future performance, and provide clear expectations to every individual that provides patient care and strives to improve.
Case discussion
The paramedic requested to complete a timed and dated supplement to the two run reports in a session with the other EMTs who worked with him on those incidents. Their input would verify his memory of the incident and his care. These supplements, marked clearly as being completed a couple weeks after the incident occurred, can be added to the overall run report. They can never substitute for prior records. The paramedic understood that his failure to document was not in line with his responsibilities and was subject to disciplinary action. He was pleased with the compliment letters but understood that no action could be taken on them due to the documentation shortcomings.”ž
His follow-up documentation review revealed no further problems. He offered to work with the information systems personnel to improve the “user interface” for the crews, so that future documentation could be completed more quickly.
Learning point:”ž Quality directors have conflicting roles in promoting high performance and correcting unacceptable behavior or processes. Quality oversight is enhanced if the process overseers are perceived as fair, balanced and eager to reward. Quality director(s) should always take opportunities to recognize care providers’ “good to great” behaviors. This maximizes the opportunity to gain credibility for the quality review process, and to develop great documentation and reporting systems. Quality emergency system design begins with great patient care reports. Some incidents will generate complaints or compliments. In my work in both the field and in the ED, compliments outweigh complaints by about a 3-to-1 ratio.”ž”ž
James J. Augustine, MD, FACEP, is an emergency physician from”žAtlanta. He is a clinical associate professor with Wright State University Department of Emergency Medicine in Dayton, Ohio. He served as medical director for a number of EMS organizations in the”žAtlanta area, including Atlanta Fire Rescue and the Atlanta International Airport. He served as first chair of the Ohio EMS Board, and has participated in field care for 27 years as a firefighter and EMT-A. He serves on the Editorial Board for JEMS. He has published numerous articles on emergency services and has participated in national and state leadership activities on emergency and trauma systems. Contact him at”žjaugustine@emp.com.
