How to make EMS quality assurance and improvement people-oriented

By Drew Rinella

Six years ago, when I started at Bonner County EMS in Sandpoint, Idaho, the agency was still young and I had the exciting opportunity to help build an EMS system. I had a strong desire to develop a people-oriented approach to QA/QI that worked toward the betterment of EMS providers rather than the traditional approach of beating them into submission.

The traditional model of EMS Quality Assurance and Quality Improvement is a failed enterprise. I propose a more effective, people-oriented alternative. Traditional QA/QI relies on the equivalent of public flogging for improvement. The typical EMT or paramedic can count on having his worst chart, for his worst call, on his worst day, written at 4 a.m. on no sleep pulled for case review, blown up on a projector screen and being made to defend that chart against his peers.

Too often quality improvement is largely punitive, leading the provider to begin making decisions not based on what is clinically best for the patient, but what will look good enough on paper to keep from getting into trouble again.

In 10 years of service, having worked for a handful of agencies, I have seen these hostile QA/QI practices lead to patients being transported when they didn't need transport, intubated when they didn't need intubation, and forced onto backboards when didn't need to be immobilized. These interventions were not the result of clinical incompetence or inability, but the Pavlovian response to berating providers for their decisions. Any reasonable person can see that traditional methods of quality improvement lead to no improvement.

Efficient correction through education
Our first step was to draw a demarcation between education and punishment. We identified that the majority of EMS providers enter the field wanting to provide an excellent service to the community and their patients. Their inclination is to do well, and overall we found that if we treat our EMTs and paramedics with respect, they will seek out and be receptive to education and improvement without the need for discipline. This is not to say that some events should not be met with disciplinary action; that may be a very appropriate measure to take in some circumstances, but punishment is overall not an effective form of education.

This is especially true of more destructive forms of punishment, such as the verbal abuse characteristic of traditional case review meetings. Berating and humiliating people makes them feel small and does not build them up into confident, competent health care providers.

The goal of EMS quality improvement should be the efficient correction of inappropriate practices and behaviors, not to exact vengeance upon the employee. To encourage good clinical decision making abilities, EMS providers must be free to operate in good faith without the fear of being hauled over the coals in front of their colleagues.

Private, discreet correction
A critical component of correction through education is the need for privacy. In order to maintain positive employee morale, attention must be paid to maintaining the provider's dignity. For example, if a provider has a consistent problem with spelling and grammatical errors in his PCRs, that provider may simply need his supervisor to pull him into the office and teach him how to use a spell checker.

If the problem continues, that provider may be offered an opportunity to attend a writing class at a local community college, and it is unlikely his colleagues will ever find out any more information beyond what the provider tells them. If there is a widespread problem with spelling and grammar errors, attention could be paid to that area during agency trainings and individual providers with spelling issues would retain anonymity in the crowd. This type of discreet correction can be applied to most clinical or operational problems.

SOP for complaints
With the help of our medical director, we developed a standard operating procedure for clinical investigations to ensure the consistent and fair handling of internal and external complaints related to patient care. One important tenet of our investigative process is to notify involved parties of the investigation from the beginning, so that their first notification of a problem is not via the rumor mill. This reduces provider anxiety — maintaining their work efficiency while the investigation is occurring, increases cooperation, and creates an environment where the provider feels respected and is more receptive to any correction that must later take place.

Allow organic sharing of lessons learned
While clinical errors are investigated and corrected confidentially, experience has shown that this does not mean widespread learning among the providers of an agency is not taking place. We have found that, when left to their own devices, many providers are more than willing to voluntarily retell the mistakes they've made to their peers through so-called war stories. If one provider hears of a medication dosing error committed by another provider, the natural reaction is for both providers to become more alert to medication dosages. In sharing these mistakes, the provider retains his dignity while redeeming himself by helping to prevent the same mistake from happening again. This process should be allowed to happen organically in a healthy agency.

Criteria for case review
It became clear to us that the best function of a case review meeting is as an educational forum, rather than a means for correcting individual problems. When treated as an educational process, the case review meeting becomes a force multiplier for the war story sharing phenomenon. We began selecting cases for monthly review with the following criteria:

1. Never select charts with significant errors or complaints against them to prevent embarrassment to the provider and the agency.
2. Minor errors are acceptable if they are expected to create good discussion.
3. Calls with educational value, or which may stimulate good discussion, are sought out and selected. Examples are charts documenting rarely used procedures like cricothyrotomy or patients with rare medical conditions.
4. Calls that triggered a critical incident stress debriefing are not selected without permission from the providers involved.
5. Calls that caused mourning among the community, such as the death of a student at the local high school, are not selected. This is more important in a small community like ours.
6. Only four to five cases are selected per meeting in order to maximize actual learning.

Above all, our goal with using the above selection criteria was to create a meeting that EMS providers would want to attend, since we believe that better learning occurs when students actually want to be in the class. In our meeting, providers get to have a positive interaction with our medical director every month, which is quite a departure from the average EMS service.

Still, memories of negative experiences with past agencies linger, and it is not an uncommon response for a provider to ask what they did wrong when notified that one of their charts has been selected. We have observed this response fade significantly as trust was built between the providers and those performing QA/QI activities.

Our methods have been criticized as being too soft handed, but in practice our approach to QA/QI has never prevented us from correcting any problems. And while it would be difficult to produce hard numbers to definitively prove that our methods are more effective than the traditional approach, we do appreciate an almost nonexistent burnout-related turnover rate at Bonner County EMS.

People-oriented system benefits
We have created a people-oriented system of quality assurance and improvement wherein we work with providers rather than against them, giving each provider the educational tools they need to improve and grow within their profession, and we are observing success with our approach.

For true quality improvement to occur, the EMS industry must abandon the failed practices of the past and consider how our QA/QI activities affect field providers, and, in turn, how that affects patient care and the profession as a whole. EMS agencies may benefit from adopting a people-oriented approach to quality assurance and improvement modeled after the methods of Bonner County EMS.

About the author
Drew Rinella is the clinical coordinator for Bonner County EMS in rural North Idaho. He is a paramedic, public servant, and competition shooter. Drew is an advocate for quality in EMS and also blogs his crusade against bad EKGs in product advertising. 

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