The Quality Assurance Process

By MICHAEL D. SMITH

Scenario: At roll call, the captain asks you to review the quality assurance (QA) process with a new EMT/firefighter with limited EMS experience. Sitting at the training computer, you explain to him the QA process for a peer review of EMS runs. Each shift reviews the previous shift’s runs for adherence to protocols, standard operating procedures, and quality of documentation.

He asks how it is possible to second-guess what happened on a run without having been there. You recognize that this is a common QA process question that focuses on the first step in any good QA process—quality documentation.

As quality EMS providers, we all strive to produce the best documentation of our patient care. Patient care reports (PCRs) (Figures 1-3) are not only permanent medical records but also legal documents that form the basis of legal proceedings. Depending on your department policies and procedures, a PCR may serve as the sole accounting of the entire patient contact.

Figure 1. Performance Improvement Review, Chest Pain

With decent documentation, a person not present on the run should be able to construct a complete picture of exactly what happened during the patient contact, including the dispatch, response, patient condition, assessments, treatments, and responses to those treatments. Well-written documentation often prevents the department from having to defend its care in a court of law.

DOCUMENTATION

Multiple methods are used to document patient contacts including electronic patient care records (ePCRs); handwritten, scanned forms; and dictated reports. Handwritten reports have been the mainstay of EMS documentation since its inception. As EMS evolved, patient documentation developed from handwritten to ePCRs to, in some cases, dictated run reports. ePCRs have many advantages over handwritten reports. They can auto-fill patient demographic information from frequently encountered patients, automatically acquire dispatch information from interfaces with computer-aided dispatch systems, remind users of protocols and pertinent assessments, and spell-check free text to provide a more professional appearance. ePCRs also make every report legible, whereas handwritten reports tend to be at the mercy of the author’s spelling and penmanship abilities.

ePCRs are expensive and can be cost prohibitive to some departments. Start-up costs tend to be the biggest capital expense, which can include computers, ePCRs, security software, printers, modems, and infrastructure to back up or maintain secure patient records. Requirements of the Health Insurance Portability and Privacy Act increase substantially with ePCR systems, requiring careful security oversight. Depending on your department’s size and the ePCR system you select, training costs can also constitute a significant start-up expense. Once the system start-up and provider education costs are taken care of, ePCR costs drop dramatically. Some departments have implemented dictated run reports much like the system’s physicians and other health care providers used to document patient visits. The EMS provider speaks his run report into a recording device, which uses speech recognition software to immediately display, transcribe, or transmit the report to a transcriptionist for conversion to a document that the provider can later proofread and transmit to the receiving facility and department server.

Like documentation systems, there are multiple documentation methods including SOAP, CHART (Figure 2), and the story narrative. These methods and others all have their pros and cons.

Figure 2. Performance Improvement Review, Intubation 

SOAP stands for the following:

  • Subjective. Includes information gained from the patient, chief complaint, or signs and symptoms. This is a very popular documentation method.
  • Objective. Represents observations and other data collected such as saturation of peripheral oxygen (SpO2), blood glucose, and electrocardiogram (ECG).
  • Assessment. Clinical assessment information such as vital signs, breath sounds, skin conditions, and shock status.
  • Plan. Your treatment plan—IVs, O2, medications, and treatment facility.

The CHART method is preferred in many areas of the country and stands for the following:

  • Complaint or chief complaint. Why did the patient call EMS?
  • History. Patient’s past medical history and history of the present illness. Includes using SAMPLE as a guide.
  • Assessment. Your assessment findings—vital signs, breath sounds, SpO2, ECG, and any other pertinent clinical findings.
  • Rx. The treatment. What have you done for the patient and the outcomes?
  • Transport. Where did you transport the patient; were there any changes to patient status or condition; and what, if any, were Medical Control’s orders?

The story narrative documentation format involves writing the entire patient contact in paragraphs and follows the subjective, objective, treatment, and outcomes format. Many EMS providers prefer the story narrative; they feel they can quote patient statements and describe more freely what transpired on a run rather than use other formats. The counter argument against this is that story narrative reports may end up being incomplete; they fail to prompt the writer to include important findings and treatment details that the writer may inadvertently leave off his narrative.

Figure 3. Performance Improvement Review, Syncope/Altered Mental Status

QUALITY ASSURANCE

Most state EMS rules or regulations require departments to implement a comprehensive QA. Actual implementation is often left up to the individual EMS service. The National Highway Transportation Safety Administration has produced a document, “A Leadership Guide to Quality Improvement for Emergency Medical Services,” that serves as a template for designing and managing a quality improvement program. In concert with the EMS Agenda for the Future, this guide is a valuable resource for implementing and maintaining a quality improvement program.

A successful QA program requires that all those involved understand a need for continuous improvement. Whether you use better documentation, improved assessment, or critical thinking skills, the opportunities to improve will always exist. Field providers being reviewed in the QA process must remember to design those processes in ways to keep the emotion out of the reviews. If members receive feedback from the QA process, it highlights something important about their documentation or patient care. Peer review QA programs employ evaluation by coworkers; these require thorough knowledge of protocols. If a reviewer is unable to form a picture of what occurred on a run, there is room for improvement. Peer review QA programs also keep members up-to-date on protocols and operational guidelines or procedures, and they also help improve the reviewer’s documentation abilities. Open minds should prevail when it comes to peer run reviews.

GETTING STARTED

The four considerations necessary to implement a good QA program follow.

Leadership.Decide who is going to champion the QA process such as a supervisor, an officer, or another member empowered to make changes in process and procedure as the need arises. The QA process will often identify operational, system, and administrative concerns that require action by chief officers or department leaders.

Information. Department administration must decide the type and quantity of information to be collected and what will be done with the data. Often, administrations will be challenged to maintain an open mind when interpreting data. Previously held perceptions may be challenged because of incomplete information, incorrect analysis, or close examination revealing previously unseen opportunities for improvement. Recognize that information generated from a good QA program frequently calls for changes.

Long-term goals/objectives.The administration should set short- and long-term QA goals. A well-run QA process is cyclical; changes made need to be evaluated and tweaked, often repeatedly. Buy-in from administration is important for overcoming resistance to change. Long-term goals should address how the QA program will test the effectiveness of changes.

Process management.No provider or department should operate in a vacuum. Benchmarking is a hallmark of a good QA program. Members and their departments should know how they compare with others. Any new procedures or protocols should be widely disseminated, compared with other services, and closely monitored during and after implementation. It may be useful to conduct trials in a single station or battalion before launching departmentwide. Best practices evolve from deliberate and thorough consideration involving management and field providers.

REPORTING

As your new EMT/firefighter begins to understand the QA program, he tells you, “I was concerned that reviewing other members’ runs would be tantamount to tattling on them if they did something wrong. I understand now that QA is for the patients’ well being in the long run.” Ultimately, this “It is not about you! It is about the patients” mindset must prevail in all EMS providers. None of us are perfect; there is always room for improvement. A good QA program facilitates quality care to the citizens we protect. Many states require EMS services to report QA findings, so design your program accordingly.

MICHAEL D. SMITH, NREMT-P, CCEMT-P, is a firefighter/paramedic with the Grandview Heights (OH) Division of Fire, a flight paramedic for MedFlight of Ohio, and a coordinator for the EMS Education Program at Ohio University—Lancaster. He has been involved in EMS since 1986 and is an outreach critical care educator for Grant Medical Center’s LifeLink. 

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