Is This Quality Improvement or a Witch Hunt?

By Mike McEvoy, Ph.D., RN, CCRN, REMT-P

Quality Improvement (QI) programs are often considered a sort of black eye by disillusioned fire chiefs and EMS providers when they’re not run in a constructive and upbeat manner. The ultimate deterioration of QI compares more to a witch hunt, in which opponents adopt a completely pessimistic attitude and search for consequences rather than opportunities. In truth, it is not difficult to implement a comprehensive and effective QI program if you maintain a positive focus from the start. Below are some typical pitfalls of a QI program and some ideas used to overcome them.

Negativity
This is a destructive force that can quickly kill a QI program. In earlier years, Quality Improvement was called Quality Assurance (QA). The connotation of QA was that of a police force to ensure quality. From its beginning, QA took on a confrontational and often negative demeanor. Resuscitation began with changing the name from QA to QI. The more positive and friendly “Quality Improvement” brings a forward moving and collaborative picture to mind. People involved in QI need to maintain a continued awareness of four solutions to avoiding the negativity trap:

  1. Recognize Excellence – there is no greater motivation than positive reinforcement for a job well done. QI efforts that recognize excellence and reward improvement will not only be more effective in bringing about change for the better but will also create a positive perception of QI efforts in your department.
  2. Present Data Positively – many audit tools seem to be designed by sourpusses. You’ve probably seen screening forms that calculate numbers of problems or deficiencies as though their focus was on the negative. This is unnatural! From the day we enter school, we are graded on a scale where 100% signifies excellence. Our QI should always report in the same positive fashion. For example, reporting the percentage of run sheets with two complete sets of vital signs is far more positive than the percentage missing two sets of vital signs.
  3. Communicate Carefully – the results of QI reviews often point to behavior, and behavior not confronted will never, ever change. QI folks end up giving a lot of feedback, both individual and to groups. A good rule of thumb when providing improvement feedback is to word it in the third person: “A second set of vitals signs was not recorded” focuses specifically on the behavior, not the firefighter. Third-person phrases lessen the defensive response we all tend to have. Compare this to saying “You didn’t take a second set of vitals,” which is far more confrontational and tackles the person, not the behavior.
  4. Information Is Currency – a typical QI program compiles mounds of data. That information is as valuable as money when shared with the front line people who worked hard to collect it in the first place. Reporting summary and statistical information has tremendous value. It educates your department members on the overall service they provide and raises awareness of the QI program. Unique and different ideas as well as improvement initiatives can come from any member with knowledge and ability to interpret the data you share.

    Paper-only QI
    This exists when quality is a distraction rather than a priority to an organization. It also can occur when the process is poorly understood by organization leadership, who may appoint someone without knowing what the job entails. If QI in your department is limited to a couple of people in some back room reviewing run reports (patient care reports), then you have a paper-only QI program. It may generate data, reports, and plenty of information, but it will probably never improve quality. QI is a culture, not a process. Its premise is that we all would like to be the best at what we do. The top brass need to sell this idea to their troops if opportunities for improvement are going to become meaningful.

    Using QI for people problems
    The emergence of QI programs has created a new and dangerous funnel for complaints against providers. It sometimes seems easier to write a lengthy memo to the local QI committee than it is to directly address an issue with an EMS provider. This is a major trap that no QI Committee should fall for. QI is not an investigative function but an outcomes monitor that deals with system issues. By some estimates, more than 90% of all QI issues will be traced back to a system issue, not a problem individual. That focus must remain paramount. When someone has an issue with another individual’s behavior, the mature course of action would be for the two parties to discuss the problem directly at a convenient time and place. For people unwilling or unable to manage conflict individually, chiefs, managers, supervisors, and personnel departments are there to deal with problem employees. Many QI committees do not accept complaints, referring them instead to a Risk Management, Legal, or Administrative Department.

    Occasionally, QI becomes aware of patient care issues that are potentially litigious. In this sensitive area, the lines between QI and administration are not always black and white. Clearly, it is not the function or purpose of QI to defend or punish individual providers. What are important to glean from serious adverse occurrences are the system implications. For example, a multimillion-dollar lawsuit alleging a missed esophageal intubation might prompt a QI committee to review protocols and equipment commonly used to detect this adverse outcome. Evolving regional or national standards may prompt the QI Committee to implement changes to decrease the possibility of future adverse outcomes or perhaps develop or recommend an educational program for the service.

    Failure to benchmark
    Over the years, I have been asked by several attorneys how it could be possible for a department with a well-organized and functional QI Committee to miss a serious and significant issue that produces a continued pattern of adverse patient outcomes. The answer is simple: failure to benchmark. Most QI Committees collect volumes and volumes of data on response times, IV success rates, turnaround times, patient satisfaction, and every other imaginable quality indicator. Many compare individual providers against each other or to service averages. Most also trend data over time to look for changes. But how would a department know whether their data compare favorably to their neighboring department? What about statewide or national averages? Many QI programs do not routinely compare their data to those of their peers.

    XYZ Fire has worked for the past year to improve its IV success rate. It has succeeded in increasing its successful starts on first attempt from 5% to 10% and is quite proud of the accomplishment. If XYZ Fire knew that its neighboring ABC Ambulance had a 94% IV success rate on first attempt, it might be inclined to approach the issue very differently.

    Benchmarking seems to me a mark of maturity in a QI program, one whose importance cannot be understated. QI data provided to supervisory personnel should benchmark each of the employees against averages of all employees. This highlights the need for education or reinforcement and helps supervisors to be more effective. Likewise, administrators should be provided with data comparing battalions and divisions to department averages. Regional QI Committees and State Health Departments should make system data available. Every department should have the ability to compare its QI data with its peer departments. I believe that every one of us would like to improve the quality of the service we deliver. From that perspective, the mission of QI programs is to place the tools needed to do just that into each of our hands.

    Mike McEvoy, PhD, RN, CCRN, REMT-P, is the EMS coordinator for Saratoga County, New York. A former forensic psychologist, he works in the Cardiac Surgical ICU at Albany Medical Center and teaches at Albany Medical College in NY. He is a paramedic for Clifton Park-Halfmoon Ambulance Corps and medical advisor for West Crescent Fire Department. He serves as a member of the New York State EMS Council and the State Emergency Medical Advisory Council and is the EMS director on the Board of the New York State Association of Fire Chiefs.

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