This publication is distributed by the U.S. Department of Transportation, National Highway Traffic Safety Administration, in the interest of information exchange. The opinions, findings, and conclusions expressed in this publication are those of the author(s) and not necessarily those of the Department of Transportation or the National Highway Traffic Safety Administration. The United States Government assumes no liability for its contents or use thereof. If trade or manufacturer's names or products are mentioned, it is only because they are considered essential to the objective of the publication and should not be considered an endorsement. The United States Government does not endorse products or manufacturers.
As NHTSA and the nation's Emergency Medical Services (EMS) family celebrate the first thirty years of organized EMS and prepare for the many challenges of appropriately serving our communities into the Twenty First Century, our continuing goal is to reduce unnecessary death and disability. The recently released EMS Agenda for the Future (NHTSA, Fall, 1996) broadens that goal to protecting the communities' health.
Our continuing partnership with the Health Resources and Services Administration, Maternal and Child Health Bureau, provided us with the opportunity to take an important step in pursuit of this expanded goal, through the development of the "Leadership Guide to Quality Improvement for Emergency Medical Services Systems".
Quality is anything that enhances the product or services from the viewpoint of the customer (patient). In EMS, our customer is not only the individual patient we serve , but the entire community. We need to align our values with community needs.
With the rapidly changing health care environment, EMS must determine how it can best serve community health, while remaining the public's emergency medical safety net. We need to provide for improved health, with improved quality and improved efficiency, while continuously monitoring our progress.
This "Leadership Guide to Quality Improvement for Emergency Medical Services (EMS) Systems" was developed to serve as a template for EMS managers who want to establish and maintain a program for continuously monitoring and improving the quality of patient care and support services in all parts of the EMS system. It encourages EMS leaders to integrate continuous quality improvement practices as essential parts of normal EMS routines.
The Leadership Guide is presented in a loose-leaf format to allow for addition of new materials and notes resulting from continued study and growth in the area of quality improvement.
NHTSA plans to develop additional materials and programs to contribute to continued growth in this important area and we would strongly encourage EMS leaders at all levels to embark on this journey with us. We hope this Leadership Guide will be a useful tool as you and your respective systems shape the future of EMS.
Department of Transportation
National Highway Traffic Safety Administration
Contract DTNH 22-95-C-05107
James N. Eastham, Jr., Sc.D., Associate Professor of Emergency Health Services, University of Maryland - Baltimore County, Baltimore, Maryland.
Howard R. Champion, F.R.C.S, F.A.C.S., Visiting Scholar, National Study Center for Trauma and EMS, University of Maryland at Baltimore, Baltimore, Maryland; Professor of Surgery and Chief of Trauma, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
Project Medical Director
Robert R. Bass, M.D., Director, Maryland Institute for Emergency Medical Services Systems, Baltimore, Maryland.
Project Manager
Patricia S. Gainer, J.D., M.P.A., National Study Center for Trauma and EMS, University of Maryland at Baltimore, Baltimore, Maryland.
Research & Technical Assistant
Jason Paluck, Emergency Health Services Department, University of Maryland-Baltimore County, Baltimore, Maryland.
Department of Transportation /National Highway Traffic Safety Administration
Division of Emergency Medical Services
EMS Specialists
Susan McHenry
Valerie Gompf
Directors
Jeffrey P. Michael, Ph.D.
Sue Ryan
Michael F. Altieri, M.D., F.A.A.P., Chief, Pediatric Emergency Medicine, Department of Emergency Medicine, Fairfax Hospital, Fairfax, Virginia; Associate Clinical Professor of Emergency Medicine and Associate Clinical Professor of Pediatrics - Georgetown University and George Washington University. Virginia State Critical Care Committee.
Wayne S. Copes, Ph.D., Vice President, Tri-Analytics, Inc., specializing in Medical Database Management, Research and Software Development. Director, Maryland Cancer Registry; Manager, Pennsylvania Trauma Center Registry; and Technical Director, Project IMPACT (national critical care database jointly sponsored with the Society of Critical Care Medicine).
Steven J. Davidson, M.D., M.B.A., Chairman, Emergency Medicine, Maimonides Medical Center, Brooklyn, New York and Professor of Emergency Medicine at SUNY-HSCB. Past Medical Director, Philadelphia Fire Department (1983-94). Fellow, American College of Emergency Physicians; Senior Director, The American Board of Emergency Medicine; Team Leader, Pennsylvania Interdisciplinary Team; Institute for Healthcare Improvement Professional Education Collaborative (1994-95).
Drew Dawson, Chief, Emergency Medical Services Bureau, Montana Department of Health and Environmental Services, Helena, Montana. President, National Association of State EMS Directors.
Lynn Eastes, R.N., M.S., Trauma Coordinator/Quality Management Coordinator, Trauma Program, Oregon Health Sciences University. Oregon State Trauma Advisory Board, Oregon State Quality Improvement Subcommittee.
John E. Gough, M.D., Assistant Medical Director, Division of EMS, Department of Emergency Medicine, East Carolina University School of Medicine, Greenville, North Carolina.
Lieutenant John Maddox, NREMT-P, ACLS, BTLS, PALS, CPR, HazMat OPS, Fire Officer I, and Instructor III. EMS Supervisor, Prince William County, Virginia Department of Fire and Rescue; CISD Coordinator; and Quality Improvement Director.
David R. Miller, President, Healthspan Transportation Services, a mobile health service providing ambulance, specialized transport and support services; Vice President for Allina Health System, an integrated health system including hospitals, physicians, and health plans, St. Paul, Minnesota.
Robert Swor, D.O., Director, EMS Program, Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan. President, National Association of EMS Physicians.
| Representative | Organization |
|---|---|
| Michael Fleenor, MD | American Academy of Orthopedic Surgeons |
| Joan Shook, MD | American Academy of Pediatrics |
| Carol Smithson | American Ambulance Association |
| Anthony Meyer, MD | American Association for the Surgery of Trauma |
| Richard McDowell, MD | American College of Emergency Physicians |
| Joseph Tepas, MD | American College of Surgeons Committee on Trauma |
| Arthur Cooper, MD | American Pediatric Surgical Association |
| Karen Johnson, RN | Commission on Accreditation of Air Medical Services |
| Lynn Zimmerman | Commission on Accreditation of Ambulance Services |
| Jean Will, RN, MSN, CEN | Emergency Nurses Association |
| Sandy Young | International Association of Fire Chiefs - EMS Committee |
| Lori Moore | International Association of Fire Fighters |
| Jonathon Best | National Association of Emergency Medical Technicians |
| Michael Kleiner | National Association of State EMS Directors |
| Robert O'Connor, MD | National Association of EMS Physicians |
| Ed Browning | National Council of State EMS Training Coordinators |
| Linda Young | National Flight Nurses Association |
| Walter Kerr, NREMT-P | National Flight Paramedics Association |
| Marilyn Gifford, MD | National Registry of Emergency Medical Technicians |
| Society for Academic Emergency Medicine |
| Introduction |
|---|
Since the enactment of the National Highway Safety Act of 1966, and the formal beginning of emergency medical services (EMS), the common goal of EMS systems has been to reduce unnecessary death and disability. While this goal remains constant, we are confronted more than ever before by the public with the demand that EMS provide the highest quality service at the lowest possible cost. There are clear expectations for improved health, improved quality and improved efficiency.
This manual provides a useful guide for EMS system leaders to use to improve quality within their organizations. This manual encourages EMS leaders to integrate continuous quality improvement (QI) practices into EMS operations to the extent that those practices become an essential and seamless part of normal EMS routines. Specific activities are suggested within three developmental stages. While specific activities may differ depending on the jurisdiction of the organization, the developmental stages of QI integration will be the same for local, regional, or statewide EMS organizations. These developmental stages are: 1) building potential for success by developing an awareness and appreciation that QI is a worthwhile endeavor; 2) expanding workforce knowledge of and capability in QI practices and techniques; and 3) fully integrating the strategic quality planning process and related quality improvement actions into the daily EMS operation.
This document uses the Malcolm Baldrige Quality Program as a model to guide your organization's QI efforts and to evaluate your progress. The Baldrige Award was established in 1987 through federal legislation as a way to: 1) promote awareness of the importance of quality improvement; 2) recognize organizations that make substantial improvement in products, services and performance; and 3) foster inter-organizational information sharing on best practices. The Baldrige Award launched a special initiative in 1994 to extend the program to the realm of health care.
The Baldrige program identifies seven key action areas or categories. The QI information in this manual is organized according to those seven categories, as follows:
Health care organizations that follow the Baldrige program have the option of asking for an external review of their progress. They report benefits gained by simply applying the Baldrige guidelines and recommendations, including improvements in: service and patient care delivery; economic efficiency and/or profitability; patient and community satisfaction and loyalty; and health outcomes.
For more information regarding the Malcolm Baldrige National Quality Award, contact the National Institute of Standards and Technology on the following Homepage: www.quality.nist.gov
Tracking your Progress
It is important to begin with the endpoint in mind. Just as a blueprint is needed to build a house, you should have a mental blueprint of how your EMS organization or system will look and operate once QI strategies and techniques are part of EMS planning and operations.
Experience from other fields shows that integrating QI into an organization or system takes several years. Remember that thousands of organizations around the world in a wide variety of industries, including health care, have been successful in developing a strong focus on quality. Their success should encourage similar efforts in EMS.
There are three significant stages of development as EMS systems begin to implement QI.
Stage I: Building Potential for Success
Your EMS organization or system will begin its QI journey when the leaders begin the process of learning about the theory, techniques and benefits of quality improvement. By the end of Stage I, senior leaders should be able to articulate these benefits, believe that these benefits can be achieved, and have a plan of action for achievement.
Stage I requires strong leadership and commitment at the local, regional and state level to: 1) learn and understand quality improvement strategies; 2) assess thoroughly the present situation of each EMS organization or system regarding quality levels; and 3) establish action plans for training and orientation in quality improvement.
Stage II: Knowledge Expansion
Stage II establishes the structural foundation necessary to fully integrate QI into the strategic planning process. In this stage, emphasis is placed on ensuring that the entire workforce of an EMS organization or system is informed about and participates in the development of the strategic quality improvement plan. Workforce members need a working knowledge of basic QI philosophy, tools, and techniques so that they can be full partners in the strategic quality improvement planning process. At the end of this phase, all EMS workforce members should be able to identify their internal and external customers, how to measure the quality of the services provided or received, and how to identify and resolve quality problems in their own work. There should also be a new sense of openness and partnership between staff and management within organizations and among local, regional and statewide systems.
By the end of Stage II, local, regional and state EMS systems should have in place the structure and process that allows evaluation and comparison of the quality indicators identified in the strategic plan. EMS organizations should be able to take action to attain the quality targets identified in their plans, determine the success of their efforts, and, when negative results occur, revise and restart their action plans for improvement. The efforts of initial QI teams should also begin to show benefits, typically in the areas of measuring and reporting critical indicator quality levels.
Stage III: Integration and Commitment
At the final developmental stage, QI activities clearly impact the organization's work processes, for example, changes in work site management and evaluation of work; use of self-directed teams; and re-alignment of work processes to achieve new quality targets on critical indicators. The workforce is empowered to take action in team settings to identify, deploy and evaluate new production methods. Teams can take self-correcting action by accessing timely information on performance levels for key quality indicators. At all levels, traditional supervision gives way to leadership that helps the workforce maintain and improve the quality of their work. At the state and regional level, there is less emphasis on regulatory inspection of local agencies and more emphasis on providing resources, comparative information and coaching to local agencies that are accountable for developing and following their own strategic QI plans.
Communication among individual members of the EMS workforce, self-directed work teams, organizations and systems speeds adoption of successful innovations. There is increased benchmarking within the organization, as well as with other organizations (inside and outside of EMS ). Regional and state EMS organizations support inter-organizational benchmarking and communication. At all levels, the EMS system promotes and encourages continuous improvement as a fundamental operating strategy.
The most important Stage III milestone is achieving results from QI efforts; for example, increased patient satisfaction and health status from improved EMS services and quality of care. Economic benefits also result, including cost savings, increased profitability or operating surplus, and more efficient use of resources.
The Importance of Results!
As you look at each of the Baldrige categories and their implications for structural and procedural changes in your EMS organization, keep in mind a very important concept: the most important results for achievement are improved health of EMS patients, improved quality of EMS services, and improved efficiency of resource use. Simply completing the steps needed to implement quality management is not the most important measure of progress. As Dr. Donald Berwick, a national leader in health care quality improvement, has aptly pointed out -- we have accomplished little if our efforts to improve quality only result in our ability to collect and analyze more data.
Summary
This chapter explored the need to develop quality improvement capabilities in EMS. The Baldrige Quality Program and its seven categories for action were introduced as a method for guiding EMS quality improvement efforts. The three developmental stages for quality improvement efforts were also presented.
The remainder of this manual covers the application of each of the seven Baldrige categories to EMS. The manual also includes a glossary of QI terms, a review of pertinent QI literature, a set of basic QI tools, and a series of evaluative questions and examples for EMS systems.
| Background |
|---|
| Deming's Principles Applied to EMS |
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There is an increasing focus on "quality" throughout United States. When talking about "Total Quality Management", "Continuous Quality Improvement", or any other name given to the quality movement, the common thread is meeting the needs of those who pay for and use the services and products provided by an organization. All types of industries, including health care, have lowered costs and improved the quality of their operations and products by working to meet the needs of the people they serve.
Many books have been written describing the philosophy and methods used in the quality movement. This section is not intended to be a substitute for those works, but rather provides a brief overview of quality management principles by reviewing the work of three leaders who have shaped the discipline. These three pioneers all stressed the importance of management awareness and leadership in promoting quality.
W. Edwards Deming. Deming began working in Japan in 1950 and was instrumental in building the Japanese industry into an economic world power. His strongly humanistic philosophy is based on the idea that problems in a production process are due to flaws in the design of the system, as opposed to being rooted in the motivation or professional commitment of the workforce. Under Deming's approach, quality is maintained and improved when leaders, managers and the workforce understand and commit to constant customer satisfaction through continuous quality improvement.
Deming and his colleague, Shewhart, promoted the PDCA cycle -- Plan, Do, Check and Act. In an EMS operation, we can
PLAN to implement a policy to improve quality and/or decrease the cost of providing services. After the plan is developed, we DO it by putting the plan into action and then CHECK to see if our plan has worked. Finally, we ACT either to stabilize the improvement that occurred or to determine what went wrong if the gains we planned for did not materialize. PDCA is a continuous cycle; any improvement realized by carrying out one PDCA cycle will become the baseline for an improvement target on the next PDCA cycle. The process of improvement (PDCA) is never ending, although the dramatic improvements of initial PDCA efforts may be hard to sustain.
Deming also developed his famous "14 points" to transform management practices. Those points are applied to EMS and summarized below.
An EMS organization's highest priority is to provide the best quality medical care and/or transportation services to its community at the lowest cost possible. An EMS organization is responsible to both its community and its own workforce to maintain a high level of excellence and value. An EMS organization must strive to maximize efficiency and effectiveness through constant improvement.
Everyone working in EMS can find ways to promote quality and efficiency, to improve all aspects of the EMS system, and to promote excellence and personal accountability. Pride of workmanship must be emphasized from recruitment to retirement. By their behavior, leaders set the standard for all workers.
| PDCA In Action |
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| EMS managers, reviewing ambulance response performance over time, discover that the goal of on-scene arrival within 6 minutes after notification only happens about 20% of the time. In response, a team of managers and medics develop a PLAN to improve this rate to 90% of the time. The plan requires new staffing patterns and a new vehicle deployment strategy. The plan is put into action (DO) on a trial basis during which the teams CHECKS response time information. If the desired result is achieved, the managers ACT to stabilize the new response capability. If the plan does not work, the team again ACTS to understand what went wrong, to learn from mistakes, and to try a new revised plan. |
Reliance on routine 100 % inspection to improve quality (i.e., a search for errors, problems, or deficiencies) assumes that human performance error or machine failure is highly likely. Instead, there should be a continuous effort to minimize human error and machine failure. As Deming points out, "Inspection (as the sole means) to improve quality is too late!" Lasting quality comes not from inspection, but from improvements in the system. For example, documenting deficiencies in EMS record-keeping does not, by itself, generate ideas that would make the task of record-keeping less error-prone. A quality-driven approach might, instead, encourage development of clear and simple record-keeping forms that minimize or eliminate the likelihood of mistakes.
Purchasers must account for the quality of the item being purchased, as well as the cost. High quality organizations tend to think of their suppliers as "partners" in their operation. Successful partnerships require clear and specific performance standards and feedback on whether those standards are being met. Supplier performance can also be improved through an understanding of supplier QI efforts; longer-term contracts that include explicit milestones for improvement in key features; joint planning for improvement; and joint improvement activities.
Quality can be built into all EMS activities and services and can be assured by continuous examination to identify potential improvements. This requires close cooperation between those who provide services and those who consume services. Improved efficiency and service can result from focusing not only on achieving present performance targets, but more importantly, by breaking through existing performance levels to new, higher levels.
On-the-job QI training ensures that every worker has a thorough understanding of: 1) the needs of those who use and/or pay for EMS services; 2) how to meet those needs; and 3) how to improve the system's ability to meet those needs. Incorporating QI into the fabric of each job can speed learning.
The job of management is leadership. Effective leaders are thoroughly knowledgeable about the work being done and understand the environment and complexities with which their workers must contend.
Leaders create the opportunity for workers to suggest improvements and act quickly to make needed changes in production process. Leaders are concerned with success as much as with failure and focus not only on understanding "substandard", but also "super-standard" performance. The effective leader also creates opportunities for below- and above-average performers to interact and identify opportunities for improvement.
The Japanese have a saying: "Every defect is a treasure", meaning that errors and failures are opportunities for improvement. Errors or problems can help identify more fundamental or systemic root causes and ways to improve the system.
Yet, fear of identifying problems or needed changes can kill QI programs! Also, some may feel that the idea of making improvements is an admission that the current way of doing things is flawed or that those responsible are poor performers.
Improved performance cannot occur unless workers feel comfortable that they can speak truthfully and are confident that their suggestions will be taken seriously. Managers and workforce members must assume that everyone in the EMS system is interested in doing his or her best!
Barriers between organizations or between departments within one organization are obstacles to effective QI. Inter-departmental or intra-organizational friction or lack of cooperation result in waste, errors, delay, and unnecessary duplication of effort. A continuous and lasting QI program requires teamwork that crosses traditional organizational lines. QI requires that all workforce members, depart-ments, and units share a unified purpose, direction, and commitment to improve the organization. Intra-organizational pathways are developed and cultivated as mechanisms by which to improve performance.
The problem with such exhortations is that they put the burden for quality on worker performance instead of poor system design. QI requires that the organization focus on improving its work processes. In so doing, service quality will increase, productivity and efficiency will rise, and waste will diminish.
For Deming, work production standards and rates, tied to incentive pay, are inappropriate because they burn out the workforce in the long run. Alternatively, a team effort should be marshaled to increase quality, which will lead to increased profits/savings that can then be translated to, for example, higher salaries or better benefits. Improvement efforts should emphasize improving processes; the outcome numbers will change as a consequence.
The workforce is the most important component of the EMS system. EMS cannot function properly without workers who are proud of their work and who feel respected as individuals and professionals. Managers can help workers be successful by making sure that job responsibilities and performance standards are clearly understood; building strong relationships between management and the workforce; and providing workers with the best tools, instruments, supplies, and information possible.
EMS workers can improve their lives through education and ever-broadening career and life opportunities. EMS needs not just good people; it needs people who are growing through education and life experiences. Management, as well as members of the workforce, must continue to experience new learning and growth.
The essence of QI is an organization-wide focus on meeting the needs of those who use and/or pay for EMS services. Effective quality management programs go beyond emphasizing one or two efforts or areas to improve performance. Every activity, every process and every job in EMS can be improved. Everyone within the organization can be given an opportunity to understand the QI program and their individual role within that effort. Improvement teams that include broad representation throughout the organization can help ensure success of initial efforts and create opportunities for cross-disciplinary dialogue and information exchange.
Joseph Juran. Juran's approach is based on the idea that the QI program must reflect the strong inter-dependency that exists among all of the operations within an organization's production processes.
According to Juran, Quality Planning is the process of understanding what the customer needs and designing all aspects of a system that is able to meet those needs reliably. Designing an EMS system to do anything less is wasteful because it does not meet patient need. Once the system is put into operation, Quality Control is used to constantly monitor performance for compliance with the original design standards. If performance falls short of the standard, plans are put into action to deal quickly with the problem. Quality control puts the system back into a state of "control", i.e., the way it was designed to operate. Quality Improvement occurs when new, previously unobtained, levels of performance ~ Breakthrough Performance ~ are achieved!
Juran also proposed the idea of the "Vital Few and the Useful Many" that helps prioritize which QI projects should be undertaken. In any organization, there will be a lengthy list of possible ideas for improvement. Since the resources to actually implement new ideas is limited, however, leaders must choose those vital few projects that will have the greatest impact on improving ability to meet customer needs. The criteria for selecting QI projects includes potential impact on meeting customer needs, cutting waste, or marshaling the necessary resources required by the project.
Juran also developed the idea of instituting a leadership group or "Quality Council", consisting of the organization's senior executive staff. The Quality Council is typically charged with the responsibility for designing the overall strategy for quality planning, control and improvement. Senior leadership involvement is a must since QI activities are as important as other management tasks (e.g., budgeting, human resource management, purchasing and training), and leaders can integrate QI into every aspect of EMS operations.
| The Juran Trilogy |
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Philip Crosby. Crosby coined the phrase "quality is free", meaning that the absence or lack of quality is costly to an organization, e.g., in money spent on doing things wrong, over, or inefficiently. Conversely, spending money to improve quality, e.g., to reduce waste or improve efficiency, saves money in the long run.
According to Crosby, ensuring quality should occur primarily at the design phase. Rather than spending time and money on finding and fixing mistakes and errors, Crosby advocates organizational changes to encourage doing a job right the first time. Crosby challenges organizations to think of how processes can be designed or re-designed to reduce errors and defects to reach a goal of "zero defects".
Crosby believes managers' policies and actions indicate their commitment to quality. He also advocates a step-by-step approach for educating the entire workforce about quality principles, extensive measurement to document system failures, and formal programs to redesign faulty production processes.
The QI principles and methods of Deming, Juran and Crosby provide a basic foundation for most QI efforts. In this document, QI principles and methods are applied to EMS organizations and systems so that EMS can begin the journey into a new era of quality. Reading about the work of others provides a start, but in the long run, it will be unwavering leadership that will provide the most significant ingredient for success. That leadership can be achieved through a personal and professional commitment to learn and apply these principles.
The following "success stories" show how QI principles have been used by EMS systems to improve their services. Each of these projects was developed based on customer needs, used data to drive the QI process, and relied on a collaborative, multi-disciplinary approach to improve quality.
"The Family Safety Program was developed based on direct input from one of our customers, the Public Health Department. We asked them how our ambulance service could better benefit the community in-between the times we were responding on calls. Since injuries to children in the community parks had been increasing, the Department asked for our help.
"With that request, we looked at our ambulance response data and found that most incidences in the parks were biking and in-line skating injuries. We then assembled a multi-disciplinary group to help us define the scope of the problem and identify possible solutions. The group consisted of paramedics, public health professionals, park and recreation staff, police department staff, school teachers and an epidemiologist. Led by the ambulance staff, the group agreed that a training program designed for kids about biking, in-line skating and playground safety might be beneficial. The group also agreed to collect data to determine if injuries were reduced as a result of the program; to reinforce the training in a creative way; and to secure funding to develop the program.
"In cooperation with the school teachers, the paramedics developed and taught a training program in the parks between calls. Each training session took about 15 minutes, after which each child was given a cool-looking reflective sticker for their helmet. The stickers helped us identify the kids who had been trained. Also, kids who were 'caught safe' through the summer received coupons for free ice cream.
A leading health care system provided funds for the program. Many local businesses donated funds, as well as helmets, bikes, and ice cream.
"The epidemiologist developed a survey tool; observers collected data at the beginning and the end of the summer and also collected data from community where there was no such training. When the data were finally compiled, the results demonstrated a statistically significant reduction in biking and in-line skating injuries."
"The goal of the Vehicle Damage Reduction Project was to reduce the costs of damage to the ambulances. Paramedics, mechanics and management formed a process improvement team to review vehicle damage data. The team determined that the greatest cause for damage was backing accidents: ambulances backing into their stalls would bang into the cement walls, damaging the bumpers. The team took two actions. First, they created a policy that required the EMS worker sitting in the passenger seat to get out of the ambulance and spot for the driver during back- up. Second, the team mounted tires on the walls to reduce damage to the bumpers. As a result, we saved money and reduced the anxiety of the ambulance crews and mechanics."
"Understanding the goals of managed care, we envisioned that paramedics could reach beyond their normal emergency medical skills to help senior citizens stay healthy and live independently in our community. We put that vision into action through the Senior Paramedic Assessment and Referral (SPAR) Pilot Project. This project linked our ambulance service, a home care agency, a hospital and a managed care organization.
"The project is centered around the fact that paramedics respond daily to help seniors manage sudden illness and injury. Some of these seniors have underlying health and social problems that are risk factors that may be minimized with appropriate attention or care. Consequently, while providing the needed emergency care, paramedics also assess the senior's living environment and characteristics of their daily lives. We found a way to capture this essential information and to refer the senior to other health care professionals for follow-up assessment and care."
| Leadership |
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The Emergency Medical Service (EMS) leader's role in promoting and developing QI begins with creating and sustaining a personal and an organizational focus on the needs of internal and external customers and consumers. Through their actions, leaders demonstrate a clear commitment to the organizational mission, values, goals and expectations that promote quality emergency medical services and performance excellence. The customer-oriented mission, vision, values, and goals of the EMS organization are best integrated into all aspects of management through effective leadership.
Emergency Medical Services Leadership
Regardless of whether the focus is at the state, regional, or local level, the EMS organization's chief officer or executive must spearhead leadership for the QI program. Under his or her leadership, all other managers or leaders must work together to: 1) set the direction for quality improvement by creating a strong patient focus; 2) create clear and unambiguous statements that define the organization's mission, and values and identify operational objectives and long-term expectations; and 3) demonstrate continuous commitment to achieving the organization's quality improvement goals. (See Strategic Quality Planning.)
Achieving ever higher levels of service performance requires that EMS leaders develop a strategic quality plan (see "Strategic Quality Planning") that integrates QI into their system. The Strategic Quality Plan should:
Patients and Other Stakeholders
EMS leaders must insure that all organizational and system processes focus on the needs of patients and other stakeholders. Within the context of this manual, the term "patient" indicates the person receiving the health care service; "other stakeholders" indicates those, other than the patient, who have an interest in the health care and other services being rendered by the EMS system, e.g., the patient's family, the community in which the EMS system operates; local, county, and state governments that provide resources and/or regulate the operation of the EMS system; insurers and other third-party payers who pay for the care being rendered; and other health care providers that work with the EMS system, e.g., hospitals, physicians, and nurses.
Patients and other stakeholders can also be thought of as customers of the EMS system, and, depending on how they relate to the EMS system, as either internal or external customers of the system. External customers include those outside the actual operation of the EMS system, e.g., patients and their families, governmental entities, the community, and insurance companies and other third party payers. Internal customers, i.e., those who are involved in or with the operation of the EMS system, include the system's employees and volunteers, members of the leadership councils or committees that plan and coordinate the system; the variety of agencies that interact to form the ongoing, functioning EMS system; and other health care providers, including hospitals, that together with the EMS service, provide health care to ill and injured patients.
The idea of internal and external customers applies to all levels of EMS organizations. For example, a statewide EMS system might have as its internal customers, local EMS agencies, regional EMS organizations, county-wide planning bodies, as well as its own state-level employees. Its external customers would include the state legislature and federal regulatory agencies that support and monitor the operation of the EMS system.
Focusing on patients and other stakeholders means first identifying who those individuals and entities are (e.g., by a simple listing of internal and external customers) and then working to understand their needs and expectations. This latter task can be accomplished in two ways. The first way involves contacting customers and asking them about their needs and expectations. For example, conducting patient surveys can provide direct and measurable information on which parts of the EMS service most affect overall patient satisfaction and health status. Alternatively, conducting focus groups of former patients often provides rich detail, although the results of these discussions may be hard to quantify for analysis purposes. It is important to remember that efforts to identify customer needs should not focus solely on patients, but should also include similar efforts with the other external and internal customers of the EMS system, e.g., regional and state level leaders forging and maintaining strong communication links with the leadership of legislative, regulatory, and professional groups.
A second approach to identifying customer needs and expectations is through input from front-line staff members who deal every day with customers, in particular, external customers, e.g., patients or personnel from other agencies involved in the EMS system. EMS workers who have daily contact with these individuals are an invaluable source of information on internal and external customers' needs.
Either of these approaches can be used to produce a list of Key Customer Requirements that can form the basis for the EMS system's mission, vision, and values statements, as well as its strategic planning goals and objectives. For example, patients and their families can identify their expectations or concerns regarding the timeliness of EMS response, the ease of access to the EMS system, or the level of courtesy and caring demonstrated by EMS personnel.
Similarly, internal customers, such as clinical providers, can inform leaders about their needs that would, in turn, lead to improved services, e.g., training programs, protocol modifications, management and human resource issues, or job safety concerns.
| Focus Groups |
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Leaders of regional and statewide systems interact with local agencies in similar fashion. The role of the state EMS leadership is to meet the needs of regional leaders who in turn meet the needs of local agencies. While local, state and regional leaders are equally interested in identifying customers, there are usually major differences in the scope of the inquiry. While local agencies focus on individual patient provider interactions, regional and state leaders are usually interested in comparisons of how entire agencies or regions are performing to meet patient and community needs. Similarly, state EMS leaders can seek out opportunities for comparisons of their own performance with their peer states as a way of judging the effectiveness of the state system in meeting customer needs.
Once internal and external customer needs are identified and a list of Key Customer Requirements catalogued, the EMS system's mission, vision, and values statements, as well as its strategic planning goals and objectives, can be completed. Prioritization of key customer requirements occurs during this effort. (See Strategic Quality Planning). The creation of those planning documents is an important leadership responsibility because they must reflect the viewpoints of the overall constituency of a local agency, region, or statewide system.
The EMS agency or system mission statement describes the fundamental reason for the existence of the organization. It should describe all the essential components of the organization, such as identification of the system's customers; geographic service area; major services provided; economic goals; and organizational strengths.
The vision statement declares where the organization wants to be in the future and serves as a major focal point of strategic quality planning. The values statement identifies the basic tenets and principles of how people will work together. The values statement covers issues of fairness, honesty, commitment, dependability and expectations.
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Operational goals and objectives are defined within the strategic quality planning process and provide day-to-day direction for system progress.
Empowerment of the EMS Workforce
People perform better and strive harder to succeed when they feel personally invested in their work. All members of the EMS system must feel empowered to make an impact on the quality of their system.
| "Empowerment"
Every EMS worker has the authority and the ability to solve problems and improve services. |
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Through careful planning and transition, managers can maintain authority and responsibility while, at the same time, increase the autonomy of and input from staff. This transition requires the creation of new working relationships among staff members. Training in topics like team dynamics and problem-solving may help provide personnel with the skills needed to make the new working relationships successful. For example, teams of pre-hospital care providers can be formed to identify ways to improve the quality of care rendered to patients. Additionally, other personnel, such as dispatchers, fleet maintenance, and data collection personnel can be added to create "Care Improvement Teams" that focus on ways by which the entire EMS response, patient care and transport process can be modified to better meet patient needs. At regional and state levels, regional councils and state advisory boards serve a similar function. These groups provide an excellent forum for the development of leadership expertise and consensus on regional and statewide quality improvement direction and policy.
Senior EMS leadership must also create opportunities for managers to develop and improve their management skills within the context of the QI effort. It is important to clarify managers' QI roles and responsibilities, as well as to ensure that their activities reflect an ongoing commitment to the organization's mission, vision, values and goals. Additionally, managers can be a strong motivating force for the entire organization to be involved in QI, since managers often function as the linchpin between senior leadership and the work-force. Consequently, early manager buy-in to QI activities is crucial.
EMS leaders can use a variety of approaches to increase manager involvement, including: encouraging increased communication among all organizational levels and departments; changing manager responsibilities to include more quality improvement team facilitation/leadership, and less inspection or supervision. Finally, all managers should participate in frequent quality, financial, and strategic performance reviews.
Managers should also be encouraged and supported in their efforts to demonstrate to the entire organization their ongoing commitment to quality improvement. For example, organization leaders should ensure that all managers have the time and incentive to participate actively as instructors and learners in QI educational activities. Additionally, managers can meet frequently with their internal and external customers; make contributions to the organization's newsletter; mentor new employees in QI values and policies; and serve as leaders and facilitators of quality improvement teams. These leadership and management activities should be evaluated periodically to determine whether they are achieving the desired result. Where results fall short of organizational goals, senior leaders need to revise and re-direct efforts into more productive initiatives.
Leadership Accountability
All members of the EMS leadership system should assess how well they each "walk the talk" of quality improvement. This might be accomplished, for example, through internal customer feedback on their leadership ("coaching") performance and how they might improve. Since in the early stages of QI, staff may be apprehensive about evaluating the boss, use of anonymous feedback may be helpful. Eventually, however, anonymity may be unnecessary as fear of reprisals lessens.
Community Citizenship
EMS organizations are part of the communities they serve and can contribute to community well-being in the same sense that every citizen is expected to contribute. For example, EMS leaders can promote community citizenship by setting the highest personal and organizational standards for ethical conduct in business and work practices. Such standards might include, for example, procedures that allow for public accountability and disclosure of performance information. EMS leaders must see to it that their organizations and staff continuously exhibit professional behavior and values.
| Summary of
Baldridge Program Leadership Objectives |
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EMS organizations also have a responsibility to cooperate with other health care, public safety, and private organizations that play a role in the overall EMS system. Participating in community-wide planning for EMS services, as well as disaster planning and response activities, provides the opportunity to forge strong links with these organizations and the community. Liaisons with other EMS-related organizations in the community will help to maintain a customer focus, as well as provide opportunities to learn more about the needs of internal and external customers. EMS organizations can also participate in statewide reporting systems that enable comparison and bench-marking between local agencies or regional systems.
Further, EMS organizations can take a leadership role in educating the public about preventive health activities, environmental protection and other community-wide issues. Education activities, such as injury prevention classes, pre-arrival emergency care and system access training, not only educate the public but also strengthen goodwill. Although the degree of community involvement will depend on available resources, all EMS organizations can make some contributions in this regard. For example, smaller organizations might take part in cooperative activities with other, larger organizations to maximize resources. Regional and state level agencies and leaders can foster these activities by providing multi-jurisdictional coordination and resources.
Finally, EMS leaders can encourage on-the-job or after-hours involvement in rganized community programs, e.g., blood drives, "toys for tots", scouting, or sports programs. Such participation can help the organization maintain its grassroots links to the community, encourage employee leadership within the community, and improve morale.
| Information and Analysis |
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The efficient collection and management of data and its transformation into useful information are fundamental to a successful Quality Improvement program. Data are necessary to describe customer needs, evaluate performance, establish goals for improvement, and monitor progress.
Selection of Data Used for Planning, Management, and Evaluation of Overall Performance
Specific data elements must be linked to key areas of organizational performance. Data elements must also be designed to meet the needs of those who will use the information. Data and information must be reliable, rapidly accessible, standardized, and timely.
| Use data to determine performance excellence |
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Ambulance run form data is essential to an effective QI program. The run form documents the patient encounter and is crucial for evaluating how well an EMS organization fulfills its key performance tasks (e.g., prehospital response, treatment and transport time intervals, adherence to established treatment protocols, and changes in patient health status). The NHTSA recommends a minimum EMS data set that should be included in an EMS organization's information system.(1) EMS systems should adopt these data elements and operational definitions verbatim in order to facilitate benchmarking comparisons. These data elements, however, may not support evaluation of locally-specified treatment, transport, or triage guidelines, or other policies. Consequently, data elements needed for local evaluation should be added, if necessary.
Stakeholder data (e.g., from insurance companies, employers, managed care companies) are used to determine the types of EMS services needed or desired. Such information can be obtained and updated periodically by questionnaire or interview. For example, the geographic area encompassed by an EMS regional system may include a number of industries that could require an EMS response in the event of a hazardous materials incident. By collecting and updating pertinent information from the companies, the EMS system can better ensure its ability to respond to such incidents by, for example, arranging for special training or necessary equipment.
Satisfaction data are used to determine how well the EMS system is meeting the needs of patients and other stakeholders. For example, was the EMS response judged to be timely? Were the providers judged to be efficient, effective, helpful, courteous? Was the necessary equipment available? While it may not be possible or appropriate to collect such data from the patient or his/her family during the initial contact, these data may be collected subsequent to the initial patient encounter.
Process data are important for identifying and managing local needs, such as, vehicle use, age, and mileage, maintenance status, reliability; provider training, education and accreditation data; financial data; other administrative data (for example, personnel hours worked). Process data are also used to determine the root cause of problems and to compare performance against standards or other peer agencies.
Data Management
Data management procedures are used to continuously monitor and improve the usefulness of local or area wide EMS information systems. Effective data management begins during the process of determining what data should be collected. The existing data set elements should first be evaluated and modified if necessary: every currently-collected data element should be reviewed to determine if it is the best possible information source for evaluating the quality, cost or the source of problems for a key organizational process. Next, the process of transforming data into useful information must be evaluated and improved. Careful consideration of the effectiveness of information distribution for the work force must occur. Specifically, managers must determine if the presentation of results effectively supports process management, decision-making and performance improvement efforts.
State Level Data Management Activities. Necessary data management activities by the state EMS office are as follows.
Comparative reports are highly useful. For example, regional reports can compare data with those from other regions; reports to a provider agency can compare that agency's results with those of other agencies within the region. Such comparisons can: 1) help recipients determine performance areas that need improvement; 2) increase benchmarking as a QI technique; and 3) hasten adoption of "best practices" throughout EMS.
The statewide registry may be the most able (because of state access to databases and more sophisticated computer personnel and equipment) to link the run form database with related database(s), e.g., hospital discharge or medical examiner databases. There are many useful applications for such linked databases, e.g., evaluating trauma triage criteria, where trauma system registry and/or hospital discharge databases are linked with the EMS registry information. Linking databases in this manner can provide a firm cornerstone for effective use of data for QI purposes.
Local Level Data Management Activities. Necessary data management activities at this level are as follows.
| Comparative Reports |
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Procedures for collecting and recording data should be specific, well-defined, and reflect an understanding and appreciation for the working environment of the providers who collect the data. Procedures can include ways to "automate" the data, e.g., direct data entry into a laptop or other data entry device, or onto a scannable form to eliminate keypunching. Direct electronic data entry is most desirable because it permits checks for data quality to be completed near the time of "collection", increases the likelihood of error correction, and reduces data omissions.
Evaluation and Improvement of Data Management
Provider / Organization Level: Ongoing evaluation of data management activities ensures quality and identifies areas requiring further development, personnel needing additional training, and equipment necessary to improve productivity.
Comparisons from other disciplines can help guide EMS data management effectiveness. For example, data accuracy and completeness rates in established cancer or trauma registries can provide some general guidance. Experiences in other registries, however, may not be directly comparable because of factors unique to those registries, e.g., the amount of data per record; or the time over which those data are collected may extend well beyond hospitalization.
Statewide Level: By virtue of its statewide perspective, the state EMS Office can be particularly useful in evaluating the effectiveness of data management. For example, the state can examine and compare data quality measures across regions, identify variations, and suggest areas and opportunities for improvement. Data management techniques and results can also be compared among similar states. Where areas for improvement are identified, the state can provide or assist with arrangements for necessary training or remedial activities.
Competitive Comparisons/ Benchmarking
Comparisons and benchmarks are important for each key EMS performance area. Comparisons and benchmarks (e.g., the best 5% of performers with respect to a particular measure), based on data from other states, regions or agencies, can put an organization's performance into perspective. Benchmarks from appropriate non-EMS organizations can also be helpful, e.g., police or home protection company response times.
Performance comparisons can occur in two ways: 1) point comparisons can be made of time-specific performance indicators that are compared to established standards; or 2) comparisons can include monitoring of trends over time in key performance areas. The results from comparisons and benchmarking may suggest no action (already among the best performers); a need to review and refine current work processes (performance is "close" to benchmark); or total re-evaluation and search for breakthrough approaches (performance is far below the benchmark).
State Leadership in Benchmark Definition: The state may be in the best position to select relevant databases for comparison and benchmarking and to provide periodic feedback to regions and organizations. Initially, benchmarks could be empirically derived from statewide EMS data. State EMS agencies can spearhead interactions with benchmark-level performers in each area, identify their "best practices" and distribute that information to others while maintaining confidentiality when necessary. State agencies can also lead the search for relevant bench-marks from other states and industries.
Where areas for improvement are identified, the state can help identify: 1) performance with respect to the benchmark; 2) activities stimulated by the shortfall; 3) resulting changes (e.g., improvement) in performance; 4) subsequent initiatives to pursue or define new benchmarks; and 5) individual provider efforts to improve performance by local benchmarking.
Analysis and Use of Organization Level Data
Use of data at the individual performer or department level differs from use at the organization and systems level. At the organizational and systems level, data can be related to quality, customers, medical markets, and operational performance. Together with relevant financial information, these data are integrated and analyzed to support organization-level review, action, and planning.
Understanding customers and markets: EMS serves entire communities and populations-at-risk. Understanding the demo-graphics and socio-cultural features of the EMS service area is important for planning all EMS activities. Access to demographic databases (e.g., the U.S. Census) is helpful, as is partnering with health insurers and managed care organizations in the service area to gather and analyze incidence data for acute illness and injury. Databases developed in cooperation with other provider groups or professional societies can be helpful, particularly those that include data from the entire health care system in the EMS service's medical trade area(s).
Improving customer-related decision making and planning: Understanding the needs of customers (i.e., payers) requires ongoing communication with the employers, private parties and governments that pay for EMS services. Billing information can provide data on payer mix and utilization, augmented with data on prevalence of paying organization, as it is likely that the population overall and the users of the service will be different.
Improving operations-related decision making and planning: Incidence and demand data are critical bits of information. Demand pattern analysis results can be used for refining current operations and long-range planning for future operations. Information from key sources, for example, patients and other stakeholders, health care practitioners, EMS service population area statistics should be obtained and updated periodically. Surrogates should be sought where necessary (e.g., organizations that assist those dependant on home ventilators) and advice obtained on relevant operational management and planning issues.
Understanding organizational capabilities: Operations performance may be evaluated using indicators of operational performance (response-time reliability, etc.) and cost (base charge, per capita annual subsidy, etc.). This allows for comparison across systems and encourages managers to constantly test and answer the question: "Are we doing the best we can with the money we have?"
System-wide efforts are vital to determine if EMS organizations make measurable clinical differences to their communities. Whenever possible, EMS organizations should use standardized methods to evaluate cardiac arrest survival. Use of cardiac arrest survival, the most widely recognized and reliably measured clinical performance indicator, permits comparison of results with other, similar systems. Similar outcome measures are sorely needed for other patients, e.g., trauma or pediatric, that would allow for outcome comparisons across systems.
Understanding competitive performance: Identifying and understanding "the competition" is important to ensure that EMS systems are responsive to the needs of patients and other stakeholders. Answering the following questions can help focus EMS systems on performance improvement:
Conclusion
Information and analysis activities can be daunting to EMS systems that have little experience in data collection, management, analysis, and interpretation. Yet, data collection- and analysis is central to the effective design and implementation of the strategic quality plan. EMS Systems should undertake those data and information activities as their current resources permit, but also seek to expand their capabilities by using the principles described in this chapter.
| Strategic Quality Planning |
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Strategic planning is the process of developing long- and short-term organizational objectives, identifying ways to achieve those objectives, and measuring the effectiveness of these efforts. Quality planning is the successful design or re-design of a system to perform to the quality standards expected by patients or other stakeholders. In the quest for continual improvement, strategic planning can be closely linked with quality planning and combined into a single organization or agency-wide planning process.(2) This chapter will focus on an integrated process that incorporates both strategic and quality planning into strategic quality planning.
Overview of Strategic Quality Planning
Strategic quality planning is neither magical nor mysterious; it is simply an organized method of determining where an EMS system or organization wants to be and how it plans to get there. Strategic quality planning is not something separate from the EMS system; rather, it is an integral, ongoing part of the system. It involves the careful integration of all components of the EMS system, including clinical performance, financial support, legal authority, personnel management, education and training, and data collection and analysis. Individual components are mutually interdependent; planning and evaluation of one component cannot occur in isolation from the others.
EMS systems involve many different organizations and individuals with separate authorities, management, and governing bodies, each of which may have its own strategic quality planning process. EMS often involves organizations and individuals not traditionally viewed as health care providers (e.g., law enforcement personnel, dispatchers, and the general public). Yet it is because of the diversity of the organizations involved that strategic quality planning is imperative to the overall improvement and smooth functioning of the entire EMS system.
The activities of each level of EMS (state, regional and local EMS organization) are different, but complimentary. Strategic quality planning, as well as the entire QI process itself, should occur at the local, regional, and state EMS system level. Just as the state EMS system must support local EMS systems, these systems' activities should be compatible with the overall statewide vision and mission.
Strategic Quality Planning at the State and Regional Level
Strategic quality planning at the state EMS level differs from strategic planning at the local or agency level. Unlike the private sector, there are no competitive or entrepreneurial demands placed on a government agency. Instead, the state EMS agency is charged with creating or maintaining public policy and meeting the needs of a different type of "customer": tax payers/citizens and EMS companies/ corporations, as well as the patient, hospitals, and health care providers. The state EMS agency is typically charged with designing or, in most cases, re-designing systems of care that will lead to optimal patient outcomes. The state is also charged with identifying demographic and economic issues that will impact the delivery of EMS care and planning to meet these changing needs. Whether it involves the design of a trauma system from the ground up, or the re-design of a system that has evolved over several decades, strategic quality planning can help the state EMS agency better meet the needs of the EMS community and those they serve.
| The goal of strategic planning is not just the plan itself; rather strategic planning encompasses the method of doing the planning. |
The state EMS strategic quality plan serves as the roadmap for achieving quality improvement in EMS for the entire state. One key to successful strategic quality planning at the state level is to involve all those individuals and organizations that will be affected by the plan. A strategic quality plan that lacks input and buy-in from those affected will only gather dust on the shelf. Mechanisms for obtaining involvement and buy-in from the various stakeholders will be discussed later in this chapter.
In order for the plan to be a useful tool in measuring performance across the state and improving service to the patient and other stakeholders, it must be:
Strategic Quality Planning at the Local/Agency Level
The nature of strategic quality planning at the local level varies according to whether the organization is in the public sector (e.g., local government agency, fire bureau, or county EMS agency) or the private sector (e.g., "Ambulance Company XYZ, Inc."). In both public and private sectors, however, strategic quality planning still involves planning new or revising existing services based on patients and other stakeholders' needs, expectations and specifications. In both sectors, the design of new processes or services must follow a prescribed quality planning formula to assure that the process is designed correctly the first time.
Strategic quality planning in the private sector is more focused on favorable market positioning in a competitive environment, as well as on financial viability. Strategic quality planning in a public agency that uses volunteers can be a great challenge. The planning process must be user friendly and designed to maintain interest and involvement from start to finish. Enthusiasm can be increased when participants understand the usefulness of strategic quality planning in guiding progress and advancing patient care. Involvement will be minimal, however, if participants view strategic quality planning as only a bureaucratic exercise.
Because each level of an emergency medical service system has different responsibilities and functions, objectives and action plans may be different. A cohesive EMS system requires compatible and complimentary vision statements, consistent key driver identification and uniformity of performance indicator definitions.
An EMS system involved in the strategic quality planning process would complete the following:
Developing the Vision Statement
A vision statement provides a futuristic look at and broad guidance for the EMS agency or system. In simple terms, the vision statement helps to make sure everyone is going in the same direction. Each objective and action plan that is subsequently devised is consistent with the vision statement, thus assuring constancy of purpose and compatibility of actions.
While development of the vision statement is directed by the leaders of the state, regional, or local EMS system, the system or agency "players" should be deeply involved in the development process. People are more likely to help implement what they help to develop. (See "Leadership").
Typically, a vision statement would be a short, motivational description of the EMS system's ideal condition. The vision statement can serve as motivation for those involved in the system and can be a steady guide through the numerous changes necessary to achieve a quality system.
The state's vision statement is broad, encompassing the entire statewide EMS system. The regional system's vision statement should be unique to that system and consistent with the state vision statement. Development of the vision statement for the local agency (e.g., ambulance service) is directed by the service's managers. The vision statement is unique to that service and is consistent with the local system and state vision statements.
Strategic quality planning structure
The right strategic quality planning structure is based upon the organizational characteristics of the EMS system. The structure must account for the fact that strategic quality planning is an ongoing process, based on the principles of quality improvement and involves the EMS system's organizational, financial and clinical aspects.
Strategic quality planning is not something new and different that requires a separate system or a separate process; instead, strategic quality planning is a process that drives all planning and all quality improvement efforts. Thus, the strategic quality planning structure must take into consideration existing planning and quality mechanisms, including state EMS advisory councils, local EMS councils, health care advisory councils and other specific statutory or regulatory requirements.
Assumptions
Underlying any planning process are implicit assumptions that steer the organization and its personnel in certain directions. These assumptions should be identified as part of the strategic quality planning process. Making assumptions explicit allows for discussion and agreement on whether the assumptions remain valid and useful for the future of the organization or whether they need to be changed or discarded.
Some examples of common assumptions regarding EMS include the following:
| EMS Vision Statement (Example) |
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| Emergency Medical Services of the future is a community-based health management system that is fully integrated with the overall health care system. It has the ability to identify and modify high risk illness and injury indicators, provide injury prophylaxis, provide acute illness/injury follow-up, and contribute to treatment of chronic conditions and community health monitoring. This new entity is totally integrated with other health care providers and public safety and public health agencies, thereby decreasing utilization of acute health care resources. Emergency medical services serves as the public emergency medical safety net.
--U.S. DOT/NHTSA, Washington, D.C.,1996. |
EMS Agenda for the Future, U.S. DOT/ NHTSA, Washington, D.C. 1996
Key drivers
Key drivers are those areas most critical to the success of the EMS system and should be consistent with the system's mission and vision. Identification of the key business drivers provides the basis for focusing the EMS system's quality improvement efforts in specific areas. Key drivers include customer-driven quality requirements, as well as the organization's operational requirements.
The key drivers are identified through the strategic planning process and are based on expert opinion, good judgment and common sense. Once identified, the key drivers should be validated by internal customers (employees, staff and volunteers) and external customers (patients and other stakeholders). Examples of key drivers for the EMS system might include, but not be limited to:
Objectives and Performance Indicators
Objectives are measurable statements that are consistent with the system's mission, vision and key drivers. Clear operational definitions are needed for each objective. When well-defined, these objectives can serve as performance indicators against which system progress toward attainment of the objective can be objectively assessed or compared.
Strategic quality planning will likely involve both procedures-oriented and outcomes-oriented objectives. Procedure-oriented objectives are those that are assumed to facilitate achievement of the broad plan objectives while outcome- oriented objectives are focused on the accomplishment of measurable outcomes.(3) Broad organizational goals tend to come from the "top down"; however, quality improvement projects are often "bottom up" and should be consistent with the broad goals. Rather than just monitor the completion of procedures, effectiveness is based on measurably improved outcomes.
Additionally, some objectives will likely be similar or even identical among state, regional, and local agency participants. Other objectives will be unique to each type of EMS structure or will vary among similar structures.
Compliance
Compliance with the objectives simply involves using available sources of data and information to measure compliance with the performance indicators.
Analysis
Where compliance falls short of the performance objective / indicator, an analysis must be completed to determine the cause of the problem. EMS is a highly complex system, and analyses (as well as the action plans that grow from the analyses) must account for this complexity. As an example, an EMS system has as one of its objectives (performance indicators) the following:
Compliance is determined to be only 10%, however. A careful analysis of the situation might identify the existence of one or more of the following reasons for the non-compliance, each of which may ultimately require action steps at different levels of the EMS system.
Possible reason: First responders are not permitted to defibrillate.
Possible reason: There are insufficient numbers of automated external defibrillators on ambulance services and rescue squads.
Possible Reason: 9-1-1 coverage is available to only 50% of the population.
Possible Reason: The general public does not know when and how to call 9-1-1.
Possible Reason: EMS personnel are not complying with established protocols
From these limited examples, it should be clear that analyzing the causes of non-compliance will likely involve the entire EMS organization and system (including policy-makers, care providers, medical directors, public safety personnel and others).
Develop and implement action plans
Action plans are where the "rubber meets the road". When the system is out of compliance with the objectives, an action plan will need to be developed to correct the cause of the problem. The action plan should be specific as to the exact steps necessary to assure compliance.
Evaluate impact of action plans
Following implementation of the action plans, there must be a re-evaluation of compliance with the objective. Did the action plan make a difference?
Modify the action plans and/or indicators
If the action plan did not make a difference, it may be necessary to attempt other action plans. The overall strategic plan should be flexible enough to be easily modified based on new information, modified priorities or changed conditions. The planning process is as important as the plan itself.
Evaluating the Effectiveness of the Strategic Quality Plan
The initial strategic quality plan prescribes the key drivers of the EMS service and corresponding measurable objectives (indicators) that operationalize these key drivers. The strategic plan also sets the goals for the level of achievement. Evaluation of the strategic plan compares the goals or desired level of achievement to the actual accomplishments.
As an example, the State Health Division of a rural western state evaluates the success of one component of its 1995 Strategic Plan in the following manner:
Key EMS Driver: Appropriate/timely patient interventions.
Objectives (performance indicators):
Endotracheal Intubations:
Procedure-Oriented Objectives:
Outcome-Oriented Objectives:
Evaluation of Compliance:
Action Plan:
Other Evaluation Methods
Because the goal of strategic/quality planning is to better meet the needs of internal and external customers, feedback is an important part of evaluating the planning process. In addition to comparison of performance against objectives / indicators, EMS leaders can use direct input from customers to determine if their needs are being met. Evaluation methods will differ slightly according to the jurisdiction involved, though each method can be used at both the state and local level.
Focus groups with consumers and customers are another effective method to use in evaluating the success of the strategic plan. Focus groups can be used at the state and EMS organization level, as well as at the local provider level (see "Leadership"). Similar to focus groups, customer surveys are another way to evaluate the outcomes of the strategic plan. Surveys are generally less expensive than focus groups, but are often limited by poor response rates and variable reliability of the data.
EMS Examples
Following is a limited example of strategic quality planning related to 9-1-1 access:
Key Driver: Prompt Public Access to the EMS system via a 9-1-1 dispatch center staffed by appropriately trained personnel.
Objectives and performance indicators:
Outcomes oriented objectives
| 1.1 | 75% of the emergency medical calls to 9-1-1 dispatch should be received by the 9-1-1 center within 5 minutes after the time of onset of symptoms or injury. |
| 1.2 | 90% of the population should have access to 9-1-1. |
| 1.3 | 95% of the emergency medical dispatch instructions should be consistent with the approved dispatch protocols. |
| Procedure oriented objectives | |
| 1.4 | Dispatchers should be included in the QI activities of the local EMS system. |
| 1.5 | There should be EMS dispatch protocols that are coordinated with the EMS system and approved by the system medical director. |
| 1.6 | There should be adequate funding for the 9-1-1 dispatch center. |
| 1.7 | All 9-1-1 operators should participate in an EMS dispatch training program meeting the standards established by National Highway Traffic Safety Administration. |
Compliance
Using the available information and data sources, compliance with the objectives should be determined and reported. (See example above.)
Action Plans
There should be action plans developed to improve compliance. (See examples above.)
Evaluate impact of action plans
Following implementation of the action plans, there must be a re-evaluation of compliance with the objective. Did the action plan make a difference?
Modify the action plans and/or indicators
If the action plan did not make a difference, it may be necessary to attempt other action plans or to modify the indicators.
| Human Resource Development and Management |
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EMS' most important asset is the dedicated people who work throughout the system. These individuals hold the key to successful and lasting quality improvement efforts.
The EMS workforce includes all those who contribute to the delivery of the EMS organization's mission and services, regardless of career or volunteer status. An EMS system's human resource practices affect the EMS workforce and are inextricably connected to EMS performance results. The EMS workforce can be empowered and enabled to develop and use their full potential to achieve their local agency and regional or statewide system vision for the future. For this to occur, the EMS organization must provide opportunities for performance excellence, as well as for personal, professional and organizational growth.
Human Resource Planning and Evaluation
Human resource planning includes all aspects of job design and personnel management of the EMS system and its personnel. Human resource evaluation focuses on assessing and improving human resource planning, practice, and performance.
Once the strategic quality planning process has started, EMS leaders must carefully translate those plans to the realm of human resources. The link between personnel resources and overall performance can be strengthened by relating specific quality goals to specific human resource goals and by identifying what human resources must be in place to help ensure success. For example, targets for morbidity and mortality reduction must consider existing skills and capabilities of the workforce. Similarly, new targets for health status outcome performance will not be achieved simply by expecting workforce members to work harder or more efficiently; new skills, training or technology may be needed. Consequently, EMS leaders may need to consider changes in: (1) work process design to improve flexibility, efficiency, coordination, or response time intervals; (2) workforce development, education, initial and refresher training (including credentialing); (3) compensation, recognition, and benefits; (4) staff composition; or (5) recruiting efforts.
Personnel-related and organizational performance data can be used to analyze personnel needs, assess the links between human resource practices and key performance results, and identify changes needed to achieve EMS system goals. Data elements may include job satisfaction, turnover, absenteeism, safety, grievances, recognition, training, and information from exit interviews, as well as overall system strengths and weaknesses that could affect the agency's ability to fulfill human resource plan requirements.
In order to develop the full potential of EMS personnel, it is critical to evaluate efforts to improve human resource planning, practice, and performance. Evaluations can be augmented by comparative or bench- marking information and used to identify specific personnel needs or new approaches or practices.
Workforce Work Systems
| Human Resource Planning |
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Re-design work processes or jobs to increase opportunity, responsibility, and decision making Promote greater labor-management cooperation Recognize and reward efforts that increase patient and stakeholder satisfaction Survey staff to identify ways to improve performance Prioritize personnel problems based on potential impact on productivity Develop recruitment / re-training strategies and initiatives Form partnerships to increase education, training and job opportunities Address safety factors |
Improvement of quality may require that the workforce be re-organized into new, more effective work units. These may include non-traditional work teams, problem-solving teams, or functional units that are formal or informal, temporary or long-term. Units may cut across customary organizational lines and be self-managed or managed by supervisors.
The total quality EMS organization is committed to operating patient care systems and administrative services that can achieve high performance. "High performance" services maximize efficiency and produce the highest level of quality possible.
Job performance can be enhanced where EMS systems: (1) design jobs that ensure that the roles, responsibilities, duties, and tasks of each workforce member are tailored to achieve the system's goals; (2) create opportunities for initiative and self-directed responsibility; (3) foster flexibility, job efficiency, task coordination, and rapid response to changing requirements; and (4) ensure effective communications across traditional units/departments. Enhancing existing jobs might include simplifying job classifications, cross-training, rotating jobs, modifying work layout or work locations, or using new technologies e.g., computer links or conferencing technology.
The EMS organization's compensation and recognition system can also be used to improve the effectiveness of the work and job design. In this manual, compensation and recognition refer to all aspects of pay and reward, including promotion, bonuses, and recognition. Recognition is extremely important in EMS systems and encourages high performance levels and work contributions that are above and beyond past efforts. Organizational reward mechanisms are equally important for both compensated and volunteer EMS organizations and help foster a sense of community in the work environment. There are many formal, informal, individual and group approaches that EMS systems use to recognize and reward performance. New approaches can also be used to strengthen links with patients and other stakeholders, e.g., community-wide recognition of the efforts of all health providers in the EMS system.
Work Force Education, Training, and Development
Education and training empower the workforce to achieve not only the job requirements, but also the goals of the EMS organization, and the vision for the entire EMS system. Most EMS education and training is directed at meeting clinical skill needs and certification requirements. In the context of a strategic quality plan, however, education and training may extend beyond the need for clinical expertise. For example, since managers will need to lead and facilitate QI teams, managers should be trained in the variety of skills relevant to these activities, such as, leadership and team facilitation. The list at right contains some of the topics that team facilitators and leaders should pursue through education and training. State lead EMS agencies can support local systems and organizations by developing curriculum and arranging multi-jurisdictional classes.
| Train to Increase EMS Workforce Effectiveness, Efficiency and Safety |
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State, regional and local agency leadership is needed to develop quality improvement objectives that address how education and training are designed, delivered, reinforced, and evaluated. Improvement areas include: (1) how the EMS workforce is involved in determining specific education and training needs and in designing delivery and evaluation options; (2) how re-credentialing requirements are translated into educational program designs; and (3) how knowledge and skills are reinforced on the job.
On a daily basis, the EMS workforce interacts directly with the system's patients and other stakeholders. Training for patient and stakeholder (front-line) contact should include not only the knowledge and skills necessary to provide effective emergency care and transport, but also those that contribute to customer awareness and needs assessment. These skills include more effective ways of listening to and soliciting input from patients and other stakeholders; managing patient and stakeholder expectations; and anticipating and handling system problems or failures.
In order to determine these non-traditional training needs, the local agency will likely need to conduct an organization-wide staff assessment. A needs determination should analyze job responsibilities and the types and levels of skills required. The actual training might occur within or outside of the EMS organization and involve on-the-job, classroom, or other types of education and training, e.g., developmental assignments within or outside of the organization. With the increasing popularity of the Internet, state agencies can become the focal point for curriculum development using distance education methods. Computer-based education programs provide opportunities for maximum scheduling flexibility to meet the needs of changing personnel schedules.
Workforce Well-Being and Satisfaction
Worker well-being and satisfaction are necessary for the organizational delivery of high quality emergency services. Consequently, leadership must focus on maintaining a work environment where workforce well-being factors (such as health, safety, and ergonomics) are included in quality improvement activities. Managers must determine and understand what the workforce needs to achieve and maintain physical, mental, and social well-being.
EMS agencies and organizations should also determine which services, facilities, activities, and opportunities will be available to the workforce to support their personal development, well-being, and job satisfaction. EMS organizations at every jurisdictional level may want to provide or support the following: personnel and career counseling; career development and employability services; recreational and cultural activities; non-work-related education; day care; and special leave and flexible scheduling for family and community service responsibilities.
Similarly, EMS leaders need to review indicators of workforce morale and motivation. The strategic quality plan should include human resource key indicator analysis and improvement objectives. Valuable sources of information include: grievance proceedings; incidents involving field provider health and safety, including infectious disease exposure; back injuries; assaults; staff evaluations of leadership and management; use of staff development and career opportunities; use of sick-time and workman's compensation; and exit interviews.
| EMS Process Management |
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This chapter examines how key processes are designed, managed, and improved to achieve higher performance. Within the context of this manual, "process management" is used to refer to the improvement of work activities and work flow across functional or department boundaries.
Design and Introduction of EMS Patient Care Services
Community financial constraints and health care reform are challenging EMS leaders to design new services and methods of operating the EMS system, to adapt to new demands for quality and cost efficiency, and to conduct evaluative research to demonstrate the value of EMS.
The QI-oriented EMS organization has in place a well-defined strategy for designing new services and for evaluating and, where necessary, re-designing existing services. Such strategies specify: (1) how decisions are made to launch new preventative, primary or emergency medical care services; (2) how environmental changes are translated into efficient patient care and work processes (e.g., changing patient and stakeholders needs, regulatory or payer requirements; technological innovations); and (3) how the timing and flow of new service proposals occurs so that the operations of all external and internal system organizations are integrated and coordinated in support of the new service.
Further, the measurement plan for quality indicators of new services should specify what variables are to be measured, who is responsible for measurement, and when and where measurement is to occur. Preliminary performance standards can be defined so that results can provide the information needed for the strategic quality improvement process.
Finally, EMS leaders should also develop specific procedures to insure that proposals and planning documents for new services are throughly considered and pre-tested, where necessary, to ensure maximum effectiveness and safety for patients and the workforce. Finally, the design, evaluation and pre-testing process itself should be subject to continuous quality improvement.
Future Trends
EMS of the future may serve a direct or supporting role in the delivery of a wide variety of services. These services may involve such diverse areas as disease and injury prevention, health maintenance and promotion, diagnostic testing and screening, post-discharge home care, and rehabilitation services. Design issues that EMS organizations typically address include:
Design approaches will differ depending on the nature of the patient service. If several design projects are carried out simultaneously, EMS leaders will need to coordinate resources among the various projects. In service design or evaluation, the key requirements of patients and other stakeholders must be paramount, e.g., safety and risk management; timeliness of care; system access; coordination and continuity of care; patient involvement in care decisions; measurement capability; availability of staff with necessary critical skills; availability of referral sources; use of technology; unit capacity and utilization; supplier capability; and documentation.
Design requirements must also account for the standard EMS processes:
When considering expanding the scope of EMS practice to include prevention or primary care services, leaders must also assess the wide mix of service options and medical professionals available.
Delivery of Patient Health Care
The delivery of key patient health care services can be managed to ensure that design requirements are met and that quality, effectiveness and efficiency are continuously improved. Critical indicators can aid in this process. Critical indicators are clearly defined measurements that compare various input and process characteristics. The regular analysis of critical indicators of quality will yield patterns of performance that will trigger quality improvement projects. Once defined, EMS leaders must select and support improvement projects based upon pre-determined criteria relevant to the importance of the project within the strategic quality objectives of the EMS organization.
Critical indicators must be developed for each key health care service; these indicators exhibit some specified phenomena that can be measured. Typically, an individual EMS field care provider will observe or experience a sentinel event that will trigger a decision to make a correction. For example, a paramedic makes a second attempt to intubate a patient after failing to hear proper breath sounds following the first attempt (sentinel event). When a sentinel event occurs (i.e., failure to get breath sounds), the provider focuses on rapid discovery of the cause(s) and use of a quick remedy of the problem based on predetermined action plans. This is effective quality control -- putting the delivery of patient care back on the right track as soon as possible. Notice the difference between quality control and quality improvement. Quality control is a rapid restoration of the process to its intended quality level. Quality improvement involves action over a longer period of time that results in achievement of new breakthrough levels of performance.
At higher levels of authority, a summary approach to process management is used. For example, for a supervisor or manager, the review of an aggregate measure that indicates a significant change in a rate or trend typically triggers a response. Continuing with the intubation example (above), the manager who has the authority and responsibility to maintain the quality of care provided by all the paramedics would monitor the intubation success rate of all providers as one group and try to find causes for the unacceptable variation in rates. The group would typically be based on a bi-weekly summation of the results of all intubation attempts. The manager would define "a standard" success or failure rate. With regular monitoring and definition of acceptable variation limits, managers can know when to act. Solutions are then designed based on the aggregate analysis of how rates differ when a variety of causal variables are controlled. For example, a sudden and unacceptable increase in the rate of first attempt intubation failures per hundred cases, where intubation was indicated, would be analyzed to determine a cause. Potential causes might include the location of the patient when failure occurred, the time of day, shift on duty, training scores, individual success/failure rates of all medics. (See Cause and Effect Diagram in the QI Tools Appendix).
If the resulting action by the managers stabilizes the success rate to acceptable limits of variation over a defined period of time, then quality control has been achieved. If the result of the intervention causes the intubation success rate to reach a new, previously unachieved level of success that is sustained, then quality improvement has also occurred. Managers who have access to organization-wide, regional and/or state data have the responsibility to identify and lead quality improvement projects.
Support Services Design and Delivery
Managing quality involves every aspect of EMS operations, including services that support the EMS system's delivery of health care. Support services include:
Through careful attention to the needs of those who use support services, these support functions can be designed and managed to meet on-going quality standards and to drive continuous improvement. Typically, those who use support services include not only patients and other stakeholders, but also the EMS workforce, departments or other units within the system.
Community Health Services Design and Delivery
Community health services are population-based services that support the general health and well-being of the community served. Such services might include, e.g., CPR, injury prevention education, immunization, population screening (e.g., hypertension, cholesterol), or indigent care. The same strategies that are used in managing and improving the quality and efficiency of direct patient health care and support services can also be applied to community health services programs.
Supplier Performance Management
Key suppliers are those outside providers that supply the goods and services that are most important to the effective functioning of the EMS system, e.g., suppliers of key materials, instruments, vehicles, devices, or services. Requirements for these goods and services typically include defined quality levels, delivery times, and price. Fully apprising key suppliers of the EMS system's ongoing and changing needs, and feedback to suppliers as to whether those needs are being met, are fund