Lets talk QA/QI

[FiremanMike]

I'd like to hear from anyone experienced with a functional QI program, specifically if you were around when it first started up.

What tips have you found to be the best way to approach QI in an environment that has NEVER received feedback on EMS runs?

 

[Carlos Danger]

I think peer review is a good idea. Everyone gets to review everyone's charts. Like everything else, some are going to be more qualified and better at it than others, but it's also a good learning tool for the lesser qualified reviewers.

Also, making the process as objective as possible, using a checklist to review the charts and requiring any "dings" to be documented in a standardized way.

 

[TomB]

The feedback has to be supportive, non-punitive, and not embarrassing. I would start with one thing your'e trying to improve and don't pick something useless like IV success rates. It should start with system surveillance. For example, you could pull all of your adenosine calls for 2015 and review them to see if adenosine was given appropriately. If you identify opportunities for improvement, send out an educational PowerPoint for the paramedics to review, then start tracking adenosine use. If someone does a good job, feed it back to the line as a case study and say, "Good job!" If you find a problem you can call the paramedic in charge and say "Hey, George, it's Tom, how are you? Do you have a minute to talk about a call? I see you guys gave adenosine last week. We don't do that very often! Can you walk me through it?" Then AFTER the paramedic explains his thought process (sometimes they will tell you "yeah I know Dr. so-and-so told me it was atrial fibrillation....) you can say, "Okay, cool. So adenosine is for REGULAR tachycardias. It's a good reminder for all of us." If it's not supportive, and if quality is not improving, then it's not QI. It's something else and probably not good. Good luck!

 

[RocketMedic]

Pretty much what Tom said, but I think that it is important to add a separation between the employment/management and clinical/management/supervision side of the operation and present a clear and non-punitive mission for the QI department, one that allows bilateral review of both the individual and the service.

People get defensive very quickly when they feel that their jobs are on the line for any perceived slip or error, which leads to incomplete or inaccurate records and a divisive mentality within the company. I think that it is important for QI to emphasize that it's first and foremost function is education and improvement. This is difficult because one of the core functions of QI is employment and quality monitoring, but there are better ways to get there than decrees. From my time at EMSA, the worst thing abut QI was the way that they (two respected paramedics, later on just one who was a rank amateur with little talent other than a brown nose) were forced (and willingly drove) more towards the conservative mean/basic/minimalistic interpretation of a protocol instead of considering the indicated treatment and the quality and thoroughness thereof. A perfect example is the administration of narcotics for pain. Most of the paramedics you'll manage probably firmly believe that pain is to be treated conservatively, and you'll probably find that a fair proportion of your paramedics never give medication unless blatantly demanded, and they'll likely view any progressive deviation from this in negative terms. Likewise, a progressive reluctance to intubate everyone vs a regressive tube-em-all approach may cause your existing informal QI system to prejudge everyone new or different as a poor provider. I think that one of your QI programs core measures of effectiveNess is how well you are able to drag the standard forward as opposed to becoming a backdoor to management's conservative leanings.

Lastly, I think that the QI guy needs to be both respected and subject to the same rules you impose.

 

[FiremanMike]

Thanks to all.. My current plan is to heavily focus on run followup so that folks can see long term results of their treatment options. I have some support from our medical director in terms of having him look over runs that I send him for his thoughts, with the hope that people may start to take more ownership of their runs.

I certainly intend to approach QI with no pretense of discipline. The most difficult part for me will to be to ease into this with baby steps, as there are deficiencies that need addressed and, as mentioned, there's been no previous QI. I want to try and keep this open to prevent the circling of the wagons "Oh ****, here comes FiremanMike again.." but rather an open dialogue that goes both ways. I know, it's probably a fantasy, but one can hope.

I do appreciate the input thus far, thanks so much guys!