12 Reasons to Outsource Your EMS QA Program

Back in 2005, I had no idea if outsourcing EMS quality improvement was a concept that could work. There were virtually no private companies devoted to performing EMS quality improvement services. I certainly heard plenty of reasons as to why outsourcing CQI was a bad idea, but it seemed to me that with the limitations in existing CQI program designs, that perhaps the time had come for a new idea. It seems that emergency medical service CQI programs reached a point in the evolutionary cycle whereby most everyone was doing the same thing without proof that the existing models worked. If you asked most field providers, the standard CQI program revolved around reviewing run reports and looking for “bad care” or possibly even bad providers who needed to be “caught” doing things wrong. That line of thinking goes against the grains of most quality improvement theory in the rest of the business world. Why were we still using antiquated methods when better ideas exist, I asked myself? More importantly, if an improved model was developed, would people embrace it?

Developing a comprehensive, well designed model proved more daunting than I had anticipated (and more costly too) but building something from the ground up often is. In the process of developing a program that is education based, non punitive, and based on the principle that providers care about what they do and are willing to do better if given the tools, I have discovered that agencies will in fact embrace a better idea. In the following paragraphs I have outlined the reasons why many agencies find outsourcing to be the best option for them.

1) An independent/unbiased view

EMS is a critical function. The system is designed to provide care and transportation to people with a variety of illnesses and injuries. The public trusts that we will arrive quickly, perform high quality patient care, and transport the sick and injured in a timely manner. While it is easy to determine response times and delays in transport, it is more difficult to determine if an agency provides high quality care. In fact there are virtually no services available that can independently verify that the patient care provided is adequate; (try hiring a consultant that will tell you how well your service provides direct patient care). Our profession relies on the service themselves to tell us that they/we are providing high quality care. This makes it difficult to persuade people who might question the agency’s motives when a question of quality arises. An independent, unbiased review is a more reliable method for convincing the public that the services you provide are what they should be. The general public is more skeptical now than ever, and an independent review is much more likely to satisfy those who question your care. Compliance programs, independent audits, and other verification processes are becoming more and more popular as everyone wants “evidence” that organizations are doing the right thing. Agencies that are proactive in bringing in independent reviewers or accrediting services have a higher degree of trust and support from the public.

2) Quantifiable Results

As mentioned previously there are few independent quality improvement companies and even fewer who have programs that provide quantifiable results. There are many consultants in the marketplace that will go into your agency and take a look around but when it comes to the patient care you provide, very few can give you quantifiable data beyond basic statistics. Girard & Associates has developed a scoring and rating system that identifies patient care that is potentially harmful to patients (using our proprietary risk scoring index) along with an actual score of how well your agency provides patient care. We can also provide scores on each field provider with a breakdown of what types of behaviors that provider does that are risky to the patient’s overall care. Our data quantifies how well providers (and the agency) take care of patients in a way that allows for clear cut strategies for what needs to be improved upon.

3) Non-Threatening, Education Based Process

Many internal EMS QA/QI programs are designed to intimidate the very providers it is intended to help. In most cases the negative consequences are not intentional but the effect is the same. Providers typically feel that the QA/QI people are the “internal affairs” department and the primary objective of the program is to ferret out bad providers. A quality improvement program must be designed to be a resource for the field personnel. It needs to be primarily an educational pursuit whereby providers can learn from past experiences, not hide from them. That means every effort needs to be made to ensure that knowledge is imparted from the process, not fear. There are many EMS folks who profess to trying to help field personnel get better but the result oftentimes is more of a heavy handed approach that creates hostility, fear, and resentment on the part of the staff. The next time you go on shift, walk around; talk to your people. Ask them if the internal QA process is fair and reasonable. Ask them if they feel as if the QA folks are there to support and assist them in their role as patient care providers. If you really want to stir things up, ask the field personnel whether the QA program provides them with the customer services they need to do their jobs better. Find out if the CQI process provides value to the patient, the providers, and the organization. If you don’t think you can get a straight answer from direct interactions try an anonymous questionnaire. You may be surprised by the answers.

4) Minimizes Internal Personnel Conflicts

Probably the single biggest reason agencies contract with us to provide quality improvement services is to minimize the conflicts inherent to internal programs. In truth, the conflicts may be more of a sign that your QA process is not based on mentoring and tutoring but on a fear based mind set, even if it is not intended that way. It is very difficult to do QA/QI internally without generating conflict. The problem is that in most cases everyone has to live with the results of the wounds inflicted by an ineffective QA program. Not only does a program need to be educational and non punitive, but equally important, the person performing the functions needs to have a specific and very particular skill set. Agencies often promote field providers to be QA coordinators based on their skill in the field providing patient care (a good idea in itself) but that is only the first criterion for the skills necessary to be an effective CQI coordinator. The wrong person in the job can do immeasurable damage to an organization and can cause rifts so strong that is takes years and significant personnel changes (which happens slowly in most agencies) to overcome it.

5) Expert QA Processes and System Design

There is no such thing as a flawless system, just as there is no such thing as a perfect patient care provider. The ideal QA program is not a perfect one, but it is one that is well designed, has minimal flaws and has an internal improvement process to improve the QA program itself. If your QA program is not “QA’ing” itself then it is not a strong program. Additionally, your field providers know the weaknesses of the process. A quick and easy way to lose the respect of the street folks is to ignore the weaknesses in the QA system while those same systems continue to point out the weaknesses of the providers (and continuing to force them to improve their behaviors). What are the weaknesses in your program? They are there, undermining the good work you are trying to do every single day. Whether you do CQI in house or hire an outsider, make sure the program is using modern improvement theories and processes and is striving to improve upon itself. A solid program will not only minimize patient care errors but will earn the trust and cooperation of the rank and file.

6) Utilizes EMS System Best Practices

Girard & Associates performs quality improvement services to many EMS agencies of all types. As such, we are exposed to some of the best practices in the industry. We have the ability to share those practices with member agencies and assist them in developing policies and procedures that address the most common and frequent patient care problems in our industry. It takes significant work trying to find and fix the issues that cause you sleepless nights. In many cases the solutions are already being used somewhere with great results. Put that efficiency and time saver to work for you.

7) Facilitates Communications between Management, the Service Medical Director, and the Field Providers

Another common and all too frequent problem is the limited interaction between the three critical players in most EMS systems: management, field personnel, and medical director. In many cases field personnel have never even met their medical director. The medical director plays a critical role in an agencies patient care and that resource is normally underutilized. Our program identifies calls requiring medical director review and we have regular one-on-one meetings with the medical director for their immediate feedback. They participate in the scoring and ranking of calls and utilize our database to track their thoughts and comments regarding practitioner’s care. Our unique and custom built software allows us to track any clinical care item of interest that the medical director or the service management needs us to track. We are then able to report back to all three parties whether everyone is in compliance with the requirements. Field personnel will have direct feedback from their medical director regarding how they are performing and what their medical director wants to see for improvements.

8) Detailed Data Collection and Report Systems

Our customized database allows us to collect extensive data regarding the level of care provided to each and EVERY call your service goes on. All communication regarding the QA process is recorded and reported on to the individual providers, management, and the medical director. In fact, feedback to each provider is provided for every patient encounter along with verification that everything was done well or a recommendation for improvement. You will not find a more comprehensive feedback mechanism in any quality improvement system anywhere! Does your program provide feedback on every call to every provider on a regular basis? Not only that, but we can also identify the areas needing improvement so that corrective action plans can be developed to minimize future occurrences.

9) Ability to Track Service and Providers Improvement Efforts to Verify Improvement is Occurring

One agency contracted with us because they had a patient care incident that the state’s OEMS department investigated and found fault with. During the interview between the OEMS investigator and the medic, the medic made the statement that he did not understand why there was an investigation started on this call. He was mystified because he had performed the same actions on “lots of calls before” and no one ever made mention that what he did should not have been done. How can he be at fault when no one ever told him it was wrong, he asked? As you might imagine, this raised all sorts of questions. How long has this medic been doing “the wrong thing” and what harm might it have caused other patients? Why didn’t the service QA program catch it before (the QA coordinator did not know it was a problem issue)? Why did the medical director not notice this going on and put a stop to it (she wasn’t aware as the QA program never flagged this activity as it was deemed OK to do by the QA coordinator and was the culture of many of the medics within that agency at that time)? In many cases problem calls don’t pop up. They are ongoing issues that did not get addressed until something very bad happened. When it does, everyone will want to know how it went unnoticed for so long. Or, if you attempted to fix it before, why is it still occurring? Our built in tracking system allows us to identify trends right down to each medic or EMT. Does yours?

10) Cost Saving

In most cases, a well thought out QA program can actually improve your service’s revenue stream. How so? Two of the most high risk areas for EMS agencies are patient refusals and BLS patients who should have received ALS. If your service is not tracking the validity of those two items (along with some others) you are not only mistreating patients but you are losing revenue in the process. In many cases the money spent on bringing in an outside QA company is offset by the increase in revenue and the decrease in risk to the agency. In fact, some insurers will provide grants for you to bring in an outside agency and will also provide reductions in insurance premiums for hiring a qualified independent QA service. Additionally, if you are doing it correctly, the time and effort are significant and the cost of outsourcing is significantly cheaper than dedicating the resources needed to do the job well in-house.

11) Decreased Payer Rejections

The federal government is now using quality standards to restrict or reduce payment for inadequate medical services. Hospitals and other providers are being penalized for low quality patient care practices and the government will be expanding “pay for quality” programs in the coming years. EMS will also see restrictions in funding in the not too distant future, including 911 providers who have often been overlooked for such close scrutiny. Can your service afford to take a pay cut? If you are like most agencies, probably not. Providing quality improvement services is a critical part of managing an EMS system and there is an increased emphasis on quality care on the part of both payers and regulators. It is part of the cost of doing business for all EMS providers in today’s challenging environment.

12) Increased Field Personnel Satisfaction

Not that long ago most providers resented the oversight provided by quality control personnel. In many systems that is still the case. However, in services where the QA program is designed to provide support, encouragement, positive feedback, and the tools for improvement, that no longer needs to be the case. If your field providers do not feel that way about your existing quality improvement efforts perhaps it’s time to try something different. Most providers want to provide good care. By and large they do in most cases. But if you don’t give them the tools they need to get better then you may have unexpected and unintended results. There is an old saying “you get the system that you build”. Let Girard & Associates work with you to build your quality improvement system.

For more information visit us at www.girardassoc.com or contact Paul Girard atpaul.girard@girardassoc.com.