Using a Third-Party Consultant for CQI

No matter how diligent, skilled and earnest you are in your job, pretty much everyone dreads a performance review. Given the opportunity to forgo it, most of us would opt out if we could. But in EMS, how good you are at your job sometimes translates into lives lost and saved. EMS providers entered the field to help people, and continually striving to provide high-quality prehospital care is what most do every day. But that doesn’t mean you don’t dread seeing exactly where you stand. Fortunately, there are objective ways of measuring performance and fostering a culture of improvement that doesn’t feel punitive.

The evolution of continuous quality improvement (CQI) in EMS

When Paul Girard was managing at a hospital-based system in Massachusetts, he was asked by the hospital administration to provide quality improvement data that EMS simply didn’t collect.

“I had to learn on the fly how to do quality improvement for my own service. In so doing, I realized that in EMS, the way we do quality improvement is basically someone needs you to run a report, and then if you did something wrong, they go yell at you,” said Girard, a 40-year EMS veteran. “That was never very effective when it was being done to me.”

That’s why the consulting firm he founded in 2005, Girard and Associates, starts with an education-focused approach that implements positive change through objective measurement and individualized remediation programs.

How it works

Girard and Associates designs, implements and manages continuous quality improvement (CQI) and quality assurance (QA) program management services for EMS and fire agencies. This is how agencies gauge how well they provide patient care and where they should focus improvement efforts.

While some EMS software has data collection and reporting functions built into QA modules, Girard and Associates’ proprietary system uses a unique database and performance scoring system that compares an individual paramedic, EMT or EMS agency’s performance against other paramedics, EMTs or agencies of a similar size.

Girard and Associates starts with a detailed audit of an agency’s EMS patient care reports to determine the quality of care that has been provided.

“Not only can we tell you how well you are doing, but we can tell you exactly what you need to do to improve,” said Girard. “We can then go to work using accurate, timely data that can be measured and improved upon.”

The audit results in an agency scorecard and score ranking report that shows the agency’s performance rating compared to other agencies. The audit also analyzes specific calls and reports on items such as STEMI identifications, sepsis alerts and stroke screenings.

High- or medium-level infractions are immediately reviewed by the agencies’ medical director and then with the EMS provider to quickly identify any real or potential issues before they become major problems. Lower-level infractions and documentation errors can be reviewed with the management team or individual providers monthly or quarterly, as desired.

Once any issues have been identified, Girard and Associates develops a customized CQI/QA plan for the agency that may include training classes for all staff or individualized remediation programs. In some cases, the problems are just poor documentation. Girard and Associates will advise providers on how to improve the documentation in the report.

“The info they’re getting from the audit reports is robust. It’s much more accurate, much more detailed, and it’s actionable data,” said Girard. “The agency gets the data, and they choose to do what they want with it, or, if they utilize Girard and Associates to manage their CQI program for them, we know exactly how to use it to improve performance.”

Why use a third party?

“EMS quality improvement is in its infancy and is not well-designed,” said Girard. “Most providers don’t have a model to look at, so they do it not only inefficiently, but they do it in a manner that creates a lot of tension in-house amongst other staff members. It’s highly critical.”

As a consulting firm, Girard says they can deliver data-based insights and offer constructive feedback to EMS providers in a way that might be less uncomfortable than if it were coming from agency leadership.

“We are a third-party service which means we remove the biases and take the personalities out of the discussion. Everyone is treated equally and fairly, regardless of whether they are a 40-year veteran or a 4-month provider,” said Girard. “Conversations amongst peers can be difficult particularly if it is your partner or friend. As a third party, we strive to make the provider understand what could have been done better and, at the same time, establish a trusted relationship.”

Paul Girard

When Girard and Associates starts the CQI program management for an agency, there is understandably some anxiety, but once EMS providers realize that they are being coached rather than chastised, it speeds up the learning process rather than building a wall of resentment or fear.

The company is looking to build trusted relationships with the individual providers and to get them to willingly change their practice, says Girard, as opposed to trying to force them to change their practice.

Coming soon to an agency near you

“Only a few states now require EMS agencies to have a CQI or QA program, and even in those states, the criteria can vary. In some cases, it’s enough for an agency to simply say it has a quality assurance program in order to pass muster with the state office of emergency management,” said Girard. “It’s only been in the past few years that OEMS are starting to ask for data such as rate of STEMI recognition or cardiac arrest survival rates that show if the agency is actually performing well.”

So, if having a CQI/QA program is not required in your jurisdiction, why would your EMS agency sign up to do something that’s going to be time-consuming and stress-inducing?

“Agencies have to be willing to do this because their mission is to help people, and they want to verify in some fashion that they are, in fact, helping people,” said Girard. “Many agencies have found that it’s better to get that from an outside agency than for them to proclaim they’re doing a great job when, in fact, they don’t know if they’re doing a great job.”

Also, there are pressures on hospitals to provide patient care metrics to Medicare. If the hospital doesn’t meet those metrics, they don’t get reimbursed.

“That’s probably the future of EMS, where your reimbursement may suffer if you’re not providing good quality care,” said Girard. “So, the incentive is getting your operations in order now, before that happens, because you can’t turn the tide on bad patient care very easily.”

Many agencies do not realize that they can use a third party to conduct their CQI and QA program, but Girard and Associates, built by an EMS veteran, is dedicated to EMS quality improvement and has built all the infrastructure needed to accomplish the process efficiently and appropriately.

“Once agencies see the power of the data and people stop complaining to them about the QA process, it becomes a win-win all around for them,” said Girard. “This is one less major headache that they don’t have to deal with.”