EMS Quality Improvement: Having the Difficult Conversation

Without doubt the most difficult part of performing quality improvement in EMS is, often times having the difficult conversation with coworkers regarding their patient care practices.

In fact, one of the main reasons clients hire Girard & Associates is to outsource their QA/QI functions for this very reason.

Having this conversation is not only stressful for the person conducting the discussion, but for the person receiving the message as well. The conversation can start off fairly benign and evolve quickly into conflicts in differing points of view, or worse, a full-blown shouting match.

Let’s face it, having to discuss a provider’s quality of work with a coworker and then pretend everything is okay afterwards can create friction. It’s hard sometimes to have these conversations and then try to decide where everyone is going to have lunch after.

There are some tricks you can employ however that can take the sting out of these discussions.

The purpose of performing quality improvement is to get providers to change from performing in the fashion they are accustomed to, to a more desirable set of behaviors that are more likely to result in an improved patient outcome or experience. In fact, it can be said that the main job of the quality officer is to be a change agent (as opposed to the common view of the officer as an enforcer of policy or protocol). In an education base QI system, the intent is to educate and to not use blunt force to get people to change behaviors. This is an important distinction, as the focus is not on whether a provider did something wrong, but a more general approach as in what can be done for the patient that may result in a more improved patient experience (and hopefully outcome).

The origin of a positive conversation actually starts before you even meet with the individual. Getting your mind in a positive state can go a long way in obtaining a positive experience. It is not uncommon for even experienced QA/QI personnel to get a bit jaded and start the interaction from a place of frustration. This can be especially true when the QI personnel must continuously repeat the same messages over and over, or even more frustrating, to repeat the same message to the same provider over and over. It can lead to a conversation that starts with, “Paul, we have had this conversation before, why are we having it again?”.

Using the wrong verbal language or body language can get you off on the wrong foot and it can be very difficult to turn the conversation around once that occurs.

Another awkward situation is when the provider you are speaking to is on the defensive the moment you approach them. Even with the right intentions sometime providers are geared up for a battle even when you are using best efforts to avoid a confrontation. Even the best employee can have a bad day or be going through personal issues that make it hard to approach these discussions with an open mind. There are steps you can take to improve the odds that the conversation you need to have does not turn into a messy situation.

Tips to successful quality improvement interactions:

Create a culture of education and collaboration in the QA/QI process

    A little prep work goes a long way. Creating a positive environment before the tough discussions can earn you points when the going gets rough. If providers believe that the QI process is truly educational, fair, and consistent, they are more likely to participate in a positive fashion. This can be done by making the process collaborative and non-confrontational. Don’t be afraid to give kudos and bend a little on the lesser important points if they are unlikely to result in true patient care improvements. Sometimes people stick to their guns (both providers and QA people) because the protocol says something as opposed to it making sense in the case being discussed. If the provider offers a valid point, don’t be afraid to give them credit.

Get your mind right before going into the meeting

    If you just got off the phone with your boss who gave you a hard time about something, don’t let that get into your QA session with a provider. QA personnel are people too, and how we act is a direct result of the factors going on around us at any given time. Just like the people we serve with our advice and counsel. And make no mistake, our job is to serve others, not provide judgment on them.

Do not prejudge the call prior to speaking with the provider

    It is not uncommon for QA/QI personnel to come to a conclusion about the care rendered on a call based on a reading of that call from the run report. This oftentimes leads to the QA person already knowing what they want out of the conversation before the meeting even takes place. This makes the provider feel like their input is not needed or considered, as the decision has already been made. Sometimes less preparation is better. The review of the call should be a journey taken by the QA staff and the provider together and conclusions reached after careful discussion, thought, and consideration with a heavy dose of provider feedback.

Construct written and verbal language that is non accusatory

Instead of using language that may put the provider on edge, consider your wording carefully and the likely impact the language may have on the providers response. Avoid language such as “why didn’t you” or “what were you thinking”, or “you should have”. Instead, consider using language that looks to clarify and understand and not criticize. Words like “perhaps” or, “another option would be” can go a long way in getting the person you’re working with to drop defenses and speak openly and honestly with you as opposed to playing defense and trying to defend less than desirable actions.

Don’t be afraid to back down if things start getting heated

    Remember, you have caught the provider at a bit of a disadvantage as you have had a chance to review the call, speak to medical direction, and/or review the protocol prior to having this meeting. The provider oftentimes is being asked to give responses to things you have been able to pre-think about, and he/she has not. If they do start to get a bit defensive, you need to be able to switch gears and continue the discussion in a less stressful way. Sometimes a humor break can work to take the temperature down a notch or finding common ground for things the provider did well on the call that you can point out works well. Just remember not to say things insincerely as that will be picked up on as well.

Get to know the providers on a personal level long before you start to have discussions with them

    When a provider walks in your door for a chat and the conversation starts with, “how is your day going”, or “how was vacation”, it can get you off on the right foot as opposed to launching right into the call’s issues. There have been discussions I have had with providers where we spent 20 minutes on how things were in their lives and only 5 minutes on the questions I had pertaining to the call. Again, you need to be sincere in your interest and not superficial as you will likely get the reverse result than intended if the provider feels you don’t really care. This is not just a tactic for putting the provider at ease. If the provider trusts you and speaks candidly with you on what is going on in their lives, you have a window into their frame of mind that may have played a part in how they are providing care. If a provider is going through serious life issues, it may be a distraction for them on the job. Life goes on beyond EMS and no one can help having difficulties in their personal lives that may distract from the work environment. A little compassion goes a long way in helping your providers get back to even keel. Afterall, we are in the compassion business, are we not? That should extend to our staff members and not just the patient.

Defend the defensible

Doing QA is a job fraught with subjectiveness. Different providers have different opinions on how calls should be performed. In fact, even medical directors have differing opinions on how calls should be performed. We generally have several different medical directors we work with at any given time for various clients and how one medical director interprets the run report and how the protocol applies is not universally agreed upon. In fact, there are wildly differing views on a wide variety of issues related to prehospital care. If the provider has a valid rationale for his/her actions (even if you don’t fully agree with the thinking) don’t be afraid to present their case in an unbiased way when discussing it with medical control. A strong defense of a provider’s actions when warranted goes a long way in building trust and respect for both the QA process and QA staff on the part of the provider. That trust will pay dividends later when more challenging issues arise.

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