The 13 Necessary Elements for High Quality Patient Care
In any EMS system there are going to be calls where, even with the best of intentions, patients do not receive the care they require. It happens every day and in every system. The fact is the job of providing pre-hospital patient care is a complex and chaotic one. It is inevitable that not all patients will be treated properly. The issue is not whether a service has adverse patient care incidents, but whether that agency has the proper support systems to properly identify and correct problems as they arise. In order to provide a “fix” for a given problem it is necessary to accurately identify the root cause of that problem.
In most EMS systems the task of identifying lapses in patient care is often relegated to the quality assurance/improvement (QA/QI) department. While this is a logical function of the QA/QI department many agencies do not have a well-designed QA/QI program resulting in the misdiagnosis of common problems. A routine procedure in many quality improvement initiatives goes something like this; something bad happens in the field during a call, the QA department audits the call and determines the medics did something wrong, the medics are brought in and the call is discussed with them, a document is produced or a conclusion is reached that the medics messed up, remediation is performed to correct the issue.
While this process may be necessary in some cases it is often not the correct action if a service is looking to improve the overall care, their service provides. It is flawed by the assumption that most patient care problems are the results of errors on the part of the field providers. Field providers do on occasion make errors that are solely their own, but in the vast majority of cases the error began before the medics even arrived on scene. Widely accepted quality improvement theory suggests that most errors in the production of a product, or in the provision of a service, are not the fault of the workers assigned to that task. They are, in fact, a result of a variety of causes that contribute to the ultimate failure at the point of production. In order to determine the actual cause of the failure, it is necessary to determine the root cause of that failure. To simply blame the field personnel is too simplistic and is oftentimes a wrong assumption.
Root cause analysis is the process of identifying what factors contributed to an outcome that was not intended. It is a diligent attempt at understanding not only what occurred and by whom, but why the incident occurred at all. If the quality department staff members stop after determining what happened and by whom they are missing the most important and instructive lesson to be learned from the incident. The Why. It is here that we see many QA/QI systems falter. If a review of the call determines what occurred and by whom and stops at this point, the most logical action to move forward is to assign blame, and once blame is assigned, the likely solutions are to educate or remediate the individual involved or apply a disciplinary solution. Is it any wonder the quality improvement process is disliked by field personnel and a mostly undesirable position for staff members to aspire to?
If a more careful analysis of each run is performed with a thorough search for the underlying causes of the patient care infraction, it would result in a variety of issues that can be categorized into 13 elements. If any of these 13 elements are not functioning properly, the results will ultimately be evident in poor patient care situations. A careful analysis of thousands of EMS patient care reports (PCRs) allows us to group the most common field provider errors and poor patient outcomes to the 13 root causes listed in Figure 1.
13 Necessary Elements to Quality Patient Care
Element 1 – Provider Education
When we consult with EMS agencies regarding patient care issues, it is not uncommon during our discussions with staff to identify variations in baseline knowledge. We sometimes can even determine which training institution they attended as a medic or EMT based on the type of comments they make regarding specific patient care situations. Even though there is a standard curriculum by which training institutions adhere, it does not account for variations in the training process. In reality, training institutions should be required to have a quality assurance department to ensure the training experience is consistent and of high quality. We often see medics from the same training organization who have differing views on how to address certain patient care issues.
There may be many reasons for the variation at the training level, including instructors of differing skill level (a product oftentimes of their own training), inadequate facilities/equipment (In our profession we love toys. Training aids are often employed because they have cool features as opposed to their proven ability to improve the training experience), students who are not fully ready and engaged to learn, and a lack of testing models that test a student’s ability to perform in the real-world environment, to name a few. The reasons are lengthy and varied and a more thorough analysis of this area needs to be performed.
We often see paramedics fresh out of school who have a hard time operating a stair chair or other device they will need to use in the field. This particular issue may be due more to the vast variety of products on the market than the training institutions inability to train the student properly or it could be a direct result of a poor job done by that instructor that day. Or another possible cause (one in which one of my physician medical directors used to say all the time), the medic or EMT “missed that day of EMT school”. The issues in this element are many but need to be considered to properly address potential issues and solutions.
Element 2 – Provider Experience Level
We often hear from quality improvement staff members that a given field provider “probably didn’t make the error” identified in an audit. When we inquire as to why they feel that way, the answer sounds something like this; that medic has tons of experience, he is an instructor coordinator who teaches this stuff, and I would let him treat my family if they were sick or injured. There are two problems with this response. The first is that the QA staff needs to remain neutral regarding any call that is going through the quality process to minimize any bias on the part of the QA staff (more on this in element 13). The second reason is our data shows that all providers tend to make errors on occasion. What the QA/QI staff needs to understand and be vigilant for is the types of errors likely to be produced by providers with differing levels of experience.
More experienced providers often make mistakes in areas that require precise judgment. For example, we often see senior field providers not ALS patients because their condition was “diagnosed” as being minor when that determination cannot fully be determined in the pre-hospital environment. Chest pain patients for example who are “ruled out” for a cardiac cause based on an examination and a negative 12 lead. They subsequently transport the patient BLS instead of ALS based on their field assessment. In some cases that may be appropriate, but frequently the paramedic quality auditors and the service’s physician medical director disagrees when they review the PCR. It is not uncommon for some of these patients to end up being admitted to the hospital for a confirmed cardiac condition.
In order for the QA process to be helpful to all providers, it needs to collect and disseminate data that is unbiased and must look for the types of issues that will be most helpful to all skill and experience levels. Even providers who have many years of experience may not have a lot of patient contact time with smaller demographic groups. Few EMTs and medics have had the opportunity to treat and interact with pedi patients, or OB/GYN emergencies for example. Some may not be comfortable with trauma or with patients exhibiting neurologic symptoms.
A client of ours worked in a small suburban EMS system for a little over 10 years. He moved on to a busier system where they had a higher pedi population and also transported those patients to a pediatric trauma center. He was an excellent medic in his former system but felt like he was not performing adequately when he needed to interact with the hospital staff at the pedi center. He began to feel anxious every time he went on a call involving children and began to question his own judgment. He took it upon himself to immerse himself in pedi classes, seminars, and the like. It took a while, but he eventually developed a competency and comfort level with this patient population. In spite of his years of experience he needed a little support and help. His service did not have a mechanism for picking up on this issue. In fact, its solution was to hire only experienced medics. Hiring only experienced medics is not, in and of itself, an adequate solution. Hiring the person with the right experience and skill set is.
This leads us to the hiring process.
Element 3 – Agency Hiring Process
Have you ever worked for an organization that hires anybody with a pulse? Perhaps you have worked with new people and wondered, where did we dig up this guy? The fact of the matter is the hiring process is the first chance that an organization has to improve the quality of the patient care in the street. Unfortunately, many agencies spend too little time and energy on finding the right person. Managers are in the very difficult position of having to get people in the door to decrease overtime or to relieve the pressure on the existing staff to fill shifts. That can sometimes be at odds with finding the right person. Finding the right person can make all the difference in the quality of patient care. If the hiring process is not aligned with the agencies mission of performing at the highest level clinically there will be problems on calls. For example, if you work in a high-volume system that is constantly innovating and trying new equipment or patient treatment protocols then you need staff members who enjoy working in that type of environment. An agency such as this who hires a medic looking for a retirement home type of environment will inevitably have problems. If the agency energy and enthusiasm level does not match that of the new employee, he/she will not only not be able to keep up but may cut corners to make it appear they are.
One agency hired a medic who was not big on administrative functions such as signing his narcotics log or doing a vehicle check list. Once hired, he went on a call and not being able to establish IV access, went to attempt an IO. Since he did not do his morning checklist, he did not notice that he had no IO needles. The patient did not receive the care she should have due to this medic’s lack of interest in doing his morning chores. One might think that that medic was to blame for not doing his checklist. The truth is the last several crew members before him also did not do a checklist. To trace the problem back further, the agency itself was somewhat lax in monitoring compliance with vehicle checklists and the service developed a pattern of inconsistency. In this case the agency hired a staff member who fit in well with the other staff members. The adverse patient outcome in this case was avoidable and is as much a result of poor management as the staff members not doing their jobs.
Another problem is many agencies do not have a hiring process sophisticated enough to find the type of people they are looking for. Many agencies hiring criteria involves a number of years of field experience, teaching experience, special areas of expertise and the like. But if your service is looking to hire a medic who can perform the job, the criteria need to match the requirements. If you want a competent EMT, you need to look for and test her competencies.
Align the organizations search criteria with the actual skill set of the prospective employee and you are likely to avoid many problems with patient care. The other problem with the hiring process is that no matter how sophisticated the process is to find the right person, it is constrained by the limitations of time and what you can accurately learn form a candidate during the interview process. The place to really see what they are made of is during the orientation process.
Element 4 – Agency Orientation Process
The hiring process is an inexact science. Over the course of 1 or 2 interviews lasting a couple of hours each, a select few members of the EMS service need to make a decision on whether this person will be a fit in the organization. If the agency is smart, they performed some level of competency testing during the hiring process. So why is it that providers still end up making critical errors during a call? For one reason the hiring process does not give people enough time to really get to know each other. There is even less time available to determine how well this provider may perform once in the streets. Even if agency X asks clinical questions or takes the provider into the SimLab to test them there is not enough time to make a full determination. That is where the orientation process takes over. While some competency testing can be performed during the hiring process the detailed competency testing needs to be done once the applicant becomes an employee. Most agencies have an orientation process, and it may be thorough, but we still see cases where an employee makes an error that can be traced back to the orientation process.
A medic was hired, and she successfully completed her orientation process and began working alongside her regular partner. Several months later the crew was enroute to the hospital with a patient experiencing chest pain. This new employee was not new to EMS. She had 18 years on the job, 12 of which were as a medic. Her patient’s pain kept increasing and the patient eventually went into a rapid heart rate requiring that she be cardioverted. After several minutes of not being cardioverted the patient went into cardiac arrest. While interviewing the medic she stated that she was not as familiar with this particular monitor/defibrillator as she thought she was. She had never used this model at her previous jobs. She did review the monitor functions during orientation several months prior (and passed her testing), but had not had the need to use it in this fashion in the intervening months.
A look at the orientation process for equipment review indicated that the medic was shown a CD presentation on the use of the unit and her preceptor spent approximately 15-20 minutes going over its features. At the time of the orientation, it all made perfect sense to her on how to use it, but the lack of needing to cardiovert over the course of the next several months tarnished her memory of its proper use. This is not an uncommon problem as is the case with so many others.
This particular problem in patient care could have been avoided with some forethought on the part of the quality control staff. The orientation process in this case may not have been adequate and there was no provision for refreshing basic equipment procedures that are used in a limited basis.
In spite of an EMT or medic’s experience level there are skills and equipment that are infrequently used. Can you be sure that all your providers are competent on all their equipment at all times? Many agencies say yes that they test the medics at refresher or mandatory retraining’s. But if your refresher or mandatory trainings allow some members to stand in the back of the room and not participate actively you may have a weakness in the process. It starts with orientation, but the process is continual. Your orientation process needs to be thorough and complete and cannot be scaled down for experienced personnel based on assumptions of competency.
Element 5 – Knowledge of Regulations
Many patient care issues can be traced back to a simple misunderstanding of the many rules and regulations that govern emergency medical patient care. It is not difficult to understand why when one considers the significant number of protocol for clinical issues along with the many administrative requirements. Besides formal protocol, many regulatory bodies issue notices, memos, administrative requirements, and various other forms of notification. It is common in our travels to encounter agencies that are unaware of various updated regulations sometimes months after they have been promulgated.
Additionally, many clinical protocols are several pages long and some of the less used medical control options are often forgotten. In our interviews with medics, we often hear that they did not realize they could use a certain drug for a special condition or perhaps they could not remember the details of its use and felt more comfortable not using it. Another common issue is the reluctance to contact medical control for advice under these circumstances. Some EMTs and medics feel that contacting medical control is an acknowledgment of their deficiency and would rather not ask and risk looking like they don’t know what they are doing.
This is a challenging area for quality control personnel that needs to be addressed head on. It may be difficult to determine the extent to which this is occurring if the agencies quality control department is viewed as a disciplinary tool. Getting staff members to speak openly and directly in order to understand the real reasons for their actions (or inactions as the case may be) can often be difficult. This is one reason why QA/QI should not be used for disciplinary reasons but should be an educational tool.
Element 6 – Agency’s Policies and Procedures
Besides the myriad federal, state, and regional regulations that providers are governed by, each EMS service likely has its own set of policies and procedures. Department policies can sometimes be vague or in conflict with other regulations. This causes confusion on the part of the field provider who may need to make a critical patient care decision but is unsure which policy they should be following. Additionally, a service medical director may have his/her own set of patient care policies they wish the providers to follow. Department policies need to be developed that are clear, concise, and thorough. They need to be revised on a regular basis (usually annually) and they need to be reconciled against the various other entities providing guidance on the same subject. It is also good practice to have the service medical director review routine department policies to ensure they do not directly or indirectly conflict with their own policies.
Element 7 – Dispatch Protocols
As with any other component of a well-functioning EMS system the dispatch process needs to be clear, concise, and well designed. Many problems can be avoided by updating dispatch procedures. There are a number of issues that crop up with poor communications. As with many patient care errors, we often can spot the precise moment when things started to go wrong. It often results in other decisions being made downstream that compounds the problem until an adverse event occurs.
A call is received for an elderly patient experiencing nausea. The call taker receives the call and dispatches a BLS unit to the scene. This is a common practice for this service as they do not have a standardized dispatch protocol. As such, each dispatcher is left to determine on their own, whether nausea is an ALS or BLS response.
Once on scene the EMTs perform an assessment, begin treating the patient, and transports to the local hospital. The patient ends up being an MI patient who then needs to be sent to a STEMI facility for further treatment. Upon QA review the auditor questions why a patient exhibiting signs of ACS did not receive ALS level care and why they did not get transported to a STEMI facility. An interview with the EMTs reveals that they did recognize that the patient may have been having an MI but because the patient did not have any chest pain and since they were so close to the hospital, they did not activate ALS as they did not want to delay care to the patient.
This type of situation exhibits a confluence of circumstances that may be the result of a variety of problems beginning at dispatch. Many communications centers either do not use preapproved protocols or are allowed to apply them loosely with no quality control oversight. We frequently hear from field providers that the quality of dispatch is not up to par. If the call taker/dispatcher does not take adequate information or does not provide proper pre-arrival instructions, it can lead to many downstream problems. In the case presented if proper call screening had occurred it may have resulted in an ALS unit getting sent on initial dispatch. One would hope that the ALS personnel would have recognized the patient’s condition as being a STEMI and treated and transported to the proper facility.
In this case, once the call was given to the BLS crew other issues developed that highlight weaknesses in the system. The BLS crew either did not recognize the patient’s condition for what it was (this may be an education problem, or an experience problem) or there may be an organizational culture problem (once on scene some agencies believe they should just transport as opposed to call for ALS support. Some even have department policies that require that BLS do just that). Some QA programs would simply blame the EMTs for not recognizing the need for ALS and remediate them. While remediation may be warranted, a critical component of the incident is being overlooked. If the dispatchers should have dispatched ALS at the outset there may be a dispatch issue. Further investigation may show that the department’s dispatch policy does not require utilizing standardized dispatch protocols or to give pre-arrival instructions. The problem started with a poor dispatch standard and the subsequent issues may have been avoided altogether if a standard had been in place and used properly. Without doubt there are several issues that contributed to the mistake. As is often the case, it is a combination of several mistakes that resulted in the final unintended outcome.
Element 8 – Pre-arrival Instructions
It is generally accepted that early intervention saves lives. In fact, the entire EMS system is based on this principal. If it were not, there would be no need for EMS systems as patients could simply drive, or be driven, to the hospital when they need care. The earlier the intervention, the greater the likelihood that a positive outcome will occur. Consider the following example. A child begins choking while eating lunch. She soon becomes blue, and mom becomes concerned enough to call 911. The dispatcher sends an ALS unit but fails to provide instructions on how to clear the child’s airway. On arrival of the ALS unit the patient is in full respiratory arrest and before the medics can clear the airway she progresses to full cardiac arrest. The medics successfully clear the airway, intubates the patient, and continues with resuscitative measures but they are unable to revive the child. If the dispatcher had attempted to give pre-arrival instructions to the mother on how to clear an airway could the child have been saved? Would the medics have arrived on scene to find a child crying and scared but otherwise healthy as opposed to finding her in respiratory arrest? If an EMS agency is dedicated to providing high quality patient care the answer is simple. Unfortunately, there are many systems where communications are relegated to answering the phone and sending a vehicle but not in being the first link in the chain of survival.
Element 9 – Scene Resources
It is surprising how often field personnel do not have the proper resources on hand to perform the job properly. In some cases, it is simply a matter of not having enough resources for a given task. A large-scale incident can easily strip your agency and the surrounding agencies of adequate resources. This may not be preventable in the unpredictable world of emergency medical services. There are, however, other predictable and preventable causes of resources being unavailable. It is not uncommon for patients to not receive ALS or not get flown to a trauma center because the agency either lacked the proper policies or did not enforce the policies in place to ensure that these resources are being utilized when needed. In some cases, BLS providers will not call for ALS support due to ill feelings between the providers even within the same service.
In other cases, politics plays a role. Agency A will not call for mutual aid from agency B due to disagreements between the two. One may be a private provider and the other a municipal agency. Or as sometimes occurs, agency A over utilizes agency B and agency B will no longer participate in a mutual aid agreement. In call or volunteer systems trying to get staff members needed to legally staff a unit may be a problem. In many of these types of cases the delay in getting the right resource or the outright inability to get what is needed limits the agency’s ability to properly care for the patient.
Element 10 – Skilled Providers
To this point we have discussed a variety of factors that influence the quality of patient care. In most cases the root cause of poor quality care does not rest with the individual provider so much as the faulty support systems he or she is forced to work within. In some rare cases the poor end result is solely the responsibility of the provider. As mentioned previously we often look to this solution first when it is normally a variety of factors beyond the control of the field provider. A proper root cause analysis can determine where the real issues lie. On occasion the error can be attributed to the overall patient care skills of the provider. Mistakes will happen, especially in the chaotic world of EMS. In the majority of cases the knowledge or skill level of the provider can be enhanced through additional education or remediation.
Once all the other causes have been ruled out the next step is to determine if the errors were caused by a skill or knowledge deficit that can be corrected. If so, every effort should be made to help the provider get to where he or she needs to be. There are a variety of mechanisms that can be used to do this. SimLabs, one-on-one instruction, classes, M&M rounds, additional ride time, ER/OR time, mentorship programs, extended orientation, to name a few. It is important to note that involving the provider in the process so they know where they stand and what the process involves is an important component. If not properly informed the staff member may feel that these efforts are meant to be disciplinary in nature.
To this point they should not be disciplinary, and a concerted effort needs to be made and a best effort put forth to help the staff member succeed. It is best to keep discipline out of the improvement process and reserved for cases where the provider shows no interest in improving themselves or intentionally continues to disregard proper patient care practices.
Another category of staff member inadequacy is the provider who is not intentionally flaunting proper practice but simply does not have the aptitude to be an EMS provider. While well intentioned, they sometimes get through the education/certification process but nonetheless should not continue as a patient care provider. If this individual cannot be coached into being an adequate provider, the agency may need to limit their role in patient care or even consider parting ways if no non-patient contact role exists.
Element 11 – Integration at Receiving Facility
Emergency medical services are part of a much larger health care system. If the goal is to provide the highest quality care to the patient, then the impact of our care needs to be considered beyond the walls of the vehicle. There are several patient care related problems that may occur at the receiving facility that can be directly traced back to the EMS service and its providers. Common problems include not giving an adequate patient care report to the receiving nurse or physician as required. On occasion we arrive at the ED and begin rattling off our verbal report only to find that the person we are speaking to is not a nurse or physician. EMTs and paramedics may also be faced with a healthcare worker who shows little interest in receiving a report. Poor communications have resulted in adverse patient outcomes. It is critical that field personnel not only communicate to hospital staff verbally but provide a well written PCR prior to leaving the facility. Poor written reports are a major problem in EMS and have resulted in significant medical-legal dilemmas. Not only is a poorly written report a problem with the patient’s care in the ED but after admission the patient’s care may be affected by what is written in the PCR. Any EMS QA program that does not spend considerable time educating providers on proper documentation is not doing its job! It is an ongoing process that requires constant reinforcement and a mechanism to provide feedback to individuals on how well they perform in their report writing. A service with poor documentation cannot perform proper quality improvement as the run report is the foundation for data collection for QA efforts.
Recently there have been increased efforts by hospitals to improve the quality of care they provide. Part of their efforts to improve care includes taking advance notice by EMS providers for patients with conditions such as STEMI, CVA, and trauma to name a few. They are relying on us to provide an accurate pre-notification of various patient conditions so they can speed up the diagnostic and patient care processes.
Element 12 – Active Medical Direction
The medical director plays a significant role in the quality of care that an agency provides. It would stand to reason that a medical director would be well versed in EMS practice and have a strong knowledge base regarding regulation as well as understanding what EMS providers do. Unfortunately, that is not always the case.
When working with EMS agencies we occasionally find the medical director has little knowledge of what really goes into making a system run. They often do not know the providers who work under them, nor do they have an adequate understanding as to how well the field providers are performing. Some medical directors have expressed their feelings that their primary role is to be available in the event of a major system error or to perform routine “signature” chores. That is, they need to be the name on the agency’s applications for drug replacement or for a service to perform ALS. They are not always aware of the roles and responsibilities they actually have and in some cases are not interested in doing more. In other cases, the agency wants a quiet medical director for just those reasons and prefers the physician stay out of operational details. This is a disservice to the patient, the service, and to the field providers. Street level personnel should know to whom they are reporting regarding patient care activities and should know the wishes of their medical director regarding patient care preferences.
The EMTs and medics have protocols to follow but there are many clinical issues not directly addressed in the protocol and their medical director should provide the guidance on how to handle those situations. In some services the field personnel have never even met their medical director.
An agencies field providers were routinely getting patient refusals for a significant number of calls. In many cases the refusals were signed by minors, patients under the influence, or patients with significant medical conditions that required immediate attention at a medical facility. The medical director was completely unaware of the situation until an adverse event occurred. The quality assurance was being done by the agency who did not feel the medical director needed to know about the high refusal rate. A review of the data showed it was a long standing, ongoing problem. Once appraised of the situation his initial solution was to “outlaw” the practice of getting refusals and trying to force all patients to be transported. When he was informed that that was not appropriate, he instituted a refusal process that tied up the crew for long periods of time on scene causing significant organizational upheaval within the service. This practice also tied up units and prevented them from responding to other calls resulting in mutual aid calls that lengthened response times and decreased the services revenue.
In this particular case the physician was not an emergency physician and did not even work in a hospital environment. He was under the impression that as medical director he could make whatever rules he liked. Since the agency and he did not work very closely together when the adverse event occurred, he was unprepared to handle it properly. There are many cases where physicians have written protocols for services that contradict the states protocol or conventional EMS practice. It puts a significant pressure on the field providers who usually are well aware that some of these practices will result in problems.
Element 13 – Results Driven CQI Process
Most agencies have some quality control mechanisms in place. For the most part everyone agrees that quality improvement is a necessary function. Beyond that there is significant variation in how the job gets done. In most services the quality improvement function is delegated to someone who has little knowledge or experience performing quality improvement. Training is hard to find and in some cases the person given the task is not terribly interested in doing it. There are few peer groups for EMS quality managers to join to share ideas and information. With this paucity in resources and knowledge how does one create a program that is effective? Having a poor QI program can cause significant problems. It creates stress on the part of the providers it is supposed to be helping. In an environment where QA/QI is used as part of the disciplinary process employees feel the need to avoid the QA program sometimes going so far as to hide problems, misrepresent facts on run reports, or not report things they should for fear of reprisals. The end result is problems do not get fixed; they get hidden until a major event occurs.
The QA/AI process should be education based, user friendly and instructional. It should provide individual feedback to all members of the organization so each staff member knows exactly what he or she needs to do to continuously improve their practice. It should be able to measure not only what went wrong but be able to identify the level of risk to the patient and the agency so resources can be dedicated to the most important and problematic behaviors. It must be flexible enough to respond to big issues quickly but have enough structure to systematically process smaller issues without cutting corners. Sometimes it is better to allow the full process to unfold than to provide a knee jerk reaction to something undesirable. Short circuiting the QA/QI process can present more problems than it solves.
Above all, the process needs to be fair and unbiased. A major contributor to poor quality care is an ineffective QA program that is viewed as a method for persecution rather than improvement. When staff members feel that some people get preferential treatment or are not called to task on things, resentment can set in. Preventing biases in the system can be difficult but it is necessary if the program is going to be successful. Building a high-quality patient care system is possible but it requires a lot of forethought and hard work and building the quality improvement infrastructure is critical to proving that your EMS system really does save lives.