Why Fire Chiefs and EMS Leaders Need Unbiased CQI
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And Why Outsourcing Is Often the Only Way to Get It
By Paul Girard
For years, EMS agencies have tried to run quality improvement programs in‑house, believing that internal oversight would naturally lead to better care. But as the demands on today’s fire and EMS systems grow — higher call volume, staffing shortages, increased regulatory and legal scrutiny, and a more skeptical public — the limitations of internal CQI models have become impossible to ignore.
The truth is simple: you cannot objectively evaluate the system when you are part of the system. And in EMS, where patient care, public trust, and agency credibility are on the line, bias — even unintentional bias — is a risk no chief can afford.
Outsourcing CQI isn’t about replacing your people. It’s about protecting them, protecting your agency, and protecting your patients by ensuring the quality review process is fair, consistent, and grounded in modern improvement science rather than internal politics or personalities.
The Bias Problem: Why Internal CQI Struggles to Stay Objective
Every chief knows the dynamic: When QA is done internally, the reviewers and the reviewed all work in the same building, wear the same patch, and often ride the same trucks. That creates unavoidable pressure — social, professional, and sometimes political.
Providers typically feel that the QA/QI people are the ‘internal affairs’ department… The result oftentimes is more of a heavy‑handed approach that creates hostility, fear, and resentment. Even when the intentions are good.
Even when the intent is good, internal CQI programs often fall into one of these traps:
- Personal relationships influence decisions — or are perceived to.
- Supervisors hesitate to challenge long‑standing cultural norms, even when those norms conflict with best practice.
- Field providers feel targeted, not supported, which shuts down learning.
- Medical directors receive incomplete or filtered information, limiting their ability to guide clinical improvement.
- Risky behaviors become normalized because “we’ve always done it this way.”
None of this is malicious. It’s human nature. But it undermines the credibility of the entire CQI process.
Why Outsourcing Removes the Bias — and Strengthens the System
An external CQI partner brings something no internal program can replicate: true independence.
An independent, unbiased review is a more reliable method for convincing the public and providers that the services you provide are what they should be. That can be a tremendous asset when discussing cases with field providers. They are much more relaxed and willing to engage when they feel that everything they are discussing is not going to be shared internally with others.
Here’s what outsourcing changes immediately:
1. Objective, Unbiased Case Review
External reviewers have no stake in internal politics, personalities, or history. Their only focus is the care delivered on the call. That neutrality builds trust — with crews, with leadership, and with the public.
2. A Non‑Threatening, Education‑First Approach
Outsourced CQI reframes the process from “catching mistakes” to coaching providers. Providers stop bracing for punishment and start engaging in improvement.
3. Reduced Internal Conflict
When difficult conversations come from an outside expert rather than a coworker or supervisor, the tension evaporates. You eliminate the “Why are you picking on me?” dynamic entirely. Our staff is trained to present information in a non-threatening and constructive manner, leading to less resistance on the part of providers.
4. Access to Industry‑Wide Best Practices
External CQI partners see thousands of calls across many agencies. That perspective is impossible to gain internally. G&A works with agencies across the country, know what works, what doesn’t, and what “normal” looks like. There is a good chance that whatever problems you may be facing, we have dealt with it over our 21 years of performing EMS CQI.
5. Better Communication Between Leadership, Medical Direction, and Crews
Outsourced programs create a structured, consistent feedback loop — something many agencies struggle to maintain on their own.
6. Quantifiable, Defensible Data
Modern outsourced CQI systems provide scoring, trend analysis, and risk identification that internal programs rarely have the time or tools to produce. This is critical for accreditation, payer scrutiny, and regulatory compliance and medical/legal risk.
The Stakes Are Higher Than Ever
One agency we started working with told me the reason they hired Girard & Associates was because during an OEMS investigation of a call with a poor patient outcome, the medic told a state investigator he didn’t know his actions were wrong because “no one ever told him.” The reason the medic stated the issues noted were never told to him was because he and the CQI coordinator “had a bad relationship”. That’s not a personnel problem — it’s a system failure.
When internal CQI misses patterns, the consequences can be severe:
- Patient harm
- Regulatory action
- Lawsuits
- Loss of public trust
- Reduced reimbursement
- Damage to agency reputation
- Difficulty hiring and retaining the best staff
Outsourcing creates a safety net that ensures these issues are caught early — not after something goes wrong.
A Stronger, Safer, More Supportive System
Fire chiefs and EMS managers want the same thing their crews want: a fair system that helps providers get better and protects the agency from unnecessary risk.
Outsourced CQI delivers that by:
- Removing bias
- Reducing conflict
- Improving communication
- Strengthening medical oversight
- Providing actionable data
- Supporting providers instead of intimidating them
The reality is, you get the system that you build. Why not build a system that eliminates the biases associated with in-house CQI?
If your current CQI model isn’t giving you unbiased insight, consistent feedback, or measurable improvement, it may be time to build something better — something independent, modern, and designed to support your people rather than police them.
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For more information, visit www.girardassoc.com.
About the Author
Paul Girard, a retired paramedic and EMS Director, is the Founder and President/CEO of Girard & Associates, Inc., a national EMS clinical quality improvement consulting firm. He has worked in EMS continuous quality improvement since the mid-1980s and founded Girard & Associates, Inc. in 2005 to help EMS agencies better monitor, evaluate, and improve the patient care they provide. An EMS CQI entrepreneur, Paul invented and utilizes a proprietary scoring and rating system that drives a teaching, coaching, and mentoring-based CQI process, supporting providers in strengthening clinical judgment, documentation quality, and professional performance. The firm delivers CQI auditing, program development, and CQI program administration for EMS agencies nationwide. Paul is also the co-host of “The G&A Way EMS CQI” podcast.
Paul can be reached at paul.girard@girardassoc.com.
