Quality Corner--Part 8: The Medical Director and Quality Improvement
The EMS medical director is a critical part of any quality improvement team; however, in many cases, the MD may not have had any education or orientation in how to accomplish QI. As the medical director for nearly 20 agencies of a variety of types in New Jersey and Pennsylvania, I am able to interact with a large number of providers. With some of these agencies, I am quite active and have weekly face time with the paramedics and EMTs. In other smaller agencies, QI feedback from a distance or online is more the norm. With this in mind, I would like to share some tips for providing prospective, concurrent and retrospective aspects of QI.
If you are fortunate enough to provide oversight to an EMS agency in a state that has established treatment protocols, you might think there is little more to offer in terms of expectations for your staff. But in reality, protocols are only one part of Prospective Quality Improvement. It actually starts the first day you walk into the department.
First impressions are important. You may not be able to change your experience or your training, but you can adjust how you interact with your staff starting on Day 1. If you present yourself as a reasonable person who is able to listen and have a good exchange of ideas, the staff will be much more receptive to your feedback. However, if you come off as "I'm the doctor, and you have to do it this way," your reception and interactions will be much more difficult. Even if you are right, it will make your job much harder.
Try to establish an opportunity to address the staff both as a large group and in smaller numbers around the kitchen table. Discuss your expectations. Do you have any 'pet peeves' that you want the staff to be aware of? Are there any "mandatory" aspects of patient care or documentation that you would like to share? For my agencies, I want the staff to obtain at least one set of vitals on all patients, even lift assists and refusals, or document why they were not able to do so. I also like them to document their "medical decision-making," whether it refers to cancellation of other resources (ALS by BLS), the decision to apply spinal motion restriction, or selection of a destination. By making all of this clear from the start, things will go much more smoothly.
Training is another form of Prospective QI in which the medical director can be involved. This may be on routine topics, or it may be on a topic that has been identified as a problem during other types of QI review. Continuing education classes are often conducted by other providers of the same level, and while this is fine, there is an inherent benefit to having the medical director teach some classes as well.
This is the form of QI that is most rarely conducted by EMS medical directors, but it is arguably the most important. Concurrent QI represents oversight and observation that occurs as patient care is unfolding on the scene. The providers can be seen interacting with patients, recognizing physical signs and benefiting from "bedside teaching" that is common in medical education in the hospital and other settings.
In order for docs to get in the field, they need to have proper training. It helps no one if an ill-prepared physician is on a scene and causes more problems than solutions. Ideally, they will have a uniform that allows them to blend in with the EMS crews. Scrubs and clogs have no place in the field.
The doc who is riding along needs to understand that his or her mere presence may make some medics uncomfortable. Medics are used to a fair amount of autonomy in the field, and when the medical director is "looking over their shoulder," it is not surprising that it may produce some anxiety. This can be mitigated by getting to know the staff and allowing them to get to know the medical director in a more benign environment, like sitting around a table chatting about various topics. Then, when the doc jumps on the truck, there will be a much better reception.
While on scene, the medical director needs to resist the urge to take over. Allow the medics to be medics. I often like to stay in the background, chatting with the family while watching the scene unfold. If a clinical issue needs to be addressed, I step up, answer the question or clarify the issue, and then step back. If the medical director takes over the scene and directs all patient care, an opportunity to observe the crew in action is lost.
The in-field medical director needs to be aware of certain pitfalls, particularly liability. A doc riding in the field needs to not only have general liability and worker's compensation insurance, but also medical malpractice. The mere presence of the physician on scene may establish a patient-physician relationship, requiring this advance level of coverage.
Retrospective QI is the more typical method utilized. As we know, this means looking at calls that have already occurred. For the most part this involves chart review and the ability to question the crew about a particular aspect of a call, give kudos and otherwise understand in a global sense what is going on with a particular agency. No officer or medical director can be on every call, so a significant number of the calls will be reviewed in this way rather than concurrently.
In many ways, chart review is about how well the staff can document what occurred. Physicians are often taught better about documentation than EMTs and medics. We know to include pertinent negatives (no recent trauma in a patient with reproducible chest pain) and pertinent positives (loss of consciousness in a patient who struck his head). We know that we need to document defensively, anticipating that our chart may be used to defend a decision we have made about patient care. Many of these pearls can be used by medics as well, and the medical director is in a perfect position to teach the providers to do so.
Chart review allows us to monitor trends, but it does require honesty from the crew. If they missed an IV three times, so be it. Use this as an opportunity to remediate rather than punish. However, with all forms of QI, there is a time when action may need to be taken. I am often told that providers think QI should not be punitive. That is true, in general, with minor and isolated issues. But if a major breach of patient care is identified, the fact that it was found in a QI review is irrelevant.
Medical directors are one cog in the QI system, but they are only as important as they make themselves. "Paper" medical directors who are never around and never spend time riding with the crews will find they have a very difficult time making quality improvement productive. Physicians need to make themselves available or reconsider the position for which they have taken responsibility, while, at the same time, the agency has the responsibility to fairly reimburse the physicians for their time. Once a good QI system is in place, it is almost inevitable that the agency will move forward.
Ken Lavelle, MD, FACEP, NREMT-P, serves as medical director for Central Bucks Ambulance in Doylestown, PA, and a number of other emergency service agencies. He is a former paramedic and EMS chief, who practiced for 14 years before attending medical school at the Jefferson Medical College in Philadelphia. He is also a member of EMS World Magazine's editorial advisory board.
- Quality Corner--Part 7: CQI as a Career Path
- Quality Corner--Part 6: It's a Team Effort
- Quality Corner--Part 5: Patient Care Standards--A Quality Comparison
- Quality Corner: Part 4--The 10 Commandments of Quality EMS
- Quality Corner: Part 3--What Is Quality Care?
- Quality Corner: Part 2--The Quality Coordinator
- Quality Corner: Part 1--Introducing the Quality Corner
- Quality Improvement Part 1: Retrospective Review
- Quality Improvement Part 2: Concurrent Review
- Quality Improvement Part 3: Prospective Review
- Building a Quality QA System
- Measure Hunting