Quality Corner--Part 8: The Medical Director and Quality Improvement

Medical directors are one cog in the QI system, but they are only as important as they make themselves.


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.

Prospective 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.

Concurrent QI

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.

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