Building a Quality QA System

This is tenth in a series of articles from MONOC Mobile Health Services, New Jersey's largest provider of EMS and medical transportation and first CAAS-accredited agency. The goal of this series is to provide insight and solutions for the different managerial and operational challenges facing the EMS leaders of tomorrow. For more, see

Quality assurance (QA), an organized method of auditing and evaluating care provided within an EMS system, is the bane of any EMS field staffer. Since field staffers already believe they are treating their patients appropriately, why do we have to do quality assurance on them?

Setting the Parameters

As EMS managers, we must be able to document the fact that we do treat patients appropriately and within every guideline or protocol our system uses. So how do we go about this in a meaningful and productive manner? First, we have to set up parameters on how QA will be performed. Will we review only a percentage of patient care reports and all specialty charts like cardiac arrests or traumas? Or do we have the capability to perform 100% chart review and gather all of the information from our patient care reports? Once we decide how many charts we will QA, we then have to determine what operational or treatment parameters will be measured.

Will we look at out-of-chute times compared with national benchmarks, or measure response times or other data the service has decided on? How about clinical treatment protocols and how well we treat our patients? These are just some of the areas that can be considered when developing your QA system. Once these parameters are determined, you will need to enter them into a data base in order to capture this useful information.

Next, you will need to determine how you will deal with staffers who violate protocols or fall outside your specific measurement requirements, and how you will inform them of these problems. Will you take a one-size-fits-all approach or a stepped approach with different levels of quality assurance notifications? No matter what the violation is in the clinical realm, you will need to remediate the offender rather than use disciplinary actions.

If you adopt a stepped approach, you will need to determine how you will use it. What will constitute a minor violation where the staffer will receive a "coaching"-type memo, bringing to his attention the violation in a soft remediation tone? An example could be violation of an operational protocol that does not involve patient care and treatment. How will you deal with a one-time protocol violation? This could be a general QA "hit" where the staffer is notified of his or her offense and a record is kept of the breach of protocol.

What type of violation will call for a sterner tactic, like an administrative counseling memo that goes in the staffer's personnel file? This could be a severe variant of a patient treatment protocol or multiple QA issues of which the staffer has been notified and does not seem to understand the significance of the issue. This should be used in conjunction with a meeting with the staffer to help him understand the significance of the issues and that he will be under greater scrutiny during patient care.

What if none of these approaches seem to get the staffer's attention? You must have the ability to place that person on clinical probation status. Remember, for clinical issues we want to remediate our staffers, not discipline them. Sometimes, however, these issues are not patient treatment problems, but employee behavioral problems. Placing them on clinical probation means they will work under more stringent parameters and require even more scrutiny of their treatment of patients and adherence to operational protocols. Only after you have reached this step and the staffer still fails to adhere to the protocols can you consider disciplinary action or termination

Managing the Information

Once you set your QA parameters and decide how you will distribute the information to your staff, you must determine what management will do with the information. The QA information should be reviewed on a monthly, quarterly, half-year and full-year basis to see any trends that may be occurring with your staff. If you changed a protocol, using the QA system you can find out how well your system is adapting to the change. You may find that some employees are having trouble with certain skills and may require remediation. This can all be tracked through a QA system.

But you can use the information from your QA system for so much more, such as creating a continuous quality improvement (CQI) program. CQI is a continual cycle of evaluation and improvement based on the findings of quality assurance. As EMS managers, we must use this information to develop a program that monitors the quality of our system.

Information gathered through your QA program can be used to ensure that field providers maintain the quality of service expected of your department. You can determine what specific areas you want to look at and begin to watch for clinical performance or treatment trends. This is called benchmarking. Much information has been published on this topic in recent years.

You may want to track cardiac arrest information and patient outcomes using the Utstein method, which can help determine how effectively you are treating your cardiac arrest victims and what impact your agency is having on the survivability of the resident population in your coverage area.

Not sure where to find help? An article in Prehospital Emergency Care journal lists six areas of benchmarking for your quality improvement plan.1 The article tells how to establish benchmarks and how to deal with the information obtained.

In December 2009, the National Highway Traffic Safety Administration (NHTSA) published a brochure on "Emergency Medical Services Performance Measure," available at, giving the recommended attributes and indicators for system and service performance.2 This brochure recommends areas to monitor, both operational and clinical, and shows what you need to set up indicator/attribute formulas.

Once you decide on the area(s) to be monitored in your CQI program, you will need to input and be able to visualize the information you are monitoring. A simple spreadsheet program can be used for this purpose. Enter the information in a spreadsheet and then convert it into any of the numerous charts that will work for your purpose. You can use charts that deal with just the raw numbers or with percentages of patient contact and treatments. These charts will allow you to visualize how your system is performing against the established benchmarks. As you review the information, you will be able to trend your system to see if there are areas where you need to pay special attention and possibly develop educational updates for your staff in those particular areas.


Even though QA maybe the bane of the field staff, it is of utmost importance to management. You can use your QA information to develop a CQI program that will show how well your system is performing and how your staff and system provide the quality care that you are expected to give your patients. Management's goal should be to turn the information from a quality assurance program into a continuous quality improvement program and merge the two concepts, with the ultimate goal of having a quality management program.


1. Evidence-based performance measuring for EMS systems: A model for expanded EMS benchmarking. Prehosp Emerg Care 12:141-151, 2008.

2. National Highway Traffic Safety Administration (NHTSA). Emergency Medical Services Performance Measure brochure, December 2009. Available at

Robert Bauter, MAS, CPM, NREMT-P, is director of clinical services for MONOC Mobile Health Services, where he oversees the quality assurance and quality improvement programs. Robert has been a paramedic since 1986, and is a Certified Public Manager with a master's degree in Administrative Science.