Quality Improvement Part 1: Retrospective Review

   Quality assurance, total quality management and continuous quality improvement are some of the catch phrases that have made the rounds over the years, giving name to the process that ensures standards of patient care are being met in EMS. For the purpose of this article, we'll use the term continuous quality improvement (CQI). Whatever you choose to call it, every EMS agency should have a quality review process. In most states, it is required by law; however, beyond this mandate, the details of how to administer a quality improvement program are frequently left to the individual agency.

   Any comprehensive quality improvement process should include three components: retrospective, concurrent and prospective. Retrospective is the review of patient care reports after the fact; concurrent is real-time evaluation of patient care; and prospective is anything done to improve the quality of patient care prior to the call being dispatched. This is the first of a three-part series of articles that reviews the three components of a quality improvement program and shows how each was successfully administered at Bucks County Rescue Squad and Central Bucks Ambulance--two midsized EMS agencies in southeastern Pennsylvania.

Retrospective

   Retrospective is a Latin word meaning after (retro) and to look or see (spective). PCR (patient care report) review is the most familiar and commonly performed aspect of quality improvement. Unfortunately, in many agencies, the retrospective review may be the entire quality improvement process. The dirty little secret in EMS is that, for some agencies, even a regular retrospective review is not being done prior to a complaint being filed. Reviewing PCRs is tedious and arduous work, but it is absolutely necessary to gauge patient care. While not strictly the purview of classic quality improvement, one offshoot benefit to the medical retrospective review is the opportunity to assess documentation for legal and billing purposes.

Documentation

   Poor documentation costs your agency money as a result of declined or decreased insurance reimbursement. Due to the ever-increasing financial squeeze being placed on EMS, this could literally mean the difference between survival and demise for many agencies in the not too distant future. Medicare has already started reducing payments to hospitals if certain performance markers are not met. For example, hospitals that treat STEMI patients with a door-to-balloon time greater than 90 minutes will not receive full reimbursement. It doesn't take a prophet to realize that performance parameters tied to insurance reimbursements are the future of medicine. The only question is whether your agency will be ahead of the curve or playing catch-up. Fair or not, the quality of care a patient receives will most often be judged by the PCR.

Peer Review

   The more PCRs you review, the better insight you will gain into the quality of care your agency is providing, as well as the job your individual providers are doing. As you look behind the curtain, be prepared for a reality check. Some who are considered the greatest EMS providers who ever lived may quickly be exposed as being quite humanly flawed, while others who are seen as nervous and timid may prove to be some of your more thorough and diligent providers. It will not always be pretty, but remember that these problems were always there; they are just now being seen for the first time. The importance of problem identification cannot be overstated. The first step in resolving any problem is recognizing and acknowledging that it exists.

Getting Started

   When I took over as quality improvement coordinator, I jumped in with both feet. Knowing nothing about quality improvement, I secluded myself in an office with a month's worth of PCRs. Several hours later, when the chief came to see what happened to me, he asked what I was doing and was surprised to find me reading all of the PCRs. He opened the center desk drawer, handed me the region's quality review criteria and explained that I just needed to review all mandatory type calls like cardiac arrests, medevac flights and multisystem traumas.