We have all heard it: "He is a real good paramedic," or "She is one of the best medics I have ever worked with." The question for us all is, how do we measure the quality of a paramedic?
While many of us in the house of medicine are evaluated routinely by peers or through external metrics, EMS providers spend most of their time with a small cadre of other EMS providers, often providing care in the back of an ambulance with little opportunity for evaluation or feedback. Much of an EMS provider's "quality” is determined from retrospective case and chart review.
How is a medical director or supervisor to assess a paramedic's abilities and quality of care? Certainly there are multiple methods, each with strengths and weaknesses. I have found that one of the most reliable and least biased is through an annual skills review and sign-off.
Skills reviews can be of all types, shapes and sizes. They range from informal skill rodeos among peers to formal reviews of skill prowess and knowledge with objective evaluators. However, in my opinion, nothing can beat a structured program with motivated evaluators invested in a better understanding of the actions and care provided by the paramedics; namely, the medical directors.
The EMS region that I work within has established a regional clinical skills and protocol knowledge review that providers from participating services must complete annually in order to maintain medical command authorization. The structure is based on a National Registry model, with stations in which the provider must complete certain requirements. The program is set up to be constructive and educational, not destructive or punitive.
Scenarios, key station objectives, and even the test bank are created by the involved medical directors. Key EMS administrative personnel assist with logistics, oversight, and facilitate the program; but the assessment of knowledge and skills is left to the medical directors.
Stations are developed to assess key areas of overall knowledge, problem-solving ability, critical-thinking skills, and understanding of protocols. Each station will generally have two proctors, one of them being a local medical command physician. Providers are evaluated using standardized reporting forms with areas for the evaluators to write general comments or specific strengths or weaknesses.
The stations are created to test important critical skills, emergency interventions and knowledge that should be foundational for EMS providers, whether it's understanding a basic piece of equipment or core understanding of a protocol. Our program is organized based on five stations. Each one looks to assess a unique area of the paramedic's medical knowledge.
The stations include:
- Airway management
- Equipment skills review
- Medical director review
- Resuscitation station
- Written test
The airway managementstation requires providers to demonstrate proficiency with basic, advanced, alternative and surgical airways. Paramedics must meet key milestones for each skill to successfully complete this station.
The equipment skills review asks paramedics to show understanding and use of all key equipment, such as CPAP, monitors and alternative vascular access devices (i.e. intra-osseous). Satisfactory completion requires demonstration on the functionality of all required equipment.
The medical director review is a one-on-one sit-down between the paramedic and a medical director. The physician utilizes a PowerPoint presentation to ask questions based on protocols and procedures. The provider is given a short tutorial on the subject based on actual protocols and must show insight into the protocol and its key elements.
The resuscitation station is a scenario-based station where the provider is placed into a randomly selected situation and must clinically assess and make appropriate interventions on a patient while being evaluated by a physician medical director. The scenario is scripted to keep the testing consistent, and each provider is randomly assigned to one of several different cases to prevent him or her from knowing what they may be walking into.