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Leadership/Management

Journey to 2050: The Future of Measurement and Quality

EMS Agenda 2050 lays out a bold vision for the future of EMS in America. While it does not address quality improvement in detail, it’s appropriate to think of the document as the beginning of a massive improvement project, one that will transform EMS as we know it.

Our challenge is to make this vision a reality. To do this we must start by understanding where we are today, then paint a clear picture of how things will be in the future. Finally, we must build a plan to take us there. 

Where Are We Now?

Many EMS agencies have a job or role with the word quality in the title: quality improvement officer, quality assurance manager, total quality management committee, etc. These positions are usually vaguely clinical and separate from operations, finance, fleet, and leadership.

Most of the focus of these titles is on meeting external requirements imposed by regulators or accreditation organizations. The primary methods are individual performance evaluation, as identified in chart audits or peer review.

Improvement strategies are likewise aimed at fixing medics through education, remediation, and punishment. Despite having “quality” positions, few EMS systems have demonstrated measurable and meaningful improvement in their agency’s care or operations.

Where Will QI Be in 2050?

In the vision outlined in EMS Agenda 2050, the principles and practices of improvement science will be integrated into all aspects of leadership. Quality is no longer viewed as something separate.
Leaders at all levels have comprehensive people-centered views of their systems. They understand variation, systems theory, learning, and how psychology affects their ability to create and maintain improvement.

EMS systems have adopted key elements of the EMS Agenda 2050 vision and built measures based on these elements. Measures are focused on outcomes and the processes that produce them that are centered on patients and supported by scientific evidence.

For many injuries and illnesses, there are multiple interventions that, taken together, improve care. These “bundles” of care address common conditions like myocardial infarction, acute coronary syndrome, stroke, traumatic brain injury, asthma, congestive heart failure, respiratory failure, seizures, psychological crisis, and sepsis.

Systems also monitor safety, measuring data such as patient and provider injuries, medication dosing errors, incorrect or missed diagnoses, and infection caused by cross-contamination. Provider safety and health is measured by tracking injuries, fatigue, and joy at work.

Systems actively assess the degree to which the care they provide is the same across underrepresented populations to prevent inequities based on factors such as ethnicity, gender, age, sexual orientation, religion, substance use, or language spoken. 

Full integration with the rest of healthcare gives us a view of the impact of our care from initial system contact to when patients are back home. 

Getting Started

Identify a handful of vital performance measures to create a balanced scorecard that shows how your system is performing. Display these measures on run charts and Shewhart control charts.
Learn how to analyze these charts so you can identify common and special-cause variation.1 Here are a few areas to consider tracking:

  • System performance on clinical bundles of care for cardiac arrest, acute coronary syndrome/STEMI, stroke, and similar serious conditions. Look at these through the lens of social equity to locate gaps in the quality of care based on race, ethnicity, gender, etc.;
  • Your patients’ experience of care from their perspective;
  • The fatigue, stress, and joy levels of your employees;
  • The financial health of your system. 

The measurement of quality depends on the availability of valid data. To enable these measures, systems need to integrate patient health records between first responders, EMS, hospitals, and clinics. Electronic medical record vendors need to recognize the importance of validating data at the time of service. We need to push for the development of user-friendly ways to document care that are less time-consuming for providers, including the integration of data from biometric devices. 

Get to know other providers in your healthcare system. Invite them to sit on your board. Offer to participate in their stroke, STEMI, trauma, and other quality-focused committees. Convene or find an existing cross-sectional working group focused on a health-related issue in your community (e.g., opioid overdoses, homelessness, human trafficking). Often your EMS perspective and data can be a key to making real progress on things that matter in your community. 

Be sure to involve frontline providers and, where possible, patients in your improvement efforts. Teams should always include people involved in actually providing and receiving service. As Don Berwick, MD, founding president of the Institute for Healthcare Improvement (IHI), says, “Nothing for me without me.” 

It’s helpful to have a framework for making improvements that you use consistently. It’s even better if you share it with colleagues from other healthcare organizations. The Institute for Healthcare Improvement’s Model for Improvement is the most widely and effectively used approach in EMS and the rest of healthcare. 

Approaches to change can include protocol changes, different ways of using equipment, new processes, education, and new medications. Rather than jumping to implement systemwide change based on what seems like a good idea, teams should perform a series of small tests of their theories using the plan-do-study-act cycle (see graphic). This will help determine which ideas reliably produce the desired results before systemwide implementation. 

Leaders should be mindful that changes they implement to improve one thing may have impacts on other aspects of their system or community. They continually assess these effects by designing balancing measures for each improvement effort designed to look for unexpected or undesired results. 

Waiting Is Not an Option

It’s likely that improvement science will continue to evolve over the next 30 years. Our use of the principles and practices should grow too. In the meantime the steps above are a good place to start—and waiting 30 years, or even 30 more days, is no longer an option.

EMS Agenda 2050 describes “community and regional quality improvement systems” that “measure, analyze, and work to improve outcomes for patients, EMS professionals, and members of the broader community.” To achieve that goal we must get to work today.

Reference

1. Institute for Healthcare Improvement. Control Charts (Part 1), http://www.ihi.org/education/IHIOpenSchool/resources/Pages/AudioandVideo/Whiteboard13.aspx.

Mike Taigman is the improvement guide for FirstWatch and served as the facilitator for EMS Agenda 2050.

Jeffrey L. Jarvis, MD, MS, EMT-P, is medical director for the Williamson County, Tex., EMS system and served on the technical expert panel for EMS Agenda 2050.
 

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