How Improvement Science Can Help EMS
Improvement science can sound nebulous if you’re not acquainted with it. But there are recognized paths and mechanisms to minimize variation within organizations and produce better outcomes without relying on happy accidents. At the NAEMSP Annual Meeting on Thursday, IHI improvement guru Dave Williams, PhD, provided some concrete examples of how EMS systems can use such methods to become better at what they do.
A preface came from his own career. As an Austin paramedic overseeing QI for his department in the mid 1990s, Williams faced problems with a new algorithm for patient immobilization. An individual medic had applied it incorrectly, but Williams suspected an issue bigger than one person. A sample review of PCRs backed him up, quickly turning up 21 cases of deviation from the protocol. The problem, he realized, was indeed systemic, and a similar approach found examples in other areas as well.
We’ve come to realize that many problems we once regarded as individual failures are actually the result of systemic factors—for instance, placing two similar-looking drugs adjacent in the drug box, then blaming medics for grabbing the wrong one in the heat of a call. Better outcomes result, Williams said, when the right structures are in place (resources and supports) and combined with the right processes.
The National Health Service did this in England when leaders found wide variations across a range of performances. In response they delved into their data and honed an evidence-based focus on the things they felt really mattered and how to measure them, then worked together to test small changes and evaluate the outcomes – the heart of the IHI’s approach.
Leaders in Qatar built on a trigger tool the IHI had developed for hospitals. Ambulance bosses there were also using defined care bundles but were concerned about other patients. They researched other trigger tools from around the globe and combed through their own data, with medics pulling random reports to look for triggers and resulting harm. The final output was a 12-point trigger tool by which they could break down aspects like category, frequency, and whether harm occurred.
North Carolina’s Mecklenburg EMS Agency (MEDIC) embraced quality as a business strategy, reorienting their organization around a system of linked processes. “If you can’t describe your work as a process,” Williams noted, “it’s difficult to improve.” They found gaps in both linkages and understanding and created new models for accomplishing goals using dashboards and statistical process control. MEDIC is now a leading example of quality as a business strategy (QBS).
Finally, Scotland’s national ambulance service rolled out safety and improvement principles as a national strategy. It’s also testing a trigger tool and QBS focus. The service has the benefit of 30 years of comprehensive patient records to review; Scots have unique ID numbers that follow them throughout their healthcare. The efforts are culminating in a five-year strategic framework called Towards 2020.
Sidebar: Qatar's Trigger Tool
The 12-point trigger tool developed by Hamad Medical Corp.'s ambulance service in Doha:
1. Injury to patient or team member during patient encounter/transport;
2. Request for additional resources, personnel, or supervisor due to change in patient condition;
3. A worsening trend (deterioration) in patient hemodynamic or mental status indicators;
4. Chest pain/suspected MI and no 12-lead ECG recorded;
5. Condition code states "stroke" or "transient ischemic attack" but FAST test not recorded;
6. No oxygen therapy in patient recorded as having one or more of the following: significant trauma, GCS <15, SpO2 <94%;
7. Administration of both morphine and naloxone;
8. Same patient return response within 24 hours;
9. Early warning score of 4+ but patient not transported;
10. MI confirmed but no prehospital thrombolysis administered and no delivery to percutaneous coronary intervention center;
11. Blood sugar level <4 mmol/L, but only on blood sugar test recorded, and patient not transported;
12. Patient unconscious and/or fitting and not transported.