Chapter 72 Defining, measuring, and improving quality Kevin E. Mackey and Scott S. Bourn
Introduction Quality in EMS can be analogous to UFOs. Some are sure they have seen them and can describe them in detail. Others believe in their existence but have never seen them. Still others doubt their existence entirely or refuse to believe they are possible. But everyone agrees that, although often difficult to define, quality is an essential component of a vibrant EMS community. This chapter will describe current knowledge about quality and improvement, and then apply those principles to EMS. Throughout the chapter, examples will be provided to make the theory tangible, and specific suggestions will be offered to help medical directors and clinical leaders apply the principles to their own practices.
Quality in EMS Traditional descriptions of EMS quality have frequently had a narrow focus on specific objectives rather than overall system performance. For example:
patient-centric : administration of aspirin to chest pain patientsparamedic-centric : number of successful versus failed intubations monthlycommunity-centric : recognition of coronary ischemic discomfort for STEMI patientsorganization-centric : percentage of patients cared for by an organization who received oxygen.In 2001, the Institute of Medicine published Crossing the Quality Chasm and described health care quality as safe, effective, patient-centered, timely, efficient, and equitable [1]. Five years later, this same organization, in the seminal report Emergency Medical Services at the Crossroads , described EMS as fragmented and stated that EMS quality is “highly inconsistent from one town, city, or region to the next” [2]. The report went on to assert that there is no agreed-upon national measure for quality and no consensus for who oversees or is accountable for quality.
The challenge for EMS leaders is to move quality in EMS, be it a state, region or a local EMS community, urban, rural, volunteer, wilderness, military, or interfacility operation, from a myth to a reality that continuously drives excellent, patient-centered care. In responding to that challenge, it will be important to remember that quality is a journey, not a destination; a process of assessment and reassessment, change, and adaption to continuously improve the delivery of the product (in this case, comprehensive and coordinated expert care) to the consumer. It is all about improvement, never being satisfied that the product is perfect.
The science of quality and performance improvement The science of improvement had its origins in manufacturing, where quality is based on reliable execution of optimal processes. W. Edwards Demings was a statistician, professor, and consultant who spent a large part of his life teaching corporate leaders how to improve design and product quality. In the early 1980s, Deming was recruited to jump-start a quality movement in the failing Ford Motor Company. Within 3 years, Ford had undergone a massive internal transformation and surpassed General Motors in sales and profits. In 1987, President Ronald Reagan awarded Deming the national Medal of Technology for his contribution in improving quality workmanship within the technology sector of the United States.
Deming believed that the ability to create improvement requires knowledge about the subject at hand (making cars or practicing medicine) combined with what he referred to as the System of Profound Knowledge. The System of Profound Knowledge asserts that improvement requires an understanding of the interaction of four factors that affect processes and outcomes. The descriptions below offer EMS examples for each.
Appreciation of a system : having an understanding of the interactions of a system and how they affect the outcome or quality measures. The EMS system is rather large, and includes dispatch, first responders, fire (including hazmat and special operations), hospitals, public health, mental health, and the EMS authority, as well as the health care provider and the patient. Any successful improvement effort must recognize the role each of these system elements plays in creating the outcome.Knowledge of variation : understanding what is a “normal variation” within a system compared to what is unexpected or unpredictable. Blood glucose levels offer a good example for describing the knowledge of variation. A patient whose daily glucose levels have fluctuated between 84 and 106 over the past 2 weeks does demonstrate variation, but the narrowness of the range suggests that it is the result of normal variations in diet and metabolic functions. This is referred to “common cause” variation because it affects all people and does not reflect a metabolic system that is “out of control.” In contrast, a patient whose daily glucose levels have fluctuated wildly between 84 and 320 during the same timeframe likely has what Deming referred to as “special cause” variation – not common to all people, and likely reflective of a system that is “out of control.” Successful quality efforts identify and focus on reducing special cause variation and DON’T waste time and resources trying to “fix” common cause variation. Like all other systems, EMS has a lot of common cause variation: cardiac arrest survival, skills success rates by paramedics, or on-scene intervals – performance varies week to week or month to month. Statistical tools such as process control charts are used to identify variation that is not common cause (such as consistent differences in cardiac arrest survival between communities). Understanding and reducing special cause variation is what process improvement, and this chapter, is all about.Building knowledge : understanding the system under consideration and using that understanding to predict what improvement efforts will successfully reduce special cause variation. The knowledge-building process not only refers to making informed predictions before beginning improvement efforts, but also the continued gathering of information on how interventions actually affected the system. For this reason, efforts to create system improvement need to be structured in a way that enables the effect of change to be carefully measured. The Plan-Do-Study-Act (PDSA) cycle is the strategy for systematically testing changes within the system and building additional knowledge, and will be discussed below.Human behavior : how humans behave and react to given circumstances. What are the “human” factors contributing to the special cause variation? And how will they respond to the proposed changes? Will there be resistance? Human behavior is often underappreciated when change efforts are undertaken, especially in a large and diverse system like EMS.Careful consideration of all four aspects of the System of Profound Knowledge will guide quality leaders in developing a change or improvement within the system.
The Model for Improvement Application of Deming’s principles to actually solve quality problems requires a structural framework that can guide the process and set parameters. Fortunately, there is a powerful tool available that can be used to guide and drive the process of quality improvement. The Associates in Process Improvement (Austin, Texas) developed this tool several years ago and it is currently used in education, health care, and public and private business to drive change and improvement. Although there are other guides and tools available, the Model for Improvement was adopted by the Institute of Healthcare Improvement as its “weapon of choice” to promote a balanced and healthy approach to improving quality within health care systems, including EMS. Use of this model within your system to define, measure, and ultimately improve quality is a major focus of this chapter.
The Model for Improvement (Figure 72.1 ) begins with three basic questions, each of which is foundational to understanding and defining the target of the improvement effort.
Figure 72.1
Source: Langley G, Moen R, Nolan K et al. The Improvement Guide: A Practical Approach to Enhancing Organization Performance , 2nd edn. San Francisco: Jossey-Bass, 2009, p.24. Reproduced with permission of John Wiley & Sons, Inc.
Aim: What are we trying to accomplish? Aim statements are very specific and address the topics of “What?,” “By when?,” and “For whom?” The aim should ideally possess qualities that will keep the intent of the aim on those things that matter. First, the aim should be patient-centered . The delivery of quality patient care is the driver of EMS and our quality initiatives should reflect that belief. Second, the aim should be focused on a practice with wide special cause variation , meaning that some providers (or communities) perform well while others do not. There is no benefit to patients in focusing improvement on practices that all providers do well (only common cause variation). While ultimately it is beneficial to address issues that virtually no one does well, it is a very difficult place to begin performance improvement efforts because there are no “best practices” available to learn from. Instead, it is wise to begin with issues that have broad variability. Finally, the aim should be evidence based and backed by solid, foundational literature and best practices . Selecting aims that have an adequate evidence base reduces the controversy around the interventions that will be tested to improve performance. Consider the following EMS improvement aim that meets these criteria.To improve the percentage of patients in respiratory distress who are normally oxygenated to 95% by March 31st. Measure: How will we know that a change is an improvement? The measure becomes the lens through which all potential change strategies are viewed to determine whether they will actually create the desired result. Like aim statements, measurement statements must be very specific and describe how the change will be measured. There are several characteristics of good measures. First, as with the aim, metrics should be patient-centered 
