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.

    At that point, I only had a couple days' worth left, so I decided to finish. When I was done, I looked at the list of issues I had identified and compared them with the region's review criteria. Ninety percent of all the issues I uncovered, many of them major, would never have been discovered if I had followed the region's criteria. Taking one step back, it was easy to see why. All emphasis was clearly placed on the high-intensity, high-profile calls, while the "routine" calls, which happen to be the majority of what we do, were trivialized. Upon review, they were anything but trivial or routine. Abdominal pain and generalized weakness are not sexy or exciting calls, but abdominal pain can be an MI, aneurysm, acute gastritis or ectopic pregnancy--all life-threatening emergencies. Likewise, generalized weakness may be the primary symptom of an MI, hypoglycemia, stroke or sepsis.

   I also found wide disparity in how these identical call types were being handled by different providers. Many of the calls were clearly trivialized to the point of being undertreated or completely untreated, sometimes despite several red flags indicating the patient was already in extremis.

   This was my first realization that conventional standards in quality improvement might leave a little to be desired. Based on the results of my review, I decided to do a 100% retrospective review. I continue to review about 3,600 calls a year, or 300 per month, at Bucks County Rescue Squad and 4,200 calls per year, or about 350 per month, at Central Bucks Ambulance. That's a lot of PCRs to read, but it has resulted in a great return on investment.

100% CQI

   If you cannot do a 100% review of your entire call volume, you absolutely need to at least do a 100% provider review. That is, review as many PCRs as possible for each provider, and do not limit it to the high-intensity, high-profile calls. You may choose to review certain types of calls on a rotating basis, such as all generalized weakness calls one month and all chest pain calls the next. You may also choose to review calls of particular interest to the medical director or call types you believe you may be having issues with.

   But, as I quickly realized, you get the greatest value by reviewing the more common calls, such as abdominal pains, generalized weakness and patient assists. Most providers are easily motivated to do a good job on the more glamorous, dire emergencies, which are typically a small percentage of your call volume. The true mark of an EMS professional is how he or she handles the "routine" call.

    Regardless of whether you do 100% call review or 100% provider review, advertise the fact that you are now doing a 100% quality review. Knowing they're being watched is a great motivator to staff to do a good job, for self-preservation if no higher moral purpose.

   If your call volume is so large 100% call review cannot physically be done by one person, ask for assistance. It's always good to have at least one backup for a job anyway. If you leave, quit or die, all the effort and progress you've made should not be lost with you.

   Convenience Matters

   Where is it written that a job must be inconvenient to count? Because of the benefit attached to reviewing as many PCRs as possible, if there's any way you can make it easier or more convenient for yourself, do it.

   In the beginning, I reviewed paper charts--stacks and stacks of them. After a few months of reviewing 50 pounds of paper charts printed from our computer-based system, I suggested that we stop printing PCRs unless there was a specific reason. This has saved countless trees and some money too. If you can access your PCR data system from a personal computer, either the agency's or your own with authorization, having the ability to review PCRs at your convenience will greatly increase the number you can review.

   My retrospective review process begins with the following items: Patient age, past medical history, patient medications, chief complaint, exam and physical findings, treatments and how the patient responded to treatments.

   I never look at the providers' names until after the PCR review is complete to avoid any prejudice on my part. I cast a wide net in my review, pulling any PCR that looks exceptionally well managed, poorly managed or difficult to manage, as well as any unusual or complicated calls and calls of interest. I also note any cases where there were frequent responses to the same address or same patient for closer scrutiny.

   Keep in mind, even though the retrospective review is typically administrative and not time-sensitive, if you discover a critical issue, such as an ongoing practice that could be dangerous to either the patient or provider, do not hesitate to take corrective action.

   An excellent example of this was when we noticed a series of unsecured combative patients being transported. There is nothing more dangerous than transporting an out-of-control patient in a moving ambulance with one provider trying to control him while the other one drives, frequently at high speed. We quickly identified the problem as many providers' failure to consider sedation for combative patients. The problem was quickly resolved by simply reminding providers that patient sedation is a safer alternative for both patient and provider than a wrestling match in the back of a moving ambulance.

   Additionally, if you notice repeat responses to the same address for similar complaints that could be indicative of an environmental emergency, such as carbon monoxide poisoning, do not hesitate to act. You may be the only person who sees the big picture, especially if the repeat calls span multiple shifts. This underscores the added benefit of early PCR reviews, ideally on a daily basis, if resources and time permit.

Active Medical Direction

   Without a doubt, most of the success of the quality improvement programs at both Bucks County Rescue Squad and Central Bucks Ambulance are due to strong medical direction involvement. Once a month, I meet with the medical director of each agency to review any issues I uncover during my peer review and present any good, bad, questionable and interesting cases as he reviews the PCR for details. The quality coordinator is knowledgeable about scope of practice, current protocols and peer perspective, but the medical director has a much broader, more in-depth knowledge of medicine in general and emergency medicine in particular. This is an invaluable resource. Remember, quality improvement should be educational. If your only knowledge base is on the same level of medicine as another medic, your capability for improvement will be limited. Feedback from someone with more knowledge is the ideal way to learn from calls, particularly those that are complicated. Suggestions are also typically much better received coming from a physician than another EMT or paramedic.

Don’t Overlook Good Performance
One of the most commonly missed opportunities by quality improvement programs is recognizing the good things being done. Overall, there is more good than bad going on in EMS any day of the week. Although the main objective of quality improvement is to identify and correct mistakes, it is also totally appropriate and beneficial to acknowledge and reward the good.

Excellent call management, and even appropriate management of a difficult call, should be acknowledged. There are many ways of doing this, the simplest being a letter of commendation from the CQI committee, chief or medical director. Central Bucks Ambulance commissioned a Top Gun plaque with 24 brass plates. With recommendation of the quality improvement coordinator and authorization of the medical director, crew members’ names and dates of their excellently managed calls are added to the plaque. In addition to the Top Gun award, Bucks County Rescue Squad similarly commissioned a Code Buster plaque for successful resuscitations and a Stork Club plaque for field deliveries of babies. Although a relatively new concept for EMS, ribbons and medals similar to those awarded by police and the fire service are available for purchase by progressive agencies that wish to reward exemplary service. Although HIPAA laws make it difficult to let the public know all the good work EMS is doing on a routine basis, for those exceptional or dramatic calls that are well-managed, you can give the press some good news to report, with permission from the patients or their families.

Conclusion

   A comprehensive retrospective review is the core of any quality improvement process, but it should not be the entire process. In our next segment, we will review the concurrent or real-time component of the quality improvement process.

   Joe Hayes, NREMT-P, is deputy chief of the Bucks County Rescue Squad in Bristol, PA, and a staff medic at Central Bucks Ambulance in Doylestown, PA. Contact him at jhayes763@yahoo.com.