From the Officer`s Desk: Fostering a Culture of Quality

“From the Officer’s Desk” is a bimonthly column aimed at EMS leaders.

Consider this scenario: EMS Chief Ryan is responsible for the EMS operations division at his service, which consists of 15 advanced life support (ALS) fire suppression units and 20 ALS transport units. The agency responded to more than 60,000 EMS requests for service and transported 48,000 patients last year.

It is a fairly busy department, and Chief Ryan is committed to ensuring his division delivers great service to its customers. However, Chief Ryan has been receiving reports that a number of customers his service transported to the hospital have filed complaints claiming they weren't treated with respect.

Other customers have complained about missing personal belongings following EMS transport. Emergency department directors have filed several complaints pertaining to crews not following the department's medical protocols, and the quality assurance team has noticed an increase in documentation errors.

Chief Ryan already has a quality assurance team in place; however, its primary focus is on medical documentation, interventions, and outcomes. He needs to expand his quality management program to encompass more than just medical oversight of patient care. 

Where Should He Begin?

First Chief Ryan needs a quality management program to assist him in getting to the root cause of poor service. The program should be able to make appropriate corrections and continuously monitor these services to ensure his section is delivering the desired quality outcomes.

In other words, the quality management program must consist of quality systems that assist in detecting quality variation, underperforming processes or systems, and non-value-add activities at all levels. Moreover, the program must have quality systems in place that ensure quality is delivered on a consistent basis. 

Quality at Work 

A quality management program must consist of a framework of systems that work together to achieve desired outcomes. It must be deep-rooted and part of the organization's culture. What do Amazon.com, the Ritz-Carlton Hotel Company, Zappos.com, Southwest Airlines and the Walt Disney Company have in common? They are extremely successful at providing excellent service, which is supported by a culture of quality throughout the organization. Every member understands what’s expected, and the culture sends a message that nothing less than quality outcomes that meet and exceed customer expectations will be accepted. Benefits to organizations include: 

• Exceeding customer expectations;
• Committing to continuous improvement;
• Achieving quality outcomes at all levels of the organization (finance, operations, training, fleet, communications, logistics);
• Establishing and meeting performance measures;
• Employee empowerment;
• Becoming a best-practice organization;
• Senior leadership support for quality initiatives;
• Quality training for all members of the organization.

Any successful quality initiative must start at the top. However, every member must sign on and embrace the initiative, so it permeates the organization's culture. Senior leaders must seek buy-in from employees and provide the training and tools for employees to achieve desired outcomes. EMS officers must ensure the initiative reaches beyond one specific service or product and includes all functional work levels.

EMS agencies must reach out to organizations that have developed robust quality management programs, regardless of the industry. The key is to keep learning in order to establish a program that aligns with the organization’s mission, vision, values, and strategic plan. 

TQM: Body and Engine

The first step is to understand what you’re trying to accomplish. Do you want your program to drive quality initiatives throughout the organization? Are you looking to improve specific processes or underperforming systems, or eliminate activities that no longer serve a purpose? Both these goals are valuable and can be achieved by instituting a total quality management (TQM) program.

TQM can be compared to a vehicle: TQM is the body; the engine, with the sum of its parts, is the quality management systems (QMS). TQM must consist of quality management systems such as: 

Quality planning—Time committed to establishing a plan to address organizationwide variations and/or services not meeting expectations. Also, seeking opportunities to continuously improve processes and systems and/or remove non-value-add activities.

Quality assurance—Continuous monitoring of processes, systems, goods, and services to ensure outcomes are being delivered within accepted parameters set by the organization.

Quality control—Tools, standards, policies, and activities to ensure the department's desired quality outcomes are being met.

Quality improvement—The evaluation of processes, systems, goods, and services must be continuous to ensure they are achieving desired outcomes. Certain quality methodologies, such as Six Sigma and Lean Six Sigma, may be used during the quality improvement phase. Moreover, the plan-do-check-act (PDCA) approach (also known as plan-do-study-act or the Deming cycle) can be used during the continuous improvement or control phase when using the Lean Six Sigma program. PDCA was designed to address the importance of ongoing continuous improvement. By doing so, processes or systems are closely monitored. If underperformance is detected, action is taken to make immediate improvements.

Total quality management requires that senior leaders support and remain engaged with the program. In addition, the TQM framework must support quality management systems such as quality planning, quality assurance, quality control, and continuous quality improvement. TQM may also follow another approach, such as the Baldrige Performance Excellence Program or International Organization for Standardization.

The Baldrige Performance Excellence Program focuses on all aspects of the organization with the goal of continuous improvement achieved through metrics, performance and outcome analysis, and a highly engaged leadership team. Organizations must demonstrate commitment to the following seven activities: leadership; strategic planning; customer market focus; measurement, analysis, and knowledge management; workforce focus; operation focus; and business results.

The International Organization for Standardization (IOS), also known as the International Standards Organization (ISO), promulgates standards designed to assist organizations seeking to improve quality outcomes. ISO has set standards throughout industries that are considered best practices by ensuring products and services are reliable and safe and meet set quality standards.

Each standard has an assigned number. For example: 

• ISO 9000, Quality management; 
• ISO 14000, Environmental management;
• ISO 22000, Food safety management; 
• ISO 31000, Risk management. 

The ISO quality management program uses the following activities to achieve quality outcomes: customer focus; leadership; involvement of people; process approach; system approach to management; continual improvement; factual approach to decision making; and mutually beneficial supplier relationships.

Continuous Improvement 

No quality management program is complete without a continuous improvement system. The following programs are more specific to process and system improvements and eliminating non-value-add activities.

Six Sigma and Lean Six Sigma can address process or system variation and eliminate activities that don't add value. Six Sigma focuses on identifying variation and is designed to help organizations achieve error-free and zero-defect outcomes. Lean Six Sigma focuses on identifying each step in a process or system that does not add value and eliminating waste, such as inventory (e.g., purchasing medical supplies that are seldom used), defective equipment, overproduction, not utilizing talent, or duplication of service.

These programs are complimentary because they work on eliminating waste and correcting variations that lead to error-free outcomes. Six Sigma and Lean Six Sigma use the DMAIC approach to signify five phases: define, measure, analyze, improve, and control. A defined set of activities accompanies each phase. Here is an example:

Define phase—The EMS officer clearly articulates goals and objectives to address variation in quality or non-value-add activities.

Measure phase—Metrics are used to evaluate the current state of the process or system not meeting the desired quality outcomes.

Analyze phase—Data from the measure phase is reviewed and compared to desired performance outcomes set by the organization.

Improve phase—If there is any variation in the organization’s performance outcomes or non-value-add activities, improvement measures must be taken to eliminate the cause.  

Control phase—Once improvement measures have been taken to ensure a correction, the process and/or system must now be controlled to ensure it continues to perform at the desired level. 

The programs require some formal training and use numerous statistical tools, but team members should not be discouraged from using these methodologies for improvements. Six Sigma has spread throughout organizations such as General Electric, Amazon.com, Ford, 3M, and Boeing as an approach to improve processes, eliminate waste, and streamline operations. While it may appear the focus is on manufacturing, both programs can improve quality outcomes in all types of businesses.

Regardless of the program chosen, the goal must be to select a TQM program that consists of quality management systems that align the organization’s mission, vision, value, and strategic plan.

Don’t Waver from the Goal

Many public safety agencies strive for quality and incorporate quality assurance into their mission statements, values, and strategic plan. However, quality assurance is only one component of the TQM program. 

The advice for EMS Chief Ryan is to select a program that's a good fit for the organization, supports ongoing quality initiatives, can assist members at all levels in eliminating system variation and non-value-add activities before they become out of control, and includes a system to make immediate improvements. In addition, the plan must be supported by the organization's leaders and embraced by internal stakeholders.

Implementation of these systems will not take place overnight, so it’s important to be patient and not waver from the commitment to quality. To achieve his objectives, Chief Ryan must continue to manage the process and systems while keeping continuous improvement at the center of his department’s service delivery. 

Orlando J. Dominguez, Jr., MBA, RPM, is assistant chief of EMS for Brevard County Fire Rescue in Rockledge, Fla. He has more than 30 years of EMS experience and has served as a firefighter-paramedic, flight paramedic, field training officer, EMS educator, and division chief. He has authored two books, including EMS Supervisor: Principles and Practice, and is a certified Lean Six Sigma Green Belt. Follow him at @ems_officer.