Quality Improvement Using the Donabedian Model

Jay Kaplan, MD, past president of the American College of Emergency Physicians, once said quality improvement (QI) wasn’t an attempt to achieve perfection—it was a journey to do things better than the day before.

In EMS we use prospective, concurrent, and retrospective measures to ensure quality in our systems. Prospective measures include how we recruit and select our teams, the processes of onboarding and training, determining competence, what equipment we use, etc. Concurrent measures include how we evaluate competence in training, on the street, and during the probationary period. Retrospective measures such as review of calls and patient care reports are designed to confirm that prospective and concurrent practices are working as intended. They are essential for reviewing adverse and sentinel events. However, the ability to correct and improve performance in real time is the gold standard we should strive for.

Beyond PCRs

There are many systems that use PCR analysis as their sole method of ensuring quality. This is a poor approach. First, it limits you to finding mistakes after they happen. This can lead your providers to view the whole QI enterprise as a “gotcha” tool. And, sadly, some places use it this way. Second, if feedback is not provided in a timely manner, the same error may be repeated. Prevention of mistakes is the goal, and this occurs through the prospective and concurrent processes.

Quality improvement should not be an exercise in intimidation. It should be your methodology for helping improve patient care over time. Like everything else we do in EMS, it must be disciplined (meaning following a format with measurable benchmarks), principled, defensible, scientifically sound, and evidence based.

Famous University of Michigan physician and economist Avedis Donabedian, MD, defined a framework that’s useful for looking at quality improvement in EMS: Patient + structure + process = outcome.

Structure is everything from the ambulance in which we respond to the medical equipment we use to the people we hire and our staffing configurations. It is our ratio of ambulances to calls. It is how we train and educate our staff and the treatment protocols and procedures we utilize.

Process is how our efforts work in conjunction with structures to achieve outcomes. They include our diagnosis, assessment, and treatment of patients and how we interact with patients, other staff, and the system. Intubation attempts, time on scene, and time to defibrillation are examples of process measures.

Outcome is straightforward. We cannot control the patient who calls 9-1-1, but we can control the systems and activities that help determine their outcome—essentially how the patient emerges from their interaction with the structures and processes we’ve created.

Prospective, Concurrent, and Retrospective Processes

Not all organizations practice the same quality improvement procedures. Some practices may be common, but some vary with local circumstances.

In the prospective process of selecting candidates for hire, everyone checks criminal backgrounds, driving records, and references and verifies certifications. Some departments may also have written tests, oral interviews, and clinical scenario reviews. One I know has candidates treat a simulated patient using a manikin with all the BLS and ALS equipment. New York City EMS used to have candidates perform a pre-employment driving test.

In medicine, in my opinion, concurrent processes are the most anxiety-producing. In EMS we are sort of bred that way—someone is always taking a look, offering a suggestion, evaluating our performance. We may have field training officers performing check rides with new employees or for yearly evaluations. They do this in real time and provide feedback immediately.

So-called “360-degree” evaluations are a tool from the business world for evaluating behavior, communication, and interpersonal relationships. You get feedback from everyone around the subject: dispatch, partners, other responders, receiving hospital staff, and patients.

This is not practical for every organization. Some may not have enough personnel to support resources like dedicated FTOs on every shift. The crews from one rural/suburban organization I know receive feedback from the ED doctor and RN immediately after their arrival at the hospital. They are a small agency with not a lot of clinical depth. This is not truly a concurrent evaluation, but it has elevated the quality of care within the organization.

We examine a variety of different measures to determine outcomes. Satisfaction surveys are important not only from the patient perspective but also for our coworkers and receiving facility staff. Cardiac arrest survival and neurological outcomes are clear outcome markers that improve with optimal structures and processes (eg, early notification, early CPR, rapid defibrillation, early ACLS, and transport to a receiving center). There are many others.

Use what works for you but don’t be afraid to try new things. By continuously improving our structures and processes, we can produce better outcomes for our patients.

Resources

Ayanian JZ, Markel H. Donabedian’s Lasting Framework for Health Care Quality. N Engl J Med. 2016; 375(3): 205–7. doi: 10.1056/NEJMp1605101.

Berwick D, Fox DM. “Evaluating the Quality of Medical Care”: Donabedian’s Classic Article 50 Years Later. Milbank Q. 2016; 94(2): 237–41. doi: 10.1111/1468-0009.12189

Donabedian A. Evaluating the quality of medical care. Milbank Q. 2005; 83(4): 691–729. doi: 10.1111/j.1468-0009.2005.00397.x

Donabedian A. The quality of care. How can it be assessed? JAMA. 1988; 260(12): 1743–8. doi: 10.1001/jama.260.12.1743

Gerard DR. Spearheading an EMS Transformation. J Emerg Med Serv. Accessed April 13, 2022. www.jems.com/ems-insider/spearheading-an-ems-transformation/

Holtermann KA. Emergency Medical Services Systems Development: Lessons Learned from the United States of America for Developing Countries. Pan American Health Organization; 2003.

Daniel R. Gerard, MS, RN, NRP, is EMS coordinator for the city of Oakland, California. He is a recognized expert in EMS system delivery and design, EMS/health-service integration, and service delivery models for out-of-hospital care.