In my post last week about the importance of being comfortable with failure, I mentioned statistics and benchmarking. Last month, I had a chance to present at my first national conference when I spoke at EMS Today as part of the EMS Compass preconference. I’ve been involved with the EMS Compass project since November of 2014 and while the process itself has had some growing pains, the mission and goals of the project involve some of the most important things to the future of our industry.
For example, it is only with a firm understanding of the role of benchmarking in quality assurance and quality improvement that we will be truly able to compare the impact that we have on patient outcomes. Understanding the impact of our care and being able to compare it to other systems is how best practices are discovered. It all comes down to asking a couple of simple questions?
The first question is an easy one, and that is simply why? If another system is seeing better patient outcomes for their STEMI cases, or if they have a higher ROSC and survival rate for cardiac arrest, you need compare your system to theirs and just ask “WHY?” Do they have a different set of CPR protocols? Do they have a more aggressive field pronouncement protocol that steers medics to stay and play instead of taking a load and go approach with their cardiac arrest patients?
The easiest way to figure any of this out is to work backwards. Take the example of ROSC and survival rates. If another system has a higher survival rate, start with where they are delivering their patients. Are they using hypothermia for their patients prior to arrival or have they omitted that step at recommendation of the AHA? Are they part of a completely different system with different protocols that might call for later intubation or a different style of airway management all together? What about their care in the field differs from the care that you provide?
After analyzing the care that takes place on scene, look at who is going to those calls. Are they sending more help than you are? Does your system even have the infrastructure to send more help if that is a difference, and what other solutions are there to solve that specific problem? Also, who is answering the 911 call? How are they answering it? What quality of prearrival instructions is a caller getting? How often are people even doing CPR? And finally, how many people in your community have received some level of CPR training before they even pick up the phone and call 911?
The whole process is about questioning, armchair quarterbacking, and determining for your specific system what works, what does not, and what is fiscally and operationally reasonable to expect of your staff. Only then can you set the bar for what your next goal, but how do you get there?
Change is hard. No, change sucks, especially in our field. We talked last week about a reluctance to have our shortcomings pointed out to us, but it needs to happen and it is okay for it to happen slowly. I am always taken back to a comment that Skip Kirkwood made to me in an interview back in 2010 about his success at Wake County. He told us that his medics come into work every day expecting something different, or some general change in what happened the tour before. They were always raising the bar, and that is what just about everyone needs to do.
Don’t make the mistake that I’ve made in the past and allow all of the change to happen at once. Ease into it. Sticking with our cardiac arrest survival example, start with training and awareness. Start adding units to cardiac arrests, for example, and start pushing field personnel to be more willing to utilize those personnel. Let your people get used to something, then introduce something else. While we are talking about the preservation of human life, we need to remember that prehospital care is a marathon and not a sprint. Meaningful changes perfected over time will be far more valuable than short term, knee jerk adjustments. While they might be well intentioned, they are frequently short sighted and based more on one incident than a pattern or *GASP* evidence.
One of the mantras of the Seattle Resuscitation Academy is measure and improve. One does not just need to apply this to resuscitation though. The thing about the QA and QI processes is they are never done, or rather they should never end. System evaluations need to be ongoing, and not just happen at the request of a government official or in response to some adverse event. We should never be surprised by anything, and we should never not know that a trend was moving in a negative direction.
Sure, it seems easy reading it here on paper and I will fully admit that being as diligent as we need to be with evaluating our respective systems is time consuming, which is why most larger services need a QA/QI department and not just one person pulling 5% of the charts and drowning under a mountain of paperwork.
First, we need to strive to understand. Only then can we improve, and realize our full potential. In the over 500 posts on this blog in the last 6 years, I feel like I have said this time and time again. It’s not my redundancy that you should take from that though, it’s the fact that it has to be said time and time again, and the fact that thorough system evaluations have not become more of a reality.