“Quality is not an act; it is a habit” (Aristotle)

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 patients
  
• paramedic-centric: number of successful versus failed intubations monthly
  
• community-centric: recognition of coronary ischemic discomfort for STEMI patients
  
• organization-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.