EMS Quality Improvement Programs

Introduction

Quality improvement is an intentional process of implementing system-level changes with continuous reassessment to improve product delivery. In emergency medical services (EMS), this product is the delivery of high-quality prehospital care. This approach differs from quality assurance, which emphasizes compliance with protocols, processes, or policies.

Quality improvement programs function most effectively in environments that implement change through robust, nonpunitive educational frameworks. Effective quality improvement programs maintain transparency. Administration and clinical staff understand the goals and methods of ongoing quality improvement initiatives.

Quality improvement programs commonly use key performance indicators (KPIs) to measure clinical performance, identify areas for improvement, and assess the impact of process changes. EMS systems should base KPIs on clinical evidence, identified system deficits, or operational needs. The goal of quality improvement is the development of a high-reliability organization that operates in a relatively error-free state over extended periods.

Quality Improvement in Emergency Medical Services

EMS clinical quality as a concept gained prominence in the 2007 Institute of Medicine (IOM) publication, Emergency Medical Services: At the Crossroads. [IOM. Emergency Medical Services: At the Crossroads. 2007] The report identified challenges across many systems, including an inability to accurately characterize the quality of care and overall EMS system performance. The report recommended the development of national performance indicators. Several organizations were engaged in efforts to establish recommended performance measures at the time. Several quality initiatives have emerged in the decades following the IOM report, including EMS Agenda 2050 and the National EMS Quality Alliance (NEMSQA).

The EMS Agenda 2050 project and subsequent publication represent a National Highway Traffic Safety Administration–funded initiative developed in conjunction with multiple government agencies. The purpose of the EMS 2050 project was to provide an updated vision for the future of EMS, with quality improvement integrated across all components of the vision statement. EMS 2050 underscores the need for quality improvement in EMS systems, stating, “Many organizations lack the resources, initiative, or desire needed to implement meaningful performance measurement and quality improvement systems, leaving them unable to determine whether the care provided is truly safe or effective.”[1]

While many EMS systems continue to lack dedicated resources for quality improvement efforts, organizations such as the NEMSQA provide resources intended to make quality improvement more accessible to EMS systems. With input from stakeholder organizations and individuals, NEMSQA has developed and validated multiple quality measures for EMS systems. These measures include recommendations for both processes and outcomes, with emphasis on patient safety, clinical process effectiveness, and patient experience. The guidelines are regularly updated and based on current evidence. While benchmarks, or performance goals, for these measures have not yet been published, NEMSQA aims to develop benchmarks in the future using actual EMS data. These measures are available on the NEMSQA website. A recent publication applied these quality measures to data from the National EMS Information System dataset, demonstrating wide variation in performance across key EMS quality measures.[2] (Source: [NEMSQA. National EMS Quality Alliance Measure Set. 2021]

Quality improvement practices vary significantly among EMS agencies across the US. A 2015 survey of EMS agencies nationwide reported that 71% of surveyed agencies had dedicated quality improvement personnel.[3] Examples of quality improvement projects include increasing prehospital aspirin administration rates in patients with acute coronary syndrome (ACS), strengthening paramedic identification of ST-elevation myocardial infarction, and decreasing peri-intubation hypoxia. Developing EMS systems have also successfully implemented continuous quality improvement programs to specifically address prehospital trauma care, with significant improvement in prespecified KPIs following targeted education.[4]

Each project began with the identification of a need for improvement. A plan was then developed, incorporating a process change and a mechanism to assess the impact of that change. The following questions should be considered prior to selecting KPIs and implementing any process improvement initiative:

• What is the aim?
• How and what should be measured?
• What changes should be implemented to improve the process, system, or outcome?

The aim should be specific, evidence-based, and focused on patient-centric outcomes, with a clearly defined timeline. Measurements should be patient-centered, specific, and quantifiable. Changes to be implemented rely on a predictive assessment of system or process modifications expected to achieve the desired aim.[5]

Plan-Do-Study-Act Cycle

Many EMS organizations utilize the Institute for Healthcare Improvement's Model for Improvement, which incorporates Plan-Do-Study-Act (PDSA) cycles. Effective PDSA cycles should be structured with participation from staff involved in all aspects of the targeted process. For example, a PDSA cycle aimed at improving cardiac arrest survival should include field paramedics, personnel from the medical director’s office, administrative staff, and logistics personnel.

Plan

The purpose of the Plan step is to establish the objective of the project clearly and concisely and ensure alignment with the aim and measurement statements as previously defined. This step includes brainstorming potential solutions, selecting a single intervention for testing, and developing a structured plan for implementation and evaluation. The quality improvement committee should define the problem using objective data whenever possible and may use adjunct tools such as driver diagrams to guide system-level improvement efforts. The committee should clearly define how both the magnitude of the problem and the presence of improvement will be measured.

For example, in a system attempting to improve aspirin administration rates, a measurable improvement may be defined as “aspirin administration is documented in 95% of patient encounters with a chief complaint of chest pain.” The Plan step includes identification of potential solutions to the question, “What intervention will lead to improvement?” A structured plan for reevaluation should be developed following the selection of a specific intervention, such as the storage of aspirin in a dedicated pocket on the cardiac monitor. The plan should address the following questions:

• What is the problem?
• What is the intervention?
• How will the problem, change, and outcome be measured?
• How will the determination of improvement be made?

These questions function as a framework to maintain methodological rigor during quality improvement planning. Explicit alignment of problem definition, intervention design, and measurement strategy supports reliable assessment of whether a change produces meaningful improvement.

Do

This segment is often the least complex in design but frequently the most challenging to execute. The Do step consists of implementing the contemplated intervention once a plan is established. A specific implementation date should be selected in the near future to initiate the process. An initial small-scale trial should be conducted rather than immediate system-wide deployment. This limited implementation, referred to as a “test of change,” allows evaluation of whether the intervention produces the intended effect. Small-scale testing often identifies unforeseen issues that may require modification prior to broader implementation. For example, a checklist intended to improve intubation success may be developed and trialed during a single shift at a single ambulance station before expansion to the entire EMS system.

Study

The purpose of the Study step is to determine whether the implemented plan resulted in a change representing an improvement. Evaluation should reflect the aim established in the Plan step. During the Study phase, participants should also identify any unintended outcomes. The team should analyze which components of the plan were effective and which did not perform as intended. Objective data required to assess change and improvement should be collected as specified in the Plan step.

For the intubation checklist example, evaluation may include comparison of intubation success rates before and after implementation, as well as assessment of compliance with checklist use. Feedback regarding the checklist itself should also be obtained from end users. Additional variables, including metrics potentially influenced by changes in intubation practice, such as scene time and cardiac arrest rates, should also be reviewed.

The most commonly used tool for evaluating tests of change is the process control chart. These charts plot the proportion of cases meeting the defined success criteria over time and include a marker indicating the point of implementation of the intervention.

Act

The Act step is intended to implement actions based on findings from the Study step. The process change is either deployed system-wide or modified prior to broader implementation. Deployment is determined by outcomes of the Study phase and achievement of desired outcomes. Following the prior example, actions may include refinement of an airway checklist based on end-user feedback or provision of additional training. Once the Act step is completed, the cycle restarts with planning, including redeployment of an improved checklist, reevaluation of success rates, expansion of implementation to the entire system, or acquisition of additional feedback. This PDSA cycle is continued in an iterative process until the desired improvement is achieved.[6]

Key Components of a Quality Improvement Program

Quality improvement in healthcare focuses on systematic efforts to enhance processes, outcomes, and overall system reliability. Effective programs integrate continuous evaluation with structured methods for identifying and addressing gaps in performance.

Nonpunitive culture

A quality improvement program must adopt a nonpunitive approach. A "just culture" strategy is a commonly used framework for this approach. Just culture is an organizational model that emphasizes shared accountability between individuals and the organization in error prevention and quality improvement.[7] This model also recognizes that errors frequently result from multiple contributing factors, including system-level issues.

Within a just culture framework, organizational responsibility includes continuous improvement of systems and processes in which providers operate, while providers remain responsible for safe clinical decision-making. Near misses are regarded as significant events comparable in importance to actual errors. A just culture approach promotes reporting of both near misses and adverse events through education-focused processes rather than punitive responses. Providers who submit reports may remain anonymous, receive feedback through closed-loop communication, and be acknowledged for reporting.[8] The framework reinforces accountability for clinical actions and ongoing education, discourages tolerance of unsafe knowledge gaps, and promotes continuous system improvement to enhance safety and outcomes.

Education

Many quality improvement projects, particularly clinical quality improvement initiatives, require educational components to disseminate information regarding the intervention. An individual or team with an educational focus may facilitate achievement of the desired improvement outcomes.

Team-based approach

A quality improvement project should include representation from all areas of an organization that may be affected by changes resulting from the improvement initiative. Inclusion of individuals with diverse perspectives increases the pool of potential solutions and contributes to the generation of more effective interventions. A larger number of ideas increases the likelihood of identifying a successful change. Organizational culture must support belief in quality improvement programs at the highest levels of leadership, including executive leadership and supervisory staff, to facilitate effective implementation of change.

Clear aims

The quality improvement committee should select aims that are clearly defined, evidence-based, and aligned with clinical priorities. The timeline for implementation and PDSA cycles should also be explicitly outlined. Data elements selected for measurement must be appropriate to the defined aim and directly relevant to the intended outcome.

Issues of Concern