Quality CQI programs

There is a difference between continuous quality improvement (CQI) and quality assurance (QA) programming. Too often the QI title is missued for QA. Do you have both programs at your service? One of them? How do they work? I am curious to see how the best CQI programs are designed and what do they measure and then how do they promote positive change. A poor QI/QA program for example is reading all the trips and deciding if care was appropriate. There needs to be a written set of standards for care/documentation established that the trip can be held to.

Tags: assurance, cqi, improvement, process, qa, quality

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Permalink Reply by CA Gingrich on January 13, 2009 at 3:50pm: Thanks for this important discussion. I come from an education background and prefer the QI program. It is all about feedback and paying attention to the care. Just paying attention improves care, but if you expect and recognize excellence the patient is even more well-served. Some see QI as pointing out mistakes or finding fault, but recognizing excellence should be the goal. Nobody wants to be the odd man out and the poor performers will soon get the idea and either improve their performance or find another career path. Nothing motivates people more than positive recognition for a job well-done. Leadership is about communicating value in people so clearly they come to see it in themselves so concentrate on the stars in your organization and the bottom dwellers are likely to improve. Thanks for the stimulation.; ▶ Reply to This

Permalink Reply by Kevin Collopy on January 13, 2009 at 4:00pm: A key step to QI is it is individual blind. While the data compiler may see who is writing a report, said name is not included in other data interpretation. A good start to a QI progam is by looking at, for example, motor vehicle crashes. Create a list of care/documentation markers: speed, protective equipment, air bag deployment, number of vehicles involved, patient position, chief complaint, immobilization, presence/absence of numbness/tingling/motor skills, etc. Share these markers with all technicians and then track them on a spread sheet. Collect for 50 runs then determine what is recorded well, what is missing, create a training do discuss why its important, and remonitor for another 50 runs. This can be extended into care (oxygen, splinting, ALS skills, etc). A key step though is sharing what the monitoring markers actually are.; ▶ Reply to This

Permalink Reply by CA Gingrich on January 14, 2009 at 7:10am: Kevin, would love to see an example of the spread sheet you use. Is there a way to see some examples? This sounds really good. Thanks.; ▶ Reply to This

Permalink Reply by Kevin Collopy on January 14, 2009 at 1:05pm: Camp G said:
Kevin, would love to see an example of the spread sheet you use. Is there a way to see some examples? This sounds really good. Thanks.

go to www.midstateems.org click on their cqi page, they have monitoring spreadsheets for cardiac arrests, asthma, etc. its very basic, but a good start. it makes the analysis technician blind; ▶ Reply to This

Permalink Reply by CA Gingrich on January 15, 2009 at 6:41am: We are currently pushing 12 Leads in the field on all Chest pains. We eventually want to be calling STEMI alerts in the field and the data is looking better, but we need more intense inservice on Dysrhythmias etc which appears to be in the works. You get what you pay attention to. Thanks again the info is great.; ▶ Reply to This

Permalink Reply by Kevin Collopy on January 15, 2009 at 9:25am: Camp G said:
We are currently pushing 12 Leads in the field on all Chest pains. We eventually want to be calling STEMI alerts in the field and the data is looking better, but we need more intense inservice on Dysrhythmias etc which appears to be in the works. You get what you pay attention to. Thanks again the info is great.

I have set up a monitoring program for 12-leads and STEMI''s in the past. If you are interested we can discuss. There are quite a few ways to do this; ▶ Reply to This

Permalink Reply by Tom Bouthillet on January 15, 2009 at 11:05am: Why just chest pain patients? I'd consider throwing a much wider net!; ▶ Reply to This

Permalink Reply by CA Gingrich on January 17, 2009 at 8:37am: Good point. We need to at some point, but this seemed like a good place to begin.; ▶ Reply to This

Permalink Reply by Tom Bouthillet on January 18, 2009 at 2:27pm: There are worse places to begin! I would recommend classifying "chest pain" as any unusual sensation, nose to navel, front and back. That will help you pick up any atypical presentations. Also consider shortness of breath (especially new exertional dyspnea or acute pulmonary edema), syncope, palpitations, diaphoresis unexplained by ambient temperature, unexplained nausea and vomiting, unexplained weakness or fatigue, especially in the elderly patient, feeling of impending doom, suspected diabetic ketoacidosis, and any heart rate < 50 or > 150.

From a QI/QA standpoint, if you only follow up on patients the paramedics identified as having chest pain, you'll never know what your paramedics are missing. I remember a 12 lead class taught by Tim Phalen back in 2001 where he showed a retrospective chart review of an EMS system that prided itself on having a great 12 lead program. They started at the hospital with all patients who had a confirmed discharge diagnosis of ACS (STEMI, NSTEMI, or Unstable Angina) and worked their way back to the EMS system. It turned out they weren't nearly as good as they thought they were! Many of the patients did not receive a 12 lead ECG in the field, many did not receive ASA, many did not receive NTG, and so on. It was very interesting to see the variety of chief complaints documented on the run sheets!

Camp G said:
Good point. We need to at some point, but this seemed like a good place to begin.; ▶ Reply to This

Permalink Reply by Kevin Collopy on January 19, 2009 at 8:31am: That is a great idea. Begining from the hospital end and working backwards. This can also be done for any respiratory distress presentation to help analyze for EMS differential of CHF versus pneumonia. Another aspect of 12-lead performance is serial 12 leads. Some medics I know insist that once a single 12 lead is performed that additional are not necessary. I suggest that it is a good way to monitor to see if what you are doing is working, and with ongoing chest pain the patient could just not have begun to show evidence of infarct of ischemia on the 12 lead just yet, and that you may caputre it by running a 12-lead with each set of vital signs. It really takes no additional effort if the leads are left in place; ▶ Reply to This

Permalink Reply by Kevin Collopy on January 19, 2009 at 8:33am: Monitoring chest pain patients and 12-lead EKG seems to be a more commonly monitored item. What other items to people have QI versus QA performance monitoring on. Lets also distinguish the two a bit better.; ▶ Reply to This

Permalink Reply by Michael Fraley on February 21, 2009 at 7:31pm: Kevin Collopy said:
Monitoring chest pain patients and 12-lead EKG seems to be a more commonly monitored item. What other items to people have QI versus QA performance monitoring on. Lets also distinguish the two a bit better.

A common QA I think of is just a general run report review. Someone is assigned to look over a run report to make sure all the required data is present. It often stems from billing and the need to clearly document certain things to be able to successfully bill. Then the report goes on to the service chief or some other experienced person to review the care and make sure it is up to protocol. I am not a big fan of these as they often have a very negative reception with the crews. When I have done them I have tried to stick with very clear, objective criteria such as the protocol. Some services even have a standard of documentation which defines what information should be documented for various patient types.

A service I am working with right now does monitors on chest pain, altered level of consciousness and respiratory distress patients. They have gathered a year of data of that now and I am tasked with analyzing what we need to do to make the numbers better for this year. I also hope to add a trauma indicator.

I am also interested in hearing about others success stories.; ▶ Reply to This