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 Skip Kirkwood on April 8, 2009 at 7:40pm: If you want to do "state of the art" QI, first read the article by Myers, Slovis et al in the April 2008 issue of Prehospital Emergency Care. It describes "treatment bundles" for those groups of patients for which medical evidence supports the benefit of ALS interventions. They include

trauma
stroke
STEMI
CHF
seizures

Then you make sure that your protocols support those state of the art treatment bundles.

Then you make sure that you provide those treatment bundles to everyone for which they are indicated.

Then, you have an evidence-based QI program.

Simple!; ▶ Reply to This

Permalink Reply by Tom Bouthillet on April 14, 2009 at 1:22pm: Skip -

How do you make sure you provide those treatment bundles to everyone for which they are indicated? Do you start with discharge diagnosis at the hospital and work your way back to the EMS system?

Tom

Skip Kirkwood said:
If you want to do "state of the art" QI, first read the article by Myers, Slovis et al in the April 2008 issue of Prehospital Emergency Care. It describes "treatment bundles" for those groups of patients for which medical evidence supports the benefit of ALS interventions. They include

trauma
stroke
STEMI
CHF
seizures

Then you make sure that your protocols support those state of the art treatment bundles.

Then you make sure that you provide those treatment bundles to everyone for which they are indicated.

Then, you have an evidence-based QI program.

Simple!; ▶ Reply to This

Permalink Reply by Kevin Collopy on April 16, 2009 at 1:32pm: Tom Bouthillet said:
Skip -

How do you make sure you provide those treatment bundles to everyone for which they are indicated? Do you start with discharge diagnosis at the hospital and work your way back to the EMS system?

Tom

Skip Kirkwood said:
If you want to do "state of the art" QI, first read the article by Myers, Slovis et al in the April 2008 issue of Prehospital Emergency Care. It describes "treatment bundles" for those groups of patients for which medical evidence supports the benefit of ALS interventions. They include

trauma
stroke
STEMI
CHF
seizures

Then you make sure that your protocols support those state of the art treatment bundles.

Then you make sure that you provide those treatment bundles to everyone for which they are indicated.

Then, you have an evidence-based QI program.

Simple!

Tom-
I think it works both ways. From the ED perspective every patient admitted with say seizures. Follow that patient back; if they were an EMS transport check for the expected treatments. From the EMS side review all trips that had a chief complaint of seizures (may have multiple hosptials). Were the treatment bundles provided? THEN check with the ED, was the ED diagnosis the same as the prehospital diagnosis. This answers the questions of 1) are we recognizing the patient's problems correctly, and 2) are we correctly treating what we recognize.; ▶ Reply to This

Permalink Reply by Michael Fraley on April 18, 2009 at 9:31am: Marshall, thanks for sharing. One question though. You mention using the scale to grade their "narrative." Does that refer only to the free text paragraphs or does it include any information documented anywhere in the chart? I encourage EMTs to use all the click boxes, pull-downs, procedure & vitals table effectively and then they don't have to put so much in their narratives. This is also what we need to do to get good data in NEMSIS.

How is the project going now that you are a few weeks into it?

Marshall Washick said:
I found this to be a really interesting thread and wanted to share our CQI process. The committee members also rate the narratives on a Likert scale of 1-4 (1 not supporting the providers impression, 4 clearly supporting the provider impression). This scale was also developed between myself and the Medical Director and unfortunately, I'm not doing it justice by summarizing it in here.

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Permalink Reply by Marshall Washick on April 26, 2009 at 6:34pm: Yes... we grade their narrative and how well it supports the selected provider impression. For example, the primary provider impression will be "chest pain/pressure", the narrative should include elements of HPI, assessment and re-assessment, and treatment/outcomes to support "chest pain/pressure". We do have some significant issues with our provider impression list, we don't have a data dictionary to define what our provider impressions are (chest pain/pressure should actually be acute coronary syndrome but because of NEMSIS, I believe that can't be changed). We do also encourage the use of check boxes and drop down menus, but the main goal is the narrative since that is what really tells the story.

The project is going well so far... and I'm finding some REAL documentation issues. It's going to be a tremendous undertaking to fix and is going to include everyone to come together to fix. I've been able to create spreadsheets to measure our performance indicators (such as ave. narrative score) and look to expand our performance indicators, but I'm finding it difficult to determine what is a performance indicator worth measuring. The problem is, there is SO much that could be measured, I don't know where to start.

Have you found the scale to be useful or interesting? Have any thoughts or opinions on improvements?

Michael Fraley said:
Marshall, thanks for sharing. One question though. You mention using the scale to grade their "narrative." Does that refer only to the free text paragraphs or does it include any information documented anywhere in the chart? I encourage EMTs to use all the click boxes, pull-downs, procedure & vitals table effectively and then they don't have to put so much in their narratives. This is also what we need to do to get good data in NEMSIS.

How is the project going now that you are a few weeks into it?

Marshall Washick said:
I found this to be a really interesting thread and wanted to share our CQI process. The committee members also rate the narratives on a Likert scale of 1-4 (1 not supporting the providers impression, 4 clearly supporting the provider impression). This scale was also developed between myself and the Medical Director and unfortunately, I'm not doing it justice by summarizing it in here.

); ▶ Reply to This

Permalink Reply by Michael Fraley on May 6, 2009 at 1:23pm: I am finding that many services are still struggling with documenting their good care, specifically using electronic PCRs. Aside from the narrative, it seems like there is still a lot of misuse or under use of the pull-downs, check boxes, etc. Since that is how we (EMS industry) will get good NEMSIS data, I think we need to encourage their proper use.

Some fields are pretty self-explanatory but others are less clear and providers do not always understand what is being asked or even what the various pre-loaded choices mean.

Does anyone have any tools for teaching the use of ePCRs specifically highlighting this stuff?; ▶ Reply to This

Permalink Reply by Kevin Collopy on May 9, 2009 at 11:58am: Michael Fraley said:
I am finding that many services are still struggling with documenting their good care, specifically using electronic PCRs. Aside from the narrative, it seems like there is still a lot of misuse or under use of the pull-downs, check boxes, etc. Since that is how we (EMS industry) will get good NEMSIS data, I think we need to encourage their proper use.

Some fields are pretty self-explanatory but others are less clear and providers do not always understand what is being asked or even what the various pre-loaded choices mean.

Does anyone have any tools for teaching the use of ePCRs specifically highlighting this stuff?

What I have seen is that there is a lack of documenting how patients respond to interventions with the checklist drug administration etc. One option is to encourage the use of the comment box with each interventionn.

Do you see more assessment based documentation problems or intevention based problems?; ▶ Reply to This

Permalink Reply by Camp G on May 11, 2009 at 1:16pm: I've been away from this thread for awhile. There is a lot of very interesting and useful imfo. Thanks for putting attention on such a important area, because it has the effect of improving the quality of care which benefits us all. I hope this one keeps going and going and going.; ▶ Reply to This

Permalink Reply by Kevin Collopy on May 12, 2009 at 5:53am: Camp G said:
I've been away from this thread for awhile. There is a lot of very interesting and useful imfo. Thanks for putting attention on such a important area, because it has the effect of improving the quality of care which benefits us all. I hope this one keeps going and going and going.

Thanks many of us hope so as well. there may be some publications on this topic in the works as well.; ▶ Reply to This

Permalink Reply by Kevin Collopy on May 12, 2009 at 5:54am: Is anyone following this conversation doing new research/studies/other work on areas other than chest pain/sob/codes/trauma?; ▶ Reply to This

Permalink Reply by Michael Fraley on May 16, 2009 at 4:21pm: I agree that documentation of response to interventions is important (and easy.) Not only is it important to the care and follow-up of that particular patient, it will help our industry determine if a drug or procedure works in general.

I would have to say I see a bigger opportunity to use the assessment section better. I think there is a lot of potential to use the assessment diagrams that Image Trends has much better. That is what we are working with my service. There are other issues but that is the biggest opportunity.; ▶ Reply to This

Permalink Reply by Kevin Collopy on June 11, 2009 at 7:30pm: Who out there is working in an organization with or without a dedicated/identified QA/QI director/supervisor?; ▶ Reply to This