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By Tim Burns and Mike Taigman
Back in the early days of EMS quality, it was common for systems to focus on a new clinical topic every month. “It’s pediatric asthma month, so we are going to review 100% of under-18 asthma cases. The CE for this month will be taught by Pediatric Pulmonary Nurse Practitioner Steve from Our Lady of Great Beta Agonist Hospital.”
The schedule for the next 12 months would include head trauma, OB emergencies, anaphylaxis, etc. The topic of the month was usually driven by the list of required CE topics needed to maintain credentials. You know, the number of hours the state required for each topic, rather than the needs of patients in your community, or what your clinical performance data suggests needs attention.
It is possible to design a system that zeros in on your most serious patient-centered, data-driven issues. Montgomery County, Maryland Fire & Rescue Service is changing the way they organize their quality improvement system for better focus and to produce better results. They are taking a systems approach by looking at their workflow from a process perspective and seeking out opportunities to improve the process for better patient outcomes. Each process they have identified has been assigned a “process owner” who is responsible for everything from data analysis, hospital relations, chartering improvement projects, monitoring performance, and reviewing calls in FirstPass.
Q&A with ACS, STEMI process owner
For example, Firefighter-Paramedic Russell Patterson is the process owner for the acute coronary syndrome (ACS) and STEMI processes. We sat down with him to discuss how process ownership works.
EMS1: As a process owner, what are you responsible for?
Patterson: I’m responsible for tracking data, coming up with system changes that improve results, and tracking and trending system changes.
All our ePCR reports are fed through FirstPass and they are passed if a patient receives the entire bundle of care we expect, or it’s flagged if there’s something off. I review all of the flagged ACS or STEMI calls, without providing feedback to the crews – looking for ways our process is not performing the way we would expect and looking for opportunities to either improve the process or improve the workflow within the process.
This process approach allows us to focus on the organization’s performance rather than zeroing in on individuals, which we have found is much better received internally and produces results for the entire group of patients who will undergo the process in the future.
How do hospitals fit into your world as a process owner?
Patterson: I attend the monthly STEMI Committee meetings at each of the four cardiac intervention center hospitals in Montgomery County. I’ve learned a lot about what happens after we drop patients off at the hospital. They have helped me see what we can do to help them speed up their parts of the patient care process in the emergency department and in the cath lab.
Before I started going to these meetings, I assumed that when we sent them a 12-lead and told them that it’s a STEMI, that their team gets activated. I’ve learned that there are several more steps that happen before the team is called and the cath lab is prepped.
The hospital staff seems to like having a clinician assigned to field operations sitting across from them in their meetings rather than a higher-ranking administrator who may not have seen the inside of a transport unit in years. They can air a complaint about what we did, and we can talk it through on the spot. I enjoy sharing the reality of field care with them and opening their eyes to what happens with their patients before they get them.
My only challenge is that with shift work, it is sometimes difficult to make the meetings. If I can’t go, the full time QI officer will go in my place and send me the notes.
What improvement opportunities have you identified so far?
Patterson: Our big focus right now is to improve the percentage of calls that successfully meet our entire bundle of care for ACS. Our current performance shows that only about half of our ACS patients get the full bundle of care, which is simply EKG within 10-minutes of first arriving asset, transmission of the EKG and administration of Aspirin.
Our goal is to make this improvement with the lightest touch possible from the quality improvement division. We could have me visit all 40 of our stations on all three shifts to talk about the importance of getting a quick 12-lead, transmitting it quickly, making sure that patients with cardiac chest pain get an aspirin. That would be an expensive way to do it and there is a good chance that it would not produce meaningful change.
So, what are you going to try instead?
Patterson: We are currently engaged in a small test of change as part of this chartered improvement project. It involves a plan, do, study, act (PDSA) cycle of using orange stickers placed on our cardiac monitors. These are intended to prompt 12-lead transmission and administration of aspirin.
We are tracking the FirstPass score for the overall ACS bundle, the 12-lead within 10 minutes, the 12-lead transmission, and aspirin administration for our small experimental group. The learning from this test will drive what we do next.
How have your peers reacted to this process owner program?
Patterson: I think that the firefighter medics like myself like this concept. Historically, they didn’t like it when a captain sent them an email about what they did or did not do. Even though our QI process is non-punitive, many people took it that way. Most of our individual crew contact these days is complements on catching a difficult diagnosis or going above and beyond for a patient.
Reviewing your QI system structure
Montgomery County, Maryland Fire & Rescue Service believes that this process owner system is a good way to develop young frontline medics to become future leaders. They learn improvement science, data analysis, project management, hospital relations and more. They gain a perspective on the larger healthcare system that’s not easily available to frontline folks.
The EMS system gains constant reviews of flagged calls. The process owners are reading and staying current on the scientific literature associated with their area. Having a go-to internal expert for questions, complaints, research opportunities, improvement ideas and innovation is helpful.
In addition to Patterson, who owns ACS/STEMI process, they have process owners for medical cardiac arrest, stroke, ALS to BLS downgrades (in a tiered system) and patient care recordation and data collection. This last one is focused on patient care records management. It involves everything from computer hardware, user interface, validation rules, state requirements and local rules.
Maybe it’s time to re-examine how your QI system is structured?
About the author
Captain Tim Burns is the emergency medical and integrated health services quality improvement officer for the Montgomery County Fire and Rescue Service. He has worked for MCFRS since 1997 and holds undergraduate and graduate degrees from the University of Maryland Baltimore County in Emergency Health Services. He can be reached at tim.burns@montgomerycountymd.gov.
