7 signs your agency's QA program is a dysfunctional mess

Does your agency's quality assurance program practice the principles of Just Culture and learn from errors to influence improvement?

By Brian Behn, BA, NR-P, FP-C

The goal of an EMS quality assurance program should be increasing safety, satisfaction and outcomes for both EMS providers and patients.

Unfortunately, many EMS QA programs are not healthy, but are instead a dysfunctional mess. Here are seven signs your EMS QA program needs work:

If the main objectives of a QA department are performing error patrol and protocol enforcement, you are missing the forest for the trees.
If the main objectives of a QA department are performing error patrol and protocol enforcement, you are missing the forest for the trees. (Photo/Vermont Department of Health)

1. Providers conceal errors

In a healthy EMS QA program, providers report errors and near misses without fear of repercussions. Self-reporting leads to marked increases in the number of opportunities for improvement in the agency and is an essential practice for any agency interested in improving safety and outcomes.

In the dysfunctional QA program, providers rarely, if ever, self-report errors; it is only when the QA department finds errors that they are brought to light. This is not a symptom of bad providers; this is a symptom of a bad EMS QA program.

2. The QA department works in a silo

Does the QA program communicate with the training department? Do they work together to find areas in the agency that can be improved upon or does the QA program exist in a silo, entirely separate from the training program?

A healthy EMS QA program must work hand in hand with the training department identifying areas for the service to improve upon. When the EMS training department and QA department work together, they can close the loop and determine if improvement is occurring in the agency.

3. What happens to a provider who makes a mistake “depends”

Providers should not have to wonder what is going to happen to them when they make an error at work, they should know well in advance exactly what the policy is.

The dysfunctional EMS QA program does not have a clear guideline for dealing with errors and it is left up to the whim of the reviewer, and can be influenced by personal preferences, egos and biases.

The opposite of this can be found in an agency with a healthy QA program where all providers understand the QA department practices the principles of Just Culture.

At a minimum, each provider in the agency understands that honest mistakes will not receive punitive action and no one will think less of them as a provider for making a mistake. While there may be an investigation into the issue and re-education or remediation is a possible outcome, it is understood that this is not punitive.

4. The QA department looks for who is to blame instead of what is to blame

Medicine has a long history of dealing with errors by using the policy of “name you, blame you, shame you.” In almost all medical errors, assigning blame is a worthless task that accomplishes nothing in preventing reoccurrence.

A healthy EMS QA department understands that human error is a starting point in an investigation, not an end point.

Only by looking at the complete picture of the entire system – which often involves components of the system such as equipment, training, and the overall culture – can the conditions that led to the error occurring be remedied.

Shifting from a person-centered approach to viewing human error as a symptom of a larger issue is at the heart of the Just Culture movement.

5. Errors do not lead to changes in the agency

Errors should lead to exploration, which, in turn, should lead to changes in the agency. A dysfunctional EMS QA program encounters errors, and distributes punishments and blame as needed with the belief that disciplinary action will act as a deterrent to future errors. This does not work.

When an error occurs, it is an opportunity for learning and for change. Sharing the lessons learned could be in the form of a newsletter, an M&M style forum or training.

In some cases, the providers involved with the error are able to and should present the material and mentor others.

6. Errors are viewed with an outcome bias

When an error occurs, does your agency need to know the outcome in order to know how to proceed? When performing QA, it is easy to fall in to the trap of viewing errors through the lens an outcome bias and using outcomes as measures of recourse.

Unfortunately, an agency that grades the severity of the error based on the patient’s outcome is doing little more than relying on chance as a measuring tool.

The notion of “no-harm, no-foul” has no place in a healthy EMS QA program. The difference between a near miss and a poor outcome often amounts to luck.

7. The QA department is only reactive, not proactive

Quality improvement should be inseparable from quality assurance. While some would argue that the differing terms amount to nothing more than semantics, quality assurance is performed retrospectively – looking at the care that was rendered, where quality improvement is a forward-facing process and looks to improve the care future patients will receive.

The healthy EMS QA department is not mired in only investigating errors and reading charts; it is actively involved in developing improvement projects for the agency. The QA department should be using the plan-do-study-act cycle to test out changes in an agency, developing protocols and engaging with internal and external stakeholders to look for unfulfilled needs.

If the main objectives of a QA department are performing error patrol and protocol enforcement, you are missing the forest for the trees.

About the author
Brian Behn lives in central Colorado, where he works for Chaffee County EMS as a paramedic and a quality assurance officer. He is a member of the NEMSMA Quality Improvement committee. He can be reached at behnbrian@yahoo.com.

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