By Guillermo Fuentes
Quality improvement for EMS has its roots in a quality management movement that dates back at least more than a century, when Fredrick Taylor published “The Principles of Scientific Management.” Since then, a three-step process has defined quality management in all industries. The three steps of quality improvement involve defining:
- What you want to measure,
- How to measure it (the metric by which we want to measure the what), and
- Who you are measuring — the individual (or individuals), the system or product.
A goal can be established, and if it is not met, corrective measures can be taken. And then the process starts again. This process is linear, defined by an “if-then” statement.
So, why has this time-tested process eroded? Why does it cause so much dissatisfaction with EMS caregivers?
Two distinct factors played a role: goal displacement and the introduction of millennials into the workplace. As consultants that evaluate systems, we frequently come across goal displacement: when the focus of the organization becomes the number, not the outcome.
Recently, we worked with a major dispatch center that had a goal of answering the phone within 10 seconds 90 percent of the time, measured hourly. This center often achieved this goal 23 hours of the day, but if it didn’t for just one hour, the day was deemed a failure and corrective actions were taken. They needed to ask themselves: Is that the intent of the metric? Does that improve service to the citizens?
Millennials, the second phenomenon, are equally important. This group, which is already the largest cohort in the U.S. workforce, has unknowingly forced policymakers to question the relevance of their decisions. QI was designed to determine what was happening? But the millennials started asking “why?”
For example, if an EMS system has a process to ensure that it achieves a response time of no more than 8 minutes and 59 seconds, what happens when a millennial EMS provider asks, “Is 8:59 relevant?”
As an EMS leader, we can’t simply answer yes. Instead, we need to explain it in the context of improved clinical outcomes or customer service.
Make QI relevant and meaningful
Today, many of the legacy business practices and operations follow the three steps of the what, the how and to whom it should be applied. But that can lead to employee dissatisfaction because the “why” is unclear.
So, what can we do about it? Should leaders discard the concept of QI? Of course not. But we do have to review two key concepts.
The first is organizational coherency. The modern organization is forced to have organizational coherency if it wants to withstand the millennials asking “why?” Organizational coherency starts with guiding objectives that carry through to every decision and policy that then become the “what” that the organization wants to measure. For example, a sales team has the objective of increasing sales. All policies and directives have to be measured against that objective and if a policy or a directive impedes sales then it would constitute an organizational incoherency. This will encourage organizations to reduce the number of objectives and force a healthy debate of “what” they can achieve.
The second is autonomy of purpose, a concept coined by Daniel Pink in his book “Drive: The Surprising Truth About What Motivates Us.” In simple transactional issues, Pink wrote, simple measures work.
For example, intubation is a transactional skill wherein the paramedic either did or didn’t intubate. If they don’t do it to a sufficient level, then training is required. This may still be challenged at the “why” level if you can’t prove outcome improvement from intubation and your objective is to save lives, but it will pass the simple “if-then” QA process.
But on complex issues such as hospital offload delays, simple measures won’t work. We often see organizations start with a goal for hospital turnaround time — such as 20 minutes 90 percent of the time — and if this fails, they become more granular: five minutes to talk to a triage nurse, 10 minutes for paperwork and so on. The measurement process goes from bad to worse. Too many variables, too many exceptions — simple QI measures will not work.
Instead, in these cases, EMS system leaders must raise the level of measurement. For one organization with an offload delay problem, the solution was to institute a program that measures employees’ by the number of calls they run and the time they spend on tasks — a metric that includes time in hospital but does not focus on it. The employees who are the top performers (most calls and shortest time on task) are rewarded with perks such as first choice when assigning shifts and schedules. Since it is autonomous, employees must figure out how to reduce their time on task in order to run one more call that shift and reap any associated benefits.
Modern QI, and its implementation by EMS leaders, has to recognize the two concepts of organization coherency and autonomy of purpose if it wants to continue to survive into the next generation of employees.
About the author
Guillermo Fuentes, MBA, is a partner at Fitch & Associates. He has management oversight of two major EMS programs and also supervises statistical and operational analysis, computer modeling and the development of deployment plans as well as major technology purchases and communications center installations for clients. He previously served as the Chief Administrative Officer of the Niagara Regional Police Agency, in Ontario, Canada, and Associate Director of EMS for the Niagara Region.
