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Bringing EMS quality improvement front and center

Improvement science expert Dr. Dave Williams highlights why not all actions are created equal when trying to implement improvement science practices within EMS


Dr. Williams, an internationally renowned improvement science expert as well as a self-described “recovering paramedic,” discussed quality improvement and patient safety during his keynote address at the 2020 NAEMSP Annual Meeting.

AP Photo/Don Ryan

SAN DIEGO — The 2020 National Association of EMS Physicians (NAEMSP) Annual Meeting started off with a keynote address by Dr. Dave Williams.

Dr. Williams, an internationally renowned improvement science expert as well as a self-described “recovering paramedic,” set the stage for a conference that highlighted quality improvement and patient safety throughout the three-day program.

Dr. Williams began his talk by reminding the crowd of the Martin Scorsese classic “Bringing Out the Dead,” starring Nicolas Cage as a burned-out paramedic in New York City.

While many of his colleagues found the portrayal of EMS disturbing, Dr. Williams felt the opposite, heavily identifying with many of the major themes in both the book and movie as they related to the high levels of variation across the industry.

Dr. Williams highlighted the international reception of the Institute of Healthcare Improvement’s Triple Aim which focuses on three dimensions: improving the patient experience of care, improving the health of populations, and reducing per capita cost. He pointed out that while EMS is happy to discuss the Triple Aim, there is little evidence of “what good looks like” within our industry – something that is easily shown by the wide variation in cardiac arrest survival across different communities.

After setting the stage with the basics of why quality improvement matters, Dr. Williams invited Nikki Little, quality and patient safety officer with Winnipeg Fire Paramedic Service; Brooke Burton, division chief for quality for Falk in Alameda County, California; and Dr. Ian Medero, the medical director of Albuquerque Ambulance Service to join him at the podium.

All three had participated in NAEMSP’s Year Long quality and safety course in the past few years, so Dr. Williams used their individual journeys to act as perfect examples of just how messy quality improvement really is. He didn’t focus on the actual change his co-panelists were trying to create, but rather walked through the process of going from idea to action to (hopefully) change.

Dr. Williams finished the keynote by asking what one thing from the course had changed the way each of the three think about quality improvement.

Little was most impressed by how impactful examining data over time could be to operations and clinical efforts.

Burton reminded the crowd that you learn as much from failure as you do success and that change often happens incrementally.

Dr. Medero was struck by the difference between quality improvement and quality assurance and the role each plays in an overall system of quality management.

Memorable quotes on quality improvement

Here are some memorable quotes from Dr. Williams that stood out.

“The system that we have can be influenced by the things that we do.”

“If you don’t like the results that you get, you have to change the system to produce a different set of results.”

“One of the reactions, whenever you’re confronted with data that doesn’t match your personal experience or how you’re feeling, is to want to question the data or resist what it says.”

“The difference between those that are making an impact, and those that are not, is the focus of attention on the results.”

“It’s very common to find people doing activities, but it doesn’t change the results for patients.”

“We all know there’s a gap between where we are today and the opportunity we have for patients and communities; we know there must be an opportunity to do better.”

Key takeaways on EMS quality improvement

Here are the top takeaways from the NAEMSP keynote address.

1. Every system is perfectly designed to get the results that it gets

One of Dr. Williams’ biggest points was that in order to change the outcomes of a given process, you must first change the structure. This point, originally championed by Donabedian, recognizes that the biggest driver to outcomes is the structure of a system. Processes will naturally revert back to their former flow if the corresponding structure of a system isn’t changed which is while re-education interventions rarely work in the long term.

2. Not all action is created equal

Organizations that continuously show improvement aren’t just doing something to do it, they are relentlessly pursuing better results. They think critically about what changes could be instituted to lead to definitive improvements and recognize that it’s an iterative process. They know that improvements happen 1% at a time.

3. Improvement is messy

If it were easy, everyone would be doing it. Quality improvement is not a one and done effort. It is not a flashy new technology or a nifty gadget that somehow does a preexisting process better than before. Quality improvement is only successful when practitioners get in the weeds of the data, the processes and the organizational structure.

4. NAEMSP is committed to the growing focus of quality improvement within EMS

Whether it’s their yearlong course, their preconference, or the growing number of sessions within the annual meeting that highlight the constructs of quality and patient safety, it’s nice to see a national organization recognize how important these ideals are to moving our industry forward.

Additional quality improvement resources

Learn more about quality improvement with these resources from EMS1:

Catherine R. Counts, PHD, MHA, is a health services researcher with Seattle Medic One in the Division of Emergency Medicine at the University of Washington School of Medicine. She received both her PhD and MHA from Tulane University School of Public Health and Tropical Medicine.

Dr. Counts has research interests in domestic healthcare policy, quality, patient safety, organizational theory and culture, and pre-hospital emergency medicine. She is a member of the National Association of EMS Physicians and AcademyHealth. In her free time she trains Bruno, her USAR canine.

Connect with her on Twitter, Facebook, or her website, or reach out via email at