EMS Quality Improvement - National, State,

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EMS Quality Improvement - National, State,
Local Indicators

• John New, Director of MIEMSS Quality Management
• Prepared For QA Officer Training Day 2,
  Session 3 1030 to 1200

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Todays Objectives

• Creating an Indicator Friendly Environment
• Understanding an Indicators Purpose(es)
• Review National, State, Local Indicators

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Something To Consider

• People seldom improve when they have no other
  model but themselves to copy after.
• Oliver Goldsmith, Irish Author -1758

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The Indicator Threat

• Evaluate Good Neighbor
• Establish Indicators
• Return trash cans 1 hr. after pickup
• Height of grass never exceeds 4 inches
• Recognition of your familys birthdays
• Annual Report Time

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Indicator Focus Areas

• Sign of an organizations
• Strength
• Weakness
• Opportunity
• Threat (Vulnerability)

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Horse and Cart Order

• What Organizations struggle with
• Quality Drives Indicators
• Vs.
• Indicators Drive Quality

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Blended Results

• Chrysler Building (77 story) (405 Lexington Ave.
  NY, NY)
• Safety Baseline - 1 death per story above the
  15th story - expected 62 deaths.
• Construction Mortality 0
• Adoption/adherence to professional safety
  standards

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Characteristics of Quality Organizations
Total Quality
Customer Focus Satisfaction
Total Involvement
Measurement
Process Management
Continual Improvement
Leadership
EMS System Results
Organizational Mission, Vision, Principles
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Quality Culture

• Authoritarian Participation
• Status Quo Continuous
  Improvement
• A Few Statistical All Trained in Experts
  Basic Tools
• Focus on Job Focus on
  Customers
• Beat on Suppliers In Partnership
  with
  Suppliers

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Dr. Basss 5 Cs

• Consensus
• Coordination
• Cooperation
• Confidentiality
• Communication

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Developing Quality Indicators

• In order to clearly determine if we are
• doing a quality job,
• improving our performance, or
• satisfying our customers,
• We must develop and use measurable meaningful
  quality indicators

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Developing Meaningful Indicators

• Indicators are used for several reasons

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Developing Meaningful Indicators

• Indicators are used for several reasons
• They help to determine the performance baseline
• by establishing What is the current performance
• They help to determine the relationship to
  standards
• by determining What is needed

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Developing Meaningful Indicators

• They help in setting goals objectives
• by determining What is wanted possible
• They alert us to problems
• by providing clear information

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Indicators and Our Daily Work

• Our work can be divided into three very large
  general areas
• Things that need to be fixed,
• Things that need to be maintained (kept fixed)
• Things that need to be improved.

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OK LEVEL
Problem Solving
1
Fix It
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Standard Setting
2
OK LEVEL STANDARD
1
18
3
Improve It
Goal/Objective Development
Prevent It
2
OK LEVEL
1
Fix It
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3
What is wanted
What is Needed
2
STANDARD
Baseline
What it is
1
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3
2
STANDARD
Indicators
1
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Quality Improvement Framework
TOOLS A recognized tool to facilitate the QI
process is the FOCUS-PDCA cycle F Find a
process to improve. O Organize an effort to
work on improvement. C Clarify current
knowledge of the process. U Understand process
variation and capability. S Select a strategy
for further improvement.
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Quality Improvement Framework
P Plan a change or test aimed at improvement. D
Do - carry out the change or the test. C Check
the results, what was learned, what went
wrong. A Act - adopt the change, or abandon
it, or run through the cycle again.
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QI Indicator Consideration

• Selection of jurisdictional indicators
• High volume
• High risk, low volume
• Benchmark standards
• Provider interest

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Characteristics of Good Performance

• When you think of good performance what
  characteristics or traits come to mind?

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Good Performance

• Timely
• Accurate
• Productive
• Good Service
• Cost Effective
• Customers Satisfied

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4
5
2
6
1
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The HOW Technique

• Indicators are essentially developed by taking
  the how question and applying it to one or more
  of the characteristics of good performance
• By using the how technique we can ask these
  questions
• How many? How costly?
• How accurate? How courteous/friendly?
• How timely? How thorough?
• How satisfied is the customer?

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National - NFPA 1710
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National - NFPA 1710
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National - NFPA 1710
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National - NFPA 1710
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National - NFPA 1710
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2005 National Consensus Meeting on EMS Clinical
Performance Indicators

• http//emsoutcomes.ncemsi.org/
• http//www.nasemsd.org/Projects/PerformanceMeasure
  s/
• Objectives
• Simple consider as EMS Starter Kit
• For Everyone target least common denominator
• Ease Use NEMSIS set
• Useful to local, regeonal, state, national
  levels

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2005 National Consensus Meeting on EMS Clinical
Performance Indicators

• Time
• Symptom onset to 911 access
• Respiratory
• patients requiring support who got it
• Time taken to provide support
• Accuracy
• PCR
• Needed ALS got it
• BLS time to defibrillation

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2006 EMS Performance Measures Project Steering
Committee

• Standardized format
• 18 question areas
• 35 indicators or attributes
• 7 performance categories
• System Design and Structure
• Human Resources (culture, training, safety,
  credentialing)
• Clinical Care and Outcome
• Response
• Finance/Funding
• Quality Management
• Community Demographics

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2006 EMS Performance Measures Project Steering
Committee

• Emergency Medical Dispatch
• Emergency Medical Dispatch Impact on Response
• Emergency Medical Dispatch Impact on Response
• Annual Turnover Rate
• Defibrillation Time Mean, 90 th Percentile
• Initial Rhythm Analysis Time Mean, 90th
  Percentile
• Major Trauma Triage to Trauma Center
• Pain Rates - Relief, Worsened, Unchanged
• Pain Intervention Rate
• 12 Lead Performance Rate
• Aspirin Administration for Chest Pain/Discomfort
• Cardiac Ischemia Triage to Specialty Center
• Emergency Patient Response Interval Mean, 90th
  Percentile
• Emergency Scene Interval Mean, 90th Percentile
• Emergency Transport Interval Mean, 90th
  Percentile

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2006 EMS Performance Measures Project Steering
Committee

• Per Capita Agency Operating Expense
• Patient Care Satisfaction Rate
• Appropriate Oxygen Use Rate
• Undetected Esophageal Intubation Rate
• Delay Causing Crash Rate per 1,000 EMS Responses
• EMS Crash Rate per 100,000 Fleet Miles
• Crash Injury Rate per 100,000 Fleet Miles
• Crash Death Rate per 100,000 Fleet Miles
• Call Complaint Distribution
• Call Complaint Rate
• EMS Cardiac Arrest Survival Rate to ED Discharge
• EMS Cardiac Arrest Survival Rate to Hospital
  Discharge

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Six Sigma EMS

• Data driven management very statistical
• Motorola 3.4 defective parts per million
• High accountability
• DMAIC
• Define
• Measure
• Analyze
• Improve
• Control

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Quality Improvement Initiatives

• Examples of jurisdictional indicators
• ICAM/PEIP
• First responder training
• Patient needs
• Intubation success rates
• Data completeness
• On-scene times
• Outcome linkage

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Quality Improvement Initiatives

• PCR information linked to Hospital ED/Discharge
  information
• Workgroup to examine
• Current rates of completeness
• Best EMS/Hospital practices
• Impact of Electronic PCR use
• Future of Patient Tracking (triage tag)

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Managing For Results An EMS Road Map for QI

• Measurement of Program Performance Continually
  assess program performance to improve quality and
  effectiveness of services.
• Inputs
• Outputs
• Efficiency
• Quality
• Outcome

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Performance Model for MovingMaryland Forward
Customer
Human Resources
CUSTOMER
Customer
Q
Leadership
Guiding Principles
Goals
Objectives
Process
Results
Vision
Mission
Customer

FOCUS
Strategic Planning
Customer
Information Analysis
Customer Feedback Learning
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Managing For Results An EMS Road Map for QI

• Definition Governors phased-in initiative to
  assure a connection between the budget for State
  services and desired results from those services.

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Managing For Results An EMS Road Map for QI

• Phase I. - Strategic Planning Set direction to
  achieve desired results over time.
• Internal/External Assessment (SWOT)
• Reflects customer and stakeholder needs - EMS
  Plan 94, 00, 02
• EMS Agenda for the Future
• Reflected in Mission, Vision, Goals, Objectives,
  and Performance Measures

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Managing For Results An EMS Road Map for QI
(Continued)

• Phase II. - Measurement of Program Performance
  Continually assess program performance to improve
  quality and effectiveness of services.
• Inputs ?
• Outputs ?
• Efficiency ? How well did we use our resources
• Quality ? How well did we meet the expectations
  of our customers?
• Outcome ? What results did we achieve?

Traditional Government Indicators
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MIEMSS MFR Key Components

• 2 Goals
• Provide High Quality Medical Care to Individuals
  Receiving Emergency Medical Services
• Maintain a Well-Functioning EMS System
• 6 Objectives
• 6 Performance Measurements
• 2 Outcome
• 4 Quality

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Outcome 1

• Goal Provide High Quality Medical Care
• Target Trauma Patient (FY 2000)
• Objective Maintain gt 95 statistical level of
  confidence that Maryland performs above the
  national norm.
• Source Data Maryland Trauma Registry
• Tools TRISS analysis, MTOS, Z score statistic
• Actions Monitor outcome quarterly (Trauma QIC)

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Outcome 2

• Goal Provide High Quality Medical Care
• Target Critically Injured Patient (FY 2007)
• Objective Reduce the overall inpatient
  complication rate by 10 or greater in Maryland
  trauma centers.
• Tools MTR Complication Report ( ICD-9-CM / ACS
  )
• Actions Utilize new Outcomes software to
  identify cases and present/follow at monthly M
  M meetings and Trauma QIC
• Source Data Maryland Trauma Registry

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Quality 1

• Goal Maintain a Well-Functioning EMS System
• Target Patients receiving EMS services (FY 2004)
  
• Objective Establish Baseline for 100
• jurisdictions gt 99 protocol compliance.
• Source Data Jurisdictional MRC Reports
• Tools Standardized reporting means
  (form/database)
• Actions Implement reporting process

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Quality 2

• Goal Maintain a Well-Functioning EMS System
• Target EMS Providers (FY 2000)
• Objective Maintain a 90 successful completion
  rate statewide for EMS radio communications with
  base stations.
• Source Data MAIS
• Tools EMS Cummunications Master Plan
• Actions Proceed with communication upgrades
• Continue to monitor

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Quality 3

• Goal Maintain a Well-Functioning EMS System
• Target Trauma patient population (FY 2001)
• Objective Maintain an 85 triage rate of
  seriously injured patients transported to a
  designated trauma center.
• Source Data MAIS
• Tools American College of Surgeons on Trauma
  
• Actions Continue to monitor

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Quality 4

• Goal Maintain a Well-Functioning EMS System
• Target Prehospital patient population (FY 2007)
  
• Objective Have two-thirds of the jurisdictions
  utilizing EMAIS.
• Source Data EMAIS
• Tools EMAIS Software, Educational curriculum,
  report functions
• Actions Education EMS community on virtues.
  Continue enhancements

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Where Are We Today?MFR FY 06 System Report Card
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Checking The National QI Pulse

• National EMS Managers Association
• NEMSMA.org EMSMA_at_yahoogroups.com
• CY 2004 CY2005 CY2006
• Capnography ALS Effectiveness Attendance
• Staffing HIPAA Control Sub. Sec.
• ALS Billing E vs P Report EMT Dumb Down
• Definition Standards Benchmarking Auto Pulse
• Whos in Charge CPAP Psyche Transfers
• EMT-P Coverage Various requests Nasal
  Intubation

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Conclusion

• Questions
• Comments
• Thank You!

Department of Quality Management