Quality Improvement (QI) is the intentional process of making system-level changes in clinical processes with a continuous reassessment to improve the delivery of a product. In Emergency Medical Services, this product is essentially the delivery of high-quality prehospital care. This differs from quality assurance, which is more consistent with protocol, process, or policy compliance. Quality improvement programs typically work best in an environment that implements change through a robust, non-punitive education program. Effective QI programs are transparent; both administration and clinical staff understand the goals and methods of any ongoing quality improvement project. Quality improvement programs often use Key Performance Indicators (KPIs) to measure ongoing clinical performance, identify areas for improvement, and assess the impact of process changes. EMS systems should build their KPIs on clinical evidence, a perceived system deficit, or an operational need. The goal of QI is to develop a high-reliability organization that operates in a relatively error-free state over a long period of time. Quality Improvement in EMS Quality improvement practices vary significantly among EMS agencies across the United States; however, a survey of EMS agencies nationwide in 2015 revealed that 71% of agencies surveyed report having dedicated quality improvement personnel . Examples of quality improvement projects include improving prehospital aspirin administration rates in patients with acute coronary syndromes, improving paramedic identification of STEMI, and decreasing peri-intubation hypoxia, among others. Developing EMS systems have also successfully implemented continuous QI programs to specifically address pre-hospital trauma care, with significant improvement in pre-specified KPIs following targeted education. Each of these projects began with identifying the need for improvement. They developed a plan that included a process change and a means for assessing the impact of that change. When developing a plan, consider three questions prior to choosing key performance indicators, and implementing any process improvement project or particular system. What is the aim? How and what should be measured? What changes should be made to improve the process/system/outcome? The aim should be very specific, evidence-based, and focus on patient-centric outcomes. Measurements and goals are also best if defined with a patient-centric focus, specific, and numeric. Changes to be made rely on making a prediction regarding a system or process change that will result in achieving the previously defined aim .Many EMS organizations elect to use the Institute of Healthcare Improvement Model of improvement: the Plan-Do-Study-Act (PDSA) cycle. Effective PDSA cycles should be organized with staff involved in all aspects of the process being improved. For example, a PDSA cycle with an aim to improve cardiac arrest survival should include field paramedics as well as staff from the medical director's office, administration, and logistics personnel. Plan-Do-Study-Act Cycle PlanThe purpose of the “plan step” is to clearly and concisely define the objective of the project and align with the aim and measurement statements as previously defined. This step should also brainstorm solutions, pick one solution to try, and generate a plan to test and implement the proposed solution. The QI committee should define the problem using as much objective data as possible. The committee should be clear about how they will measure both the extent of the problem and how they will determine if their change is an improvement. For example, if a system is attempting to improve aspirin administration rates, a successful change could be “aspirin administration is documented in 95% of patient encounters with a chief complaint of chest pain.” The “plan” step also includes brainstorming potential solutions to answer the question “what intervention will lead to improvement?” After the selection of a specific intervention, such as employee education, a plan for reevaluation must be outlined as well. The plan should answer several questions, including “What is the problem?" “What is the intervention?” “How will we measure the problem, the change, and the outcome?” and “How do we know a change is an improvement?”DoThis is perhaps the least complex, but often the most difficult step to accomplish. Once a plan is made, the "Do" step is simply executing the plan. Pick a specific day in the immediate future to implement the plan. Instead of immediately implementing the plan across the entire system, first, perform a small trial of the change. This small step, known as a "test of change" allows the team to see if their change has the desired effect. Often, this small test identifies unexpected areas that should be addressed before the wider implementation of the change. For example, if the change being tested is a checklist to improve intubation success, the checklist could be developed and trialed with one shift at a single ambulance station before deploying it for an entire system.StudyThe purpose of the “study” step is to determine if the plan that was designed and implemented caused a change that was an improvement. This should reflect the aim defined in the “plan” step. During the “study” phase, participants in the project should also look for any unintended outcomes. The team should discuss what aspects of the plan were functional and what parts of the plan did not work as intended. The objective data necessary to evaluate change and improvement should be collected as defined in the “plan” step . For the above intubation checklist example, this step could include evaluating success rates of intubations before and after the checklist, compliance with the use of the checklist. The QI committee or staff should also get feedback on the checklist itself from the end-user. Other data, such as time on-scene, cardiac arrest rates, or other data that may be impacted by a change in intubation practices should be considered in this step as well. The most common tool for measuring the effects of these tests of change is the process control chart. These charts plot the proportion of cases that met the definition of success over time. They also include a marker demonstrating the point in time at which the change was implemented.ActThe “Act” step is designed to take action on items found in the “study” step. The process change will either be deployed system-wide or readjusted prior to institution. Deployment is dependent on the results of the “study” phase, after determining if the change resulted in the desired outcome [12]. Following the prior example, this might include improving an airway checklist based on the feedback provided by end-users or providing additional training. Once the “Act” step is complete, the cycle begins again with planning: re-deploy an improved checklist, evaluate success rates, deploy the idea to an entire system, or receive additional feedback.This PDSA cycle is continued in an iterative process until the desired improvement is achieved. Key Components of Quality Improvement Program Non-Punitive CultureA QI program must use a non-punitive approach. A “Just Culture” strategy is a common example of this approach. Just culture is an organizational method that emphasizes the accountability of both the individual and the organization in the prevention of errors and improvement . Just culture also acknowledges that errors are often caused by a combination of factors, including system factors. In a “just culture” the organization must be responsible for improving the system and processes that providers are working in, while also ensuring the providers are responsible for safe choices. It considers “near misses” to be as significant as actual errors. A just culture approach encourages self-reporting of both near-misses and actual errors by promoting education rather than punishment. Providers who come forward with a report should be able to remain anonymous, be included in a closed-loop synopsis of events, and be praised for reporting . It promotes accountability for one’s actions and education, an intolerance of ignorance, and a desire to improve the system for improved safety and outcomes constantly.EducationMany quality improvement projects, especially clinical quality improvement projects, will require education of some form to propagate the information regarding the intervention. An individual or team with an educational focus is likely to be beneficial in achieving the desired improvement outcomes.Team-Based ApproachA quality improvement project should involve representatives from any part of an organization that may be affected by the changes as a part or result of an improvement project. Additionally, involving individuals with many perspectives will increase the pool of unique ideas. The more ideas, the more likely the group is to find a successful change. The culture of the organization must foster belief in QI programs at the highest levels to encourage change (CEO, supervisors, etc.) .Clear AimsThe QI committee must select aims that are well defined and evidence-based. The timeline for action and PDSA changes must be outlined as well. The data to be measured must be appropriate for the defined aim.

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