QA and QI—The Same Thing, Right?

One of your responsibilities as an EMS supervisor is to review electronic patient care reports at the end of each shift. It is often rather mundane, but reading many narratives can occasionally be an entertaining task. You are satisfied that compliance is high with items such as performing 12 leads, monitoring end-tidal carbon dioxide, and administering aspirin to suspected cardiac chest pain patients. When later reviewing monthly statistics, however, you notice a trend. It appears that several patients who were later diagnosed with acute coronary syndrome (ACS) had not received aspirin.

You speak with the EMS chief and find out that this trend occurs to some extent on all shifts and requires further investigation. A widespread problem is systemic and requires action. A simple but overlooked fact is discovered; your guidelines address care for chest pain but do not mention ACS with an atypical presentation that is often experienced by elderly, female and diabetic patients. Compliance with existing guidelines is good but improvement is needed.

The subworld of EMS has engaged in some form of quality assurance (QA) for decades. While early methods may have been less formal or structured, most agencies of the last half-century employed some sort of “chart review” to help ensure that providers were performing and recording in an appropriate manner. Over time, this evolved into a more formalized process, especially as advanced life support care proliferated. There became a need for a medical director to ensure that the care given under their license was properly delivered. In short, QA is used to verify compliance with existing standards of the agency and profession.

As our profession became increasingly more sophisticated, and more treatment modalities developed, that basic need grew into a desire for improvement. Quality improvement (QI) refers to the process that is used to make things better. If QA was our only goal, progress would be limited. For most agencies, this process is actually used on a continuous basis (CQI). It is important to do this with an eye on the future.

At one time, I was performing both the QI and EMS training functions for an agency. This was a perfect match of responsibilities that should ideally work together in any agency. Many times, a department will decide on a training schedule based on what has not been done for a while or what somebody thought might be appropriate at the time. While some of the basics, such as BLS and advanced airway care, should be repeated on a regular basis, other topics should ideally be identified based on need. While individual reports, or at least some portion of them, are often reviewed, there should be a mechanism for noting overall trends of care, both positive and negative.

Reviews may identify individual problems that should be narrowed as to their origin. At times, QA might identify one provider who missed the mark. Identification of whether the problem was deliberate or unintentional points to the required remediation. A blatant deviation error might require discipline while an unintentional one may be resolved through counseling. There is also a larger opportunity to identify an area that needs training or retraining.

Paramedic training and scope of practice has expanded greatly since the early days of a handful of drugs and procedures; this was also an era when a cardiac arrest required two amps of sodium bicarbonate and one dose of epinephrine prior to defibrillation of ventricular fibrillation. It would be bad to assume that a person who became certified over the decades since learned the entire curriculum well. Whether the lesson did not click or was perhaps taught by someone who did not understand it well, there are times when care might fall short.

When one individual misses the mark, retraining is easily directed. A more global issue exists when several providers make the same errors. That is where the need for agency-wide training is identified. An example of this arose from a few missed STEMI patients. Many providers remembered that the monitor they used would automatically print a record of sustained ST elevation. What was not clearly conveyed, however, was that two and one-half minutes of continual elevation was required to trigger the printer. While individual results may vary, ECG changes may be transient and either develop or disappear in up to a quarter of cases, often within that amount of time. This became an opportunity for educating all providers of that fact and increasing awareness of the need for vigilance.

QA and QI may share quality as part of their names, but refer to different processes. Put briefly, QA helps to ensure compliance with existing standards (what is being done today) while QI aims toward future evolution and improvement (what could be done tomorrow). In the opening scenario, QA review resulted in QI though a simple guideline update.

Lew Steinberg has been involved with EMS since 1971, and is still certified as a firefighter, paramedic and instructor of many disciplines. He is a former fire chief and has worked in both prehospital and in-hospital settings. He may be contacted at ffpmlew@bellsouth.net