How to do QA Without Being an Asshole.

This is a  rambling, poorly organized blog post about EMS QA that started out as an answer to a question posted on facebook and turned in to a collection of random thoughts on the subject. People often find themselves assuming the role of QA with little to no training on the subject. I know myself and many others have learned quite a few lessons the hard way.Goals:
What is the goal of your QA program? You do have a goal, right?

If the ultimate goal of your QA program is protocol compliance people at your service are going to hate you. I cringe when I think back to some of the errors I made years ago when starting to do QA. One time I told someone that if they give a patient aspirin then they must go all the way and give 3 doses of nitro, not 1, not 2, but three doses because they are initiating the chest pain protocol, if they are worried enough to give aspirin they need to go through the whole cardiac chest pain protocol. QA asshole

If the answer to the question about what are you hoping to achieve with your QA program is something along the lines of the state/medical director/boss said we need to have one it might be time to step back and do some reflection on why you are doing what you are doing.

The goal of a QA program should be simple, doing what is best for the patient and optimizing the EMS system to allow that to happen. This is done retrospectively by monitoring the system with run charts, report reading, etc and proactively by education and trying to foresee problems and looking for areas to improve.

When reading reports asking yourself if the kind of care the patient received is what you would want for yourself or a loved one is a good test.

Doing what is best for patients sometimes that requires breaking the rules. This is not to say that we should encourage people to disregard well written protocols but to understand that doing the right thing is more important than just following orders.  I tell providers that I do not care what they do as long as it is in the patient’s best interest and they can justify it. This does not mean to do a peri-mortem C-section because that would be probably impossible to justify as we have no training on it and it is not a commonly accepted practice at the paramedic level.

How to not do QA. 
One of my friends sent me a message about how QA should NOT be done.

“It was an auscultated blood pressure in a critical patient (post ROSC transfer with Levophed). Oscillometric NIBP had failed to obtain a reading (later troubleshooting identified an air leak), so I reverted to manual reading. On auscultation, I could hear the first Korotkoff sound, but lost the sounds 10 points lower as it blended in to the ambient background noise. So I reported the only pressure I was able to obtain. While it’s less ideal than a full set of blood pressure and obviously unable to calculate MAP, it’s superior in accuracy to palpated systolic blood pressures only.

I kept getting the PCR kicked back by CQI because there was no Diastolic BP noted in auscultation. Had the note been “Can you just add a note on this in the comments”, it would have been done and over with. But the note was that the diastolic was missing and to add it or mark it palpated. When I pointed out that it simply wasn’t obtained, I was scolded and told that ” From this point forward, you are now aware that [redacted] Ambulance will only accept blood pressures obtained by auscultation with a systolic and diastolic value, blood pressures obtained by palpitation, and blood pressures obtained using the cardiac monitor.”

When we had a face to face meeting over this, he tried to back up his position with an outline of the state EMT curriculum, where it says that EMTs are taught to take blood pressure by palpating the systolic or auscultating for the systolic and diastolic.

When a system’s QA process boils down to arguing who is right, it is a failure. While the provider may eventually say “fine, you’re right” it is them saying that to get the QA officer to leave them alone, not because they have internalized the debate and came to an understanding about what was best for the patient.

Spectrum of treatments:  Getting to “Why”

Realize for many patients there are several treatment options that are all correct. Many providers do things I would not do and vice versa and all the options are okay. When presented with a patient that received a treatment modality that is not what you would do, reach out to the provider and find out what their rationale for the treatment was. The goal here is the development of clinical judgement in providers.

Just Culture:
Every person involved in assuring the quality of medical care should learn about the ideas of Just Culture and understand the basic tenants of using it. It certainly has helped me be less of a QA asshole A few definitions are needed:

Mistake: An honest unintentional error occurs.
At-risk behavior:  A behavior where the risk is not recognized, or the provider incorrectly assess the benefit as being greater than the risk. At risk behavior still has good intentions and the provider believes it to be justified. At risk behavior is where we see people taking shortcuts.
Reckless behavior: intentionally disregarding the rules and causing a dangerous situation for no benefit. Example: A paramedic decides to teach an addict a lesson by administering a paralytic and intubating them and then pushing 2mg of narcan so they wake up in withdraw, paralyzed and intubated.

What do you do with this information?
Always use non punitive action for mistakes: Yes, you can kill someone with an honest mistake and not get in trouble. This does not mean the issue will not be addressed at an educational level and system level, nor does it prevent you from legal or civil issues stemming from any damages that occurred, but you won’t get in “trouble” at work.  This encourages people to discuss their mistakes and more importantly to share what they learned and to look for solutions to problems.

Coaching for at risk behaviors:  this can be as simple as a conversation or as complicated as a several month long written remediation plan with objectives that must be met before returning to independent practice as a provider. Most of the time simply discussing the issue and presenting the risk vs benefit portrayal from an outside perspective is all that is needed.

Reckless behavior:  This is a conscious choice to avoid best practices and has no benefit to anyone except the provider, and often places the patient in a position where harm could occur. This is when it is time for punitive action up to termination. Remember the paramedics a few weeks ago that had a contest to see who could get the most large bore IV’s in patients? They would fall in to this category.
System issue vs individual issue: Many of the issues  are not simply provider issues, there is often a system component to them as well. Just Culture should strive to fix system issues that could cause unsafe actions to occur in the future. Knowing human error is inevitable and mistakes are going to occur you must look for ways to minimize them in your system. If you have two drugs that look very similar but could be catastrophic if mixed up we must look for a solution. It could be as simple as getting a different brand, ensuring that the drugs are stored in a separate cabinet or putting a sticker on one of the vials.


A few Common statements you will encounter as the QA officer:
“You weren’t there…” This phrase is often used in conjunction with at risk behavior when someone made a choice that although seemed right at the time was not justified when viewed with hindsight. This is when someone is getting defensive and may call you an armchair quarterback. Lower their defenses. Tell them they are right, I was not there and all I have is an outside perspective on the events and I want to know what I am missing in my understanding of the events because I was not there and I only have the report to go on.  The goal here is not to beat people up for making bad choices but to help them make better choices in the future and to help them see the process of how they make those choices in the heat of the moment.

“Nothing bad happened …” People will tell you that they do not understand why you are making a big deal out of this because nothing bad happened. This is also known as an outcome bias and is a logical fallacy because while nothing bad happened, it certainly could have.  No one would find it acceptable for a friend to justify their drunk driving the previous evening because they made it home fine and nothing bad happened.  We have an obligation to not subject our patients to undue risks.

I’ll try to follow up with part II where we apply the Just Culture algorithm to some real cases in the next few days.

If anyone has any cases they would like to submit for discussion, please send them to me.

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