The goal of an EMS quality assurance program (QA) should be increasing safety, satisfaction, and outcomes for both EMS providers and patients. Unfortunately, many QA programs are not healthy, they are a dysfunctional mess.

Compare your agency’s quality assurance program to the seven signs below and see how you match up.

Providers conceal errors. In a healthy QA program providers report errors and near misses without fear of repercussions. Self-reporting of leads to marked increases in the number of opportunities for improvement in the agency and is an essential practice for any agency interested in improving safety and outcomes. In the dysfunctional QA program providers rarely, if ever, self-report errors; it is only when the QA department finds errors that they are brought to light. This is not a symptom of bad providers; this is a symptom of a bad QA program.

The QA department works in a silo. Does the QA program communicate with the training department? Do they work together to find areas in the agency that can be improved upon or does the QA program exist in a silo, entirely separate from the training program? A healthy QA program must work hand in hand with the training department identifying areas for the service to improve upon. When the training department and QA department work together they can close the loop and determine if improvement is occurring in the agency.

What happens to a provider who makes a mistake “depends.” Providers should not have to wonder what is going to happen to them when they make an error at work, they should know well in advance exactly what the policy is. The dysfunctional QA program does not have a clear guideline for dealing with errors and it is left up to the whim of the reviewer, involving things such as personal preferences, egos and biases. The opposite of this can be found in an agency with a healthy QA program where all provides understand the QA department practices the principles of Just Culture. At a minimum, each provider in the agency understands that honest mistakes will not receive punitive action and no one will think less of them as a provider for making a mistake. While there may be an investigation into the issue and re-education or remediation is a possible outcome, it is understood that this is not punitive.

The QA Department looks for who is to blame Instead of what is to blame. Medicine has a long history of dealing with errors by using the policy of “name you, blame you, shame you.” In almost all medical errors assigning blame is a worthless task that accomplishes nothing. A healthy QA department understands that human error is a starting point in an investigation, not an endpoint. Only by looking at the complete picture of the entire system, which often involves components of the system such as equipment, training, and the overall culture can the conditions that led to the error occurring be remedied. Shifting from a person-centered approach to viewing human error as a symptom of a larger issue is at the heart of the Just Culture movement.

Errors do not lead to changes in the agency. Errors should lead to exploration which in turn should lead to changes in the agency. A dysfunctional QA program encounters errors, distributes punishments and blame as needed with the belief that disciplinary action will act as a deterrent to future errors. This does not work.

When an error occurs it is an opportunity for learning and for change. Sharing the lessons learned could be in the form of a newsletter, an M&M style forum or training. In some cases the providers involved with the error are able to and should present the material and mentor others.

Errors are viewed with an outcome bias. When an error occurs does your agency need to know the outcome in order to know how to proceed? When doing QA it is easy to fall into the trap of viewing errors through the lens an outcome bias and using outcomes as measures of recourse. Unfortunately, an agency that grades the severity of the error based on the patient’s outcome is doing little more than relying on chance as a measuring tool. The notion of “no-harm, no-foul” has no place in a healthy QA program. The difference between a near miss and a poor outcome often amounts to luck.

The QA Department is only reactive, not proactive. Quality improvement should be inseparable from quality assurance. While some would argue that the differing terms amounts to nothing more than semantics, quality assurance is performed retrospectively- looking at the care that was rendered, where quality improvement is a forward facing process and looks to improve the care future patients will receive. The Healthy QA department is not mired in only investigating errors and reading charts; it is actively involved in developing improvement projects for the agency. QA department should be using the plan-do-study-act cycle to test out changes in an agency, developing protocols and engaging with internal and external stakeholders to look for unfulfilled needs. If the main objectives of a QA department are performing “error patrol” and “protocol enforcement” they are missing the forest for the trees.

Note: While nothing here is a direct quote, some of the concepts in this article draw heavily from the work of Sidney Dekker. If you have not checked out his work, I highly recommend you do

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