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Transforming Quality in EMS
Special RepoRt
How quality of care in HealtHcare and eMS driveS clinical iMproveMent —
and operational and financial SucceSS
By Alexander Garza, MD, MPH Medical DirectorFirstWatch Solutions, Inc.
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Section I How healthcare is investing in quality
Healthcare is moving to quality measurement, bringing with it improved patientcare—andfinancialimplications.Simplystated,thecomponentsofthe AffordableCareActaredirectlyrelatedtocontrollingcostthroughafocuson qualityofcare.
Section II The imperative to measure clinical and operational quality in EMS
The same quality measures that are driving change in healthcare described inSectionIwillsoonbecomingtoEMS.ProgressiveEMSagenciesare monitoring, measuring and managing quality to improve patient care andensuresuccesswhenfinancialincentivesbecomerealities.Inthissection, wewilldescribehowqualityimprovementhasevolvedinEMS,andwhymany agenciesstrugglewithimplementingaqualityprogram.
Section III How FirstWatch supports quality care and operations in EMS
Basedonvalidatedscienceandstandards,andinconjunctionwithlocalEMS protocols,FirstWatchhasdevelopedEMSqualitymetricsandmeasuresthat areessentialforhighperformingEMSsystems.Usinguniquesoftware applicationsandinformationflowdesigns,FirstWatchleveragesdata fromComputerAidedDisptach(CAD),ElectronicPatientCareRecords(ePCR) and hospital data to capture and analyze data in real time, giving managers actionableinformationtoimprovequalityinoperationsandpatientcare.
CONTENTS
Copyright©2014FirstWatchSolutions,Inc. 322EncinitasBlvd.,Suite100Encinitas,CA92024USA
Phone:760.943.9123|www.firstwatch.net
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Section i How healthcare is investing in quality
“Quality is everyone’s responsibility” – W. Edwards Deming
Quality Improvement was born out of the fields ofengineeringwiththeinstitutionofmetrics,statisticalprocesscontrolsandothermethodstoeliminateerror.The motivation was to improve production, which wouldtranslatetobetterqualityandcostefficienciesthatwouldinturnimproveprofits.
Healthcare, on the other hand, has historically used a model of being paid for performing services to patients rather than improving the care ofthepatient.In thepast, therewas little incentiveformakingthedeliveryofhealthcaremoreefficient,eliminateerrorsor develop quality control processes. Indeed, mostof the time services and interventions were “bestefforts”anddiscreteeventsthatfocusedonsimplisticoutcomes rather than measured against definablestandards with validated measures to improve outcomes.Therewas littlediscussiononeliminatingerror or developing quality “systems.” This “system”wasenabledbyamarketopting topay for serviceswith little attention paid to value, particularly quality orefficientcare.
Inthislegacymodel,thereisnoincentivetoimprovepatient care. A hospital that invests in quality,providing top-notch care on a cardiac patient will receivethesamereimbursement(andpossiblymore)thananotherhospitalthatprovidesinferiorcare.Innoother industry is this acceptable as amodel for thedeliveryofservices.
This model is not sustainable and partially explains whytheU.S.healthcaresystemisthemostexpensiveintheworld,accountingfor17%ofthegrossdomesticproductwithsomeofthepoorestoutcomemeasuresamongindustrializedcountries.
EMS exists now where healthcare was before thePatient Protection and Affordable Care Act (ACA)—withreimbursementforprovidingaservice(transport)ratherthanquality.Andjustasthecostofhealthcareoverall has skyrocketed, so has the cost of EMS. Arecent report by the Health and Human Services(HHS)OfficeoftheInspectorGeneraldetailshowthecostofprovidingEMScaretoMedicarerecipientshasgrown exponentially and far faster than the overallcost of providing medical care. This, as well, is anunsustainablemodel.
This has led us to a new environment in healthcare—withnewregulations,legislation,policiesandwaysofthinking.
This move to quality in healthcare is based in part on theInstituteforHealthcareImprovement’s(IHI)TripleAimthat“describesanapproachtooptimizinghealthsystem performance.” The three dimensions, whichcomprisetheTripleAim,are:
•Improvingthepatientexperienceofcare(includingqualityandsatisfaction)
•Improvingthehealthofpopulations
•Reducingthepercapitacostof healthcare
FIgurE 1: THE “old” FInancIal ModEl
AdmitPatienttoHospital ProvideServicesBillforServices
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FIgurE 2: THE IHI TrIPlE aIM
Source: www.ihi.org
Many healthcare organizations are adopting theTripleAimframeworkasthebasisforimprovingcare,including the Centers for Medicare and MedicaidServices (CMS). Using this framework, the federalgovernment has developed several programs with the goaltobendthecostcurvebyimprovingcare. ThiswillmorethanlikelyalsobethefutureforEMS.
lESSonS THaT “ouT oF HoSPITal” ProvIdErS can lEarn FroM “In HoSPITal”
With the implementation of the ACA, the federalgovernment has now begun to place value on quality insteadofquantity.Thenewfocusison“systemsofcare” and measuring performance. Major programsunder the CMS have put quality in the front seat,with an emphasis on pay-for-performance and pay-for-measurement. The associated quality metricswill become increasingly standardized and required.The result is that hospitals and other healthcare organizations are now being paid—or penalized—basedonthequalityofcare.
MEaSurIng QualITy
The Hospital Inpatient Quality reporting (IQr) program is an excellent example of how thegovernment is leveraging common data elements to give an assessment of the industry. This is verycommon in other industries, but is now findingacceptanceinhealthcare.
TheHospital IQRProgramwasdevelopedasaresultoftheMedicarePrescriptionDrug,ImprovementandModernizationAct(MMA)of2003andthenadjustedwiththeDeficitReductionAct(DRA)of2005.
The Hospital IQR Program is intended to equipconsumerswithqualityof care information tomakemoreinformeddecisionsabouthealthcareoptions.Itis also intended to encourage hospitals and clinicians to improve thequalityof inpatientcareprovided toallpatients.TheHospitalIQRProgramcurrentlytracks72 quality measures that include everything fromimmunizationstotreatmentofheartattacks.
Tohelpconsumersmakeintelligentchoicesregardingthepurchaseofhealthcareandtoimprovetransparency,many of the Hospital IQR program measures arepublished on the Hospital compare website (http://www.hospitalcompare.hhs.gov/). According to CMS.gov,Hospital Compare “is a consumer-orientedwebsite that provides information on how wellhospitalsproviderecommendedcaretotheirpatients.Thisinformationcanhelpconsumersmakeinformeddecisionsabouthealthcare.HospitalCompareallowsconsumers to select multiple hospitals and directly compare performance measure information relatedtoheartattack,heartfailure,pneumonia,surgeryandotherconditions.”
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TheresultsonHospitalCompareareorganizedby:
•PatientSurveyResults
•TimelyandEffectiveCare
•Readmissions,ComplicationsandDeaths
•UseofMedicalImaging
•LinkingQualitytoPayment
•MedicareVolume
These measures allow the consumer to directly viewperformance of key indicators across geographic areas as well as how a hospital compares to national and state averages.
HoSPITal coMParE
Key Concepts
• Screenshot 1 shows that Hospital Compareusesseveralmeasurestogradehospitals,withdefinitionsforeach.
• Screenshot 2 compares regional hospitalsonthe“averagenumberofminutesbeforeoutpatientswithchestpainorheartattackgotanECG.”Noteacomparisontostateandnationalaveragesforreportinghospitalsisincluded.
• Screenshot 3 compares the same hospitalson“outpatientswithchestpainorpossibleheartattackwhogotaspirinwithin24hoursofarrival.”
FIgurE 3: HoSPITal coMParE WEBSITE
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Hospital1 Hospital2 Hospital 3 Hospital4 Hospital5
Hospital1 Hospital2 Hospital 3 Hospital4 Hospital5
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Originally a voluntary program as part of IQR,Medicare now requires CMS to adjust payments tohospitals that do not participate by reducing their applicable reimbursement percentageby2%. Sinceimplementation of the financial penalty, hospitalparticipation has increased to more than 99% ofMedicare-participatinghospitals.
The Hospital value-Based Purchasing (vBP) program uses the data supplied by the IQR in an effort toimprovethequalityofcare.ThisprogramisintendedtotransformMedicarefromapassivepayerforservicestoaprudentpurchaserofservices,payingnotjustforquantityofservicesbutforqualitycareaswell.
According to CMS.gov, the VBP program is “…forhospitals, clinicians, and other stakeholders whoshare CMS’ commitment to transforming the qualityof hospital care by realigning hospitals’ financialincentivestodoso.”
TheVBPprogramcannowsetbenchmarksandprovideincentivestohospitalstoreachthesebenchmarksaswellaspenalizethosethatarepoorperformers.
The formulas are complex; however, they are basedon simple to understand domains including ClinicalProcessofCare,PatientExperienceandMortality.
clInIcal ProcESS oF carE doMaIn
The Clinical Process of CareDomain, also known asmeasuresof timelyandeffectivecare,measurehowoften patients receive appropriate care known tooffer the best results. These includemeasures suchas getting a patient having a heart attack from theemergency department to the cardiac catheterization labwithin90minutes.
PaTIEnT ExPErIEncE oF carE doMaIn
The Patient Experience of Care Domain uses anational,standardizedsurveythatasksadultpatientsabout their experiences during a recent hospital stay. This includes measures such as how well thedoctor or nurse communicated to the patient as well ascleanlinessof thehospitalenvironmentandpainmanagement.
MorTalITy
Added in2014 isameasureof30-daymortality forpatientssufferingfromheartattacks,congestiveheartfailureandpneumonia.Theseareimportantmarkersforthedeliveryofqualityofcare.
Basedonthequalityofcare,thequalityofexperienceand mortality measurements, hospitals face theprospect of increased revenue for quality care andpatient experience—or a decrease in reimbursement ifcareisdeliveredpoorly.
THE PuSH For QualITy
Intotality,thisresultsinanewfoundpushforqualityinhealthcareorganizationsandhospitals.Theaimisto provide better patient care, better manage costs, reward excellence and penalize underperformance.
SohowdoesthispushforqualityaffectEMS?
EMS,unfortunately,hasfewmetricstomeasureitselfby to show value or quality. Currently, there are nouniversallyagreeduponmetricsfortheEMSindustryto benchmark against. However, it is imperativethat EMS move quickly in the direction of metrics,measurementandquality.
HowWillHospitalsBeEvaluated?
Total Performance Score
clinical Process domain Score
45%
+ + =Patient Experience
domain Score
30%
outcome domain Score
25%
Total Performance
score
FIgurE 4: HoSPITal PErForMancE MEaSurES
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Section ii The imperative to measure clinical andoperationalqualityinEMS
Uptothispoint,EMShasbeenlargelymissedintheevolution and emphasis on quality in healthcare.Although quality has been discussed, and is being addressedinsomepocketsbyforward-thinkingEMSleaders and agencies, governmental organizations haveplaced littleemphasisondrivingEMSsystemstoimprovequality.ThisisreflectedinhowMedicarehas traditionally paid for service by EMS providers,which is based on the transport of the beneficiaryinsteadofthequalityorcaredeliveredtothepatient,oroutcomes.ThisissimilartothewayhealthcarewaspurchasedbeforethereformsoftheACA.
In other areas of healthcare, there are establishedquality measures that are defined by Health andHumanServices(HHS),includingtheNationalQualityFoundation (NQF) or the Agency for HealthcareResearch and Quality (AHRQ). This is not the casein EMS, where there are few established metricsfor quality of care for the out-of-hospital patient.Enormous variations in the quality of EMS systemsexist.
QualITy varIaTIonS: THE cardIac arrEST ExaMPlE
Thoughcardiacarrestpatientsmakeuponly1-2%oftheEMSpatientpopulation,thereisnoquestionthatthequalityofcaredeliveredbyEMSprovidersdirectly
affectswhetherapatientwillsurvive.Thispopulationofpatientscouldalsoreasonablybeseenasavalidsampleofallpatientswithinthesystem—andthusasasurrogatemarkerforquality.
MostEMSprovidersaretrainedtoacommonstandardin the care of cardiac arrest, so presumably thereshould beminimal bias in level of training. Thoughsome component of survival is dependent upon in-hospitalcare,thereturnofspontaneouscirculationinthefieldisahighpredictorofsurvivalandislargelydependentuponEMSandthecommunity.
CardiacarrestsurvivalusingUtsteincriteria(asetofguidelines for uniform reporting of cardiac arrest),rangesfromnear0%to50%acrossthecountry.ItisthereforelogicaltostatethatthelargestinfluenceonsurvivalfromthismedicalconditionisahighqualityEMSsystem.
CardiacArrestisaprimeexampleofhowqualitywillbe assessed by governmental organizations, and result in either financial incentive for excellence orpenaltiesforunderperformance.
metric Measurement/Evidence
ReturnofSpontaneousCirculation
%ofPatientswithROSCUsingUtsteinCriteria
SurvivaltoHospitalDischarge%ofPatientswithDCUsingUtsteinCriteria
NeurologicalStatusofSurvivors%ofPatientswithNeuroIntactUsingNeuroFunctionalStatus
Cardiac arrest, like many other clinical conditions, has very clear metrics and measurement:
FIgurE 5: cardIac arrEST METrIcS/MEaSurEMEnT
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SIMIlarITIES To THE “InPaTIEnT” SIdE
JustasthequalityprogramsoutlinedinSectionIaretaking hold in healthcare and hospitals, there willlikely soon be an expectation that EMS care—andreimbursement—willbebasedonquality.Manyofthemeasurementsusedontheinpatientsideofcarearedirectlyapplicabletotheout-of-hospitalenvironmentincludingthingssuchas:
•ThetimeittakestoperformanECGonachest pain patient
•Measurementofthetimeittakesfor aheartattackpatienttogetfromthe scene to the cardiac catheterization lab
Beyond the clinical care domains, in most systems patientexperienceisnotroutinelymeasuredfortheout-of-hospital patient. However, it would not bedifficulttotranslatetheinpatientmeasurestotheout-of-hospitalpatientbyaskingsuchthingsas
•Wasyourpainrelieved?
•Didtheparamediccommunicatewith you?
•Howcleanwastheambulance?
TheseareimportantmeasurestolookattomakesurethatEMSisdeliveringvaluetothecommunity.
As a result, progressive EMS agencies are puttingpracticesandtechnologyinplacetoensurequalityofcare is measured, while at the same time managing costs.
BEnEFITS oF MEaSurIng QualITy In EMS
EMS has some distinct advantages and somechallenges when it comes to measuring its value and qualityofcare.
EMSisaperfect laboratoryfor lookingatquality.Byandlarge,EMScontrolsthedeliveryofemergencycareand transport for entirepopulations andgeographicareas with limited or no competition. This is goodand bad for different reasons. It is good because itmeans the delivery of this care can be centralizedandorganized. It ismeasuredonmultipleplatformsfromthetimetodeliveryofcaretocentralizedrecordkeeping.Allthehealthcareprovidersaretrainedtoacertainlevelandfollowcommonprotocols.Asaresult,it ismorestraightforward todevelopquality controlmeasuresandtoimpactthedeliveryofcarebecauseitisanorganized“system.”Thesamecannotbesaidabout the restofhealthcare.At the same time, EMSis a poor model because there is less competition, resulting in diminished innovation. With no marketpressure,thereisafailuretoinvestinimprovingthe“system”andmeasuringquality.
InalmostallEMSsystems,datatomeasurequalityisbountiful—in ePCR, CAD and other tools, platformsand systems.What’s key is capturing that data, andthenmeasuringit.Therealityisthatthiscanbedonewithoutchanginganyofthesystemsalreadyinplacein an EMS agency. In the next section,we’ll discussoptions and opportunities to capture, measure and reportthisdata.
Systems that understand the need to improveefficiencies and demonstrate value are investing indataanalyticsandinformationtoimprovethequalityofcaredeliveredtothepopulationstheyserve.TheyarewellpositionedfortheEMSofthefuture.
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Section iii How FirstWatch supports quality care andoperationsinEMS
The traditional approach to Quality Improvement inEMS is labor intensive, time consuming and oftenconfusing, leaving little time toactually improvecare.EMSagenciesneedtheabilitytomonitorandanalyzepatient care data, identifying deviations rapidly,consistentlyandautomatically.
These tasks used to take days or weeks, involvingstacksof records,multipledataentryproceduresandreportsthatwerealwaysamonthlate.Withtheadventofelectronicdatacapture,datacannowbecollectedin minutes and reviewed quickly and without dataloss due to entry errors. The same capabilities thatallow EMS to be so well-positioned with regard toquality improvement also allow data to be collected and reviewed in a much more timely fashion thantraditionalmedicine.Withinminutes,theentirepatientexperiencecanbereviewedfromthetime911iscalledtodeliveryatthehospital.
Most importantly, quality improvementmanagers cannow focuson actually improving thedelivery of EMSrather than the collection, entry and analysis of data.Beyond these clinical aspects, improving the quality, collection and analysis of data improves billing andfinancialrecovery.
More than 300 agencies across the U.S. and Canadause FirstWatch to monitor real-time 911 and EMSpatientdataforearlydetection,situationalawareness,enhanced operations—and improved clinical care.Those agencies started down this path to improve organizational effectiveness and clinical care, andthey are now positioned well for the future of EMSreimbursement.
FirstWatchusesautomatedEMS-centric reportingandreal-time, web-based data visualization tools. User-defineddatafilters called “triggers”helpmonitor theagency’s performance against defined operationaland clinical objectives. Real-time data is displayedin dashboards and can be accessed on any device connectedtotheinternet.
KEy FIrSTWaTcH FEaTurES For EMS IncludE:
•a variety of data sources—Any informationthat iscaptured in a database (e.g., CAD, ProQA, ePCR, RMS,hospital data) can be monitored by FirstWatch. Theprocessisautomatedwithnoneedfornewtrainingoranychangesinhowstaffcurrentlyworks.
•Improved operational performance — FirstWatch monitors key performance indicators (KPIs) in realtime, such as response times, scene times and hospital drop-offs.
•Improved clinical performance — FirstWatch provides automated, real-time feedback on adherence topatientcareprotocols,enablingmoreeffectivequalityimprovementprograms.
•dashboards make data easy to visualize —KPIsarepresented on dashboards so users can quickly andeasilyseethestatusofanydatasettheywishtosee–andonanydevicethatconnectstotheInternet.
North Shore Long Island (NY) Jewish Health System uses FirstWatch to monitor key performance indicators and ensure clinical and operational quality.
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• Early warning utility—Atthesametimeit’smonitoringKPIsandhelpingimproveclinicaloutcomes,FirstWatchcanbesettoalertforearlysignsofachemical,biologic,radioactiveornuclear attack,or fornaturallyoccurringepidemicsorpandemics.
• Sentinel event/situational awareness alerts — FirstWatchcanbeusedtoreduceworkloadandincreaseawarenessbyautomatingkeynotifications for sentinelorsituationalawarenessevents,forexample:reportsofasuspiciouspackagefoundatornearahighthreatfacility,STEMI, stroke, cardiac arrest, hazmat or MCI events tonameafew.
• customized alerting—Usersdeterminetowhomandhow an alert will automatically be sent–for example,pager,email,fax,textmessage,etc.
• Pre-set or customized triggers—Userscanusepre-settriggerstoprovidealertsforcommontypesofincidents,andcanalsohavecustomizedtriggersfortheirspecificneeds.
• Secure processes meet HIPaa requirements — FirstWatch systems and processes ensure security, meetingorexceedingallHIPAArequirements.
The FirstWatch App offers real-time EMS performance, operational and clinical compliance data for iPad or Android tablet. A version for iPhone and Android phones is coming soon.
FIrSTPaSS ovErvIEW
FirstPass,createdbyFirstWatch,isaclinicalmeasurementand protocol monitoring tool designed to alert users to deviations inexpected treatments tomedicalprotocols.FirstPass provides continuous monitoring of ePCR andotherdatatoquicklyidentifyandprovidereal-timealertsrelatedtoprotocoldeviations,incomplete“carebundles”(which include scientifically validated patient careprotocols),missingdataelementsorurgentpatientsafetyissues. A standard bundle of protocols are designed to
measure predefined quality metrics for STEMI, stroke,trauma, cardiacarrest andairwaymanagementpatients.The protocols are configured with quality metrics, yettheagencyhastheabilitytoaddmetricsspecifictotheiragencyorlocality.
Thefollowingarequalitysystemstandardsthatarebeingused by some progressive EMS agencies. These qualitymeasures can be readily reviewed using existing data sources, including ePCR, CAD, hospital data and othersoftwareandplatforms.
The quality metrics are segmented into the followingcomponents:
1. System Performance Measures: These are indicatorsthatarecommonmeasuresacrossEMSsystemsandarereadily comparable among systems. Examples includeresponsetimesandcardiacarrestsurvival.
2.clinical Performance Measures:Theseevidence-basedclinical measures have been endorsed or are emerging as best practices and have shown value to the patient population when performed correctly. An example ofthiswouldbeSTsegmentelevatedmyocardialinfarction(STEMI).
3.Patient Safety/risk reduction Performance Measures:These are evidence-based and best practice measures thatreducethepatient’sriskofpreventableharmaswellasreducerisktothesystemasawhole.Examplesofthisincludeairwaymanagementandnarcoticsmanagement.
4.Financial Performance Measures:Howefficientisthesystem as a whole? Considerations include unit hourutilization, billing cycle, penalties, cost per capita, billing informationcompleteness,etc.
SuMMary
EMSorganizationsneedtobemonitoring,capturingandmeasuring data continuously and in near real-time to ensure quality patient care and ensure optimum clinical and operational performance. Previously, this requiredexhaustivestafftimeandefforts,cobblingdatatogethermanuallyfromvarioussources.
But in today’s environment, with financial incentivesandpenalties loomingforEMS,there’sevenmoreofanimperativetofocusonquality.FirstWatchhelpsagenciestakethisinformation-drivenapproachtoEMSseamlessly.
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AlexanderGarza,MD,MPH
AlexanderGarza,MD,MPH,servesasmedicaldirectorofFirstWatchandisanotedhomelandsecurityadvisor.Dr.Garzaisanimportantliaisontothepublichealthandsafetycommunities,usinghisuniqueperspectivetounderstandchallengesanddevelopinnovativesolutions.“Ibelieveinthepowerofdatatoimprovesystems,”hesays,“andI’vealwaysenjoyedworkingwithpublichealthandsafetycommunities.”
Dr.Garza’scareerhascenteredonthedeliveryofemergencycare,publichealthandsecurity.HebecameanEMTin1986andhasgraduallyworkedineverylevelofprovidingcareandleadershipinemergencymedicine.Thisincludedworkingasaparamedic,aflightmedic,emergencyphysician,anArmyofficerincombattheaterandanEMSadministratoratthemunicipalandstatelevel.IntheimmediatepastheservedasassistantsecretaryforhealthaffairsandchiefmedicalofficeroftheDepartmentofHomelandSecurity.
Hehaswrittenextensivelyon issues involvingEMSandsecurity.He isconsideredanexpert inweaponsofmassdestruction,healthdiplomacyintheU.S.ArmyCivilAffairscommunity,healththreatstonationalsecurityandstrategicandoperationalexcellence.Hehaslecturednationallyandinternationallyonhealthandsecuritytopicsaswellasthedeliveryofcaretoout-of-hospitalpatientsandhascounseledleadershipatthehighestlevelsofgovernment.
Additionally, Dr. Garza serves as an associate dean for public health practice and associate professor ofepidemiologyatSaintLouisUniversity’sCollegeforPublicHealthandSocialJustice.Thereheteaches,learnsand engages in research with faculty and students in the areas of emergencymanagement, public healthpreparednessandepidemiology.“ThroughmyworkatSLUIhopetobringreal-worldstrategiestotheclassroomasanexampleforbettermergingtheworldsofacademia,publichealthandsafety.”Dr.GarzaresidesinSt.Louis,Missouri,withhiswife,Melissa,andthreeveryactiveboys.
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Phone:760.943.9123
www.firstwatch.net
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