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Local EMS agencies in North Dakota work together to encourage quality improvement efforts at the local, regional and state levels 

The first time North Dakota state EMS officials invited some local agencies to participate in a pilot quality improvement program, they didn’t know what kind of response to expect.

They worried that some agencies would not want to openly discuss any issues or concerns. After only a few meetings, though, they realized that wouldn’t be a problem.

“We’re seeing the services really open up,” said Jeffrey Sather, MD, North Dakota’s State EMS Medical Director. “They’re saying ‘Here are the issues and here are our experiences and how we can improve.’”

North Dakota EMS officials first brought together representatives from six agencies in the state’s northwest region more than a year ago; since then, they have met several times to review data, discuss cases and identify ways to improve care. The collaboration between agencies and willingness to share mistakes, lessons learned and ways to improve has been especially helpful for the small services.

“It has been a great experience,” said Diane Witteman, operations manager for Mohall Ambulance, a combined paid and volunteer BLS service just south of the Canadian border. “We’re a small rural community; our run volume is about 190 runs a year. We’ve been able to look and see what others are doing, and it gives us a better feel for whether it’s something we can do.”

The quality improvement group gathers quarterly, with leaders from the six agencies, their medical director and state officials attending the meetings. The state has supported the effort by using data that the agencies submit to the North Dakota EMS information system in order to analyze specific topic areas, such as cardiac arrests, calls with prolonged scene times, and more.

“When you have such small agencies, you can’t afford for each ambulance to learn its own lessons. You need to rely on some kind of system,” said Lindsey Narloch, a research analyst with the North Dakota Division of EMS.

For each meeting, Narloch provides reports that identify incidents for the group to review based on established criteria. For example, the group looks at calls with scene times greater than 40 minutes, as well as all cardiac arrests. She also shows them reports that look at overall documentation performance or whether the agencies obtained 12-lead ECGs and whether those ECGs were transmitted to the hospital.

The topics were chosen during the initial meeting as part of a collaborative effort to decide what to measure and evaluate. The group chose 12-lead ECGs and mechanical CPR as two areas to examine, because recent grants had led to acquisition of new devices, and the agency representatives wanted to see how they were being used in the field. At the second meeting, they looked at the data.
“The group was a little skeptical,” Dr. Sather said. “Our data wasn’t 100% accurate. We learned a lot about how our data was submitted.”

Seeing the data being used, though, helped show where it was helpful, and where it needed improvement. While the ultimate goal of the quality improvement effort is to improve patient care, the first step was to improve data collection so they could accurately evaluate the care being delivered.

“We weren’t always detailed enough in our documentation,” Witteman said. After talking to leaders from other agencies, Witteman was able to bring home ways to improve her service’s documentation of patient care.

The goals of the program, Sather said, include encouraging the agencies to perform peer review and quality improvement activities in their own agencies. But at the same time, the interagency collaboration has been one of the most popular aspects of the effort, with more agencies now asking to join. Sather said they hope to bring more agencies in and eventually expand to other areas of the state.

As the program moves forward, the most important thing, participants said, is that agencies of various types and sizes are all beginning to see the importance of quality improvement and examining performance and data in order to provide better care. Moving forward, agencies across the country will be able to use the performance measures developed by the EMS Compass process to measure performance – because EMS Compass measures are being designed using the NEMSIS v3 standard, agencies will be assured they are measuring the same thing as their neighbors, making collaborative efforts like the one in North Dakota even easier.

“Some of the agencies are starting to run their own reports. Some of them didn’t even know how to run a report before,” Sather said. “But we’re starting to see the services themselves actually use that data.”