Introduction to CQI History (in relation to EMS)
There is an increasing focus on "quality" throughout United States. When talkingabout "Total Quality Management", "Continuous Quality Improvement", or anyother name given to the quality movement, the common thread is meeting theneeds of those who pay for and use the services and products provided by anorganization. All types of industries, including health care, have lowered costsand improved the quality of their operations and products by working to meet theneeds of the people they serve.Many books have been written describing the philosophy and methods used inthe quality movement. This section is not intended to be a substitute for thoseworks, but rather provides a brief overview of quality management principles byreviewing the work of three leaders who have shaped the discipline. These threepioneers all stressed the importance of management awareness and leadershipin promoting quality.
W. Edwards Deming(1900 – 1993)
W. Edward Deming began working in Japan in 1950 and was instrumental inbuilding the Japanese industry into an economic world power. His stronglyhumanistic philosophy is based on the idea that problems in a productionprocess are due to flaws in the design of the system, as opposed to being rootedin the motivation or professional commitment of the workforce. Under Deming'sapproach, quality is maintained and improved when leaders, managers and theworkforce understand and commit to constant customer satisfaction throughcontinuous quality improvement.Deming and his colleague, Shewhart, promoted the PDCA cycle -- Plan, Do,Check and Act.
PLAN
to implement a policy to improve quality and/or decrease the cost of providing services. After the plan is developed, we
DO
it by putting the plan intoaction and then
CHECK
to see if our plan has worked. Finally, we
ACT
either tostabilize the improvement that occurred or to determine what went wrong if thegains we planned for did not materialize. PDCA is a continuous cycle; anyimprovement realized by carrying out one PDCA cycle will become the baselinefor an improvement target on the next PDCA cycle. The process of improvement(PDCA) is never ending, although the dramatic improvements of initial PDCAefforts may be hard to sustain.
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The PDCA Cycle
Deming also developed his famous "14 points" to transform managementpractices. Those points are applied to EMS and summarized below.
1.
Create constancy of purpose .
An EMS organization's highest priority is to provide the best qualitymedical care and/or transportation services to its community at the lowestcost possible. An EMS organization is responsible to both its communityand its own workforce to maintain a high level of excellence and value. AnEMS organization must strive to maximize efficiency and effectivenessthrough constant improvement.
2.
Adopt the new philosophy .
Everyone working in EMS can find ways to promote quality and efficiency,to improve all aspects of the EMS system, and to promote excellence andpersonal accountability. Pride of workmanship must be emphasized fromrecruitment to retirement. By their behavior, leaders set the standard for allworkers.
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3.
Cease dependence on inspection toachieve quality.
Reliance on routine 100% inspection toimprove quality (i.e., a search for errors,problems, or deficiencies) assumes thathuman performance error or machine failureis highly likely. Instead, there should be acontinuous effort to minimize human error and machine failure. As Deming points out,"Inspection (as the sole means) to improvequality is too late!" Lasting quality comes notfrom inspection, but from improvements inthe system. For example, documentingdeficiencies in EMS record keeping doesnot, by itself, generate ideas that wouldmake the task of record keeping less error-prone. A quality-driven approach might,instead, encourage development of clear and simple record-keeping forms thatminimize or eliminate the likelihood of mistakes.
4.
Do not purchase on the basis of pricetag alone.
Purchasers must account for the quality of the item being purchased, as well as the cost. High quality organizationstend to think of their suppliers as "partners" in their operation. Successfulpartnerships require clear and specific performance standards andfeedback on whether those standards are being met. Supplier performance can also be improved through an understanding of supplier QI efforts; longer-term contracts that include explicit milestones for improvement in key features; joint planning for improvement; and jointimprovement activities.
PDCA In Action
EMS managers, reviewingambulance responseperformance over time,discover that the goal of on-scene arrival within 6minutes after notificationonly happens about 20%of the time. In response, ateam of managers andmedics develop a PLAN toimprove this rate to 90%of the time. The planrequires new staffingpatterns and a newvehicle deploymentstrategy. The plan is putinto action (DO) on a trialbasis during which theteams CHECKS responsetime information. If thedesired result is achieved,the managers ACT tostabilize the new responsecapability. If the plan doesnot work, the team againACTS to understand whatwent wrong, to learn frommistakes, and to try a newrevised plan.
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