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Quality Improvement through Education and Positive Reinforcement
Author: John R. Brophy
Copyright: Copyright 9-1-1 Magazine, Feature Content
By John R. Brophy
Originally published in our April 2008 issue.
All the quality assurance data in the world is virtually meaningless if it is not followed up with a strong quality improvement initiative. Gathering the information and generating reports are just part of the process. Analyzing the data from both an individual and organizational standpoint to identify strengths and weaknesses must be included as well as providing feedback and guidance to the people who need the information to improve what they do. Additionally, from an organizational standpoint the analysis should include the input of communications center personnel with respect to contributing factors such as staffing, equipment, and policy implementation or revision thereby taking an aerial as well as ground-level view of all items that may affect the quality of service provided.
The PDCA Cycle
Back in the 1950s Deming and Shewart promoted what they called a Plan, Do, Check, and Act cycle that was used in Japan to help build its industry into a world power. Applying this PDCA cycle provides a comprehensive and logical chain of events to dispatch quality assurance and improvement programs. Our Policies and SOPs provide the Plan and are likely based on a combination of regulatory requirements and past experience. Each and every day dispatchers participate in the Do phase. Then, quality assurance reviews are conducted to Check what is being done against the policies and procedures in place. The question is how often do we Check these policies for continued appropriateness to the ever-changing world in which we operate compared to how often we Check our people for compliance? Could it be that they are ahead of the curve and applying common sense to an out dated policy or are they inappropriately deviating? Looking at all of these factors and more leads us to the final aspect of the cycle; it is now time to Act. How agency leaders Act or respond to what is discovered in the quality assurance process should not be limited to a standard cookie-cutter approach to all items of concern that are identified. Determining root cause of a particular deviation or trend before taking action will improve the effectiveness of the quality improvement aspect of the process.
Comparisons and Benchmarks – Scores Only Tell Part of the Story
Many quality assurance and improvement programs use a score-based format that provides various weights to various aspects of the call screening process. Information such as call back verification is given a different weight than determining the patient’s breathing status and rightly so because each area of the call has a different relative importance. The overall score of the call is then determined when all criteria met are added together and then compared to a threshold required for the call to be within standards. While this approach provides a nice overall view of how the call as a whole was handled I have found that looking at each individual indicator that is scored for both individual and organization-wide trends is a valuable, if not necessary next step. While your analysis of the score alone may show a particular dispatcher having met the threshold percentage set as the organization’s standard, looking further into each individual scoring point of a call will provide additional information that can be used in the quality improvement process. For example, you may find a dispatcher who, while always scoring above the threshold misses the same question on most calls. Looking at just the overall score some would say they are meeting the overall standards and in fact they would be right. However, discovering that they make the same simple mistake on a regular basis and providing them with feedback and guidance will correct an ongoing behavior that otherwise would go unnoticed. Taking it a step further to an organizational view, suppose now we follow the same process and find that while most dispatchers are meeting the agency threshold on most calls but the overall agency compliance with one or two key questions is below the threshold. We have now not only identified a trend, but perhaps an agency “norm” as well. Having done so, we can now develop a plan to address the issue in a positive way such as increased focus or including it in upcoming continuing education activities. Adding trend identification and analysis to an existing quality assurance program need not be cumbersome. The information on the key indicators is already being gathered, it just needs to be used to identify trends and norms as well as scores.
Taking an Educational Approach to Quality Improvement
To some extent making people aware of their mistakes is necessary and can perhaps provide them with some guidance by identifying their shortcomings, but consistently leaving it at that is likely to come up short in the long run for the individual dispatcher and the organization. Taking the approach that “the QI process should be primarily educational and the goal is to educate the employee and to change a behavior” (Jansen, 2006) is a more positive and far reaching approach. By identifying cause versus assigning blame, we can arm line supervisors with the information they need to educate personnel.
A tool that I developed to aid in the training of new dispatchers was a training resource binder complete with copies of policies, articles, and teaching tools from a variety of sources. It is a simple thing to to put together, but it must not just be put on the shelf. It should be a living resource that is updated as new ideas come about and old policies are replaced. While my initial focus in putting it together was new dispatcher training, I have found that it is a valuable resource for remediation and professional development exercises as well. If, for example, you identify through your quality assurance review that a dispatcher had difficulty with a child caller, you could pull out an article on handling child callers and use it as a tool to help you provide information and guidance to the dispatcher that will help them do it better next time.
Providing a source of information that is targeted to an individual area in need of improvement and having people provide you with feedback in the form of summaries, key points, and their opinions as to how the assignment can help them improve is simple and cost effective. Think about how much better they will feel when you not only come to them armed with something to help them instead of just questions or criticisms. And be sure to remind them that the reason the article even exists is reflective of the fact that that they are not alone and that someone else has already encountered the same or similar difficulties.
Replace Punitive Consequences with Positive Reinforcement
In the September/October 2007 issue of 9-1-1 Magazine I wrote that “having disciplined professionals will go farther than having employees that must be disciplined through punitive measures.” Unfortunately, all too often punitive measures are linked closely with quality assurance and improvement programs. Providing regular feedback on performance as part of the process is vital because if the only time the dispatcher hears anything about their performance is when they make a mistake it will not be completely their fault that the perception is that QA = Discipline.
Identifying their strengths and reinforcing what dispatchers are doing well is as important to the process as pointing out their shortcomings and providing them with the support and resources to overcome them. If they sense that you see the good that they do and not just their errors dispatchers will be more inclined to listen and respond positively to your constructive criticisms.
Applying Heinrich’s Risk Management Theories to Dispatcher QI
First, let’s take a brief look at Heinrich and his work. H.W. Heinrich worked for an insurance company in the 1930s and had occasion to study tens of thousands of accident reports for both cause and blame. His work lead to the theory that if you take a group of people doing the same or similar tasks (dispatchers, firefighters, plumbers, electricians) many of the same mistakes that have occasionally ended up in tragedy were made hundreds of times before by others with less severe outcomes. Unfortunately, the reality is that historically lessons have mostly been learned by the study of these tragedies instead of having been prevented by sharing a “near-miss.” If you look at your dispatchers they are part of your dispatch center, which is just one of many in your state and one of even more in the country. All the mistakes need not be made by the same dispatcher, or even in the same dispatch center, but if we look across the board nationally the mistakes that are being made are not isolated occurrences.
Let’s take an example where a police, fire, or EMS unit responds to the incorrect address and the delay results in the death or serious injury of a member of the public. An investigation is conducted and it is determined that the dispatcher did not verify the address where the help was needed with the caller. Action is taken as a result and before long the incident is a distant memory. What if we were to look further and discover that others made the same or similar mistakes numerous times in the past without significant consequences. Was the cause of the tragedy the individual dispatcher’s mistake, or was the problem more systemic – that, in spite of policy, the routine failure to verify an address with the caller has become the norm?
To identify mistakes before they become mishaps or tragic events involving serious injury or death, honesty in reporting of the mistakes must occur. This is why it is important to realize that “interjecting discipline into the QA process will encourage employees to provide false data out of fear of being disciplined” (Ludwig, 2006). Using QA data for educational versus disciplinary purposes will go a long way toward developing an environment in which people feel comfortable seeking out guidance when they make a mistake instead of hoping no one notices or, worse yet, actively covering it up. Heinrich believes, and I concur, that by sharing mistakes in a non-punitive and non-judgmental way we can learn from each other’s mistakes so that the likelihood and frequency of negative occurrences is reduced.
Don’t Just Provide Feedback – Accept It!
While some quality assurance and improvement programs include a peer review component most QA-QI programs are top-down and retrospective in nature, providing feedback in one direction after the fact. When discussing the quality of the services you provide it is important not to focus only on individual performance and their cumulative effects of agency trends. Listening to the feedback and encouraging the input of dispatchers who are at their consoles doing the job every day is an invaluable intangible. What I mean is that you may not be able to easily quantify what they are saying so that it can be included in a report or trend chart, but their perspectives will provide valuable insights as to the things a typical quality assurance review of various components of the job will not reveal. The input of the people doing the job every day may also identify an agency flaw such as insufficient staffing based on call volume or even provide a catalyst policy revision that may be long overdue. In short, a concern that one dispatcher brings to light may be affecting many others who for any number of reasons, including not having an opportunity to provide feedback may have endured but not mentioned.
Make Quality Part of Every Day
Whether a call review or any analysis is done prospectively or retrospectively and regardless of who performs it, making quality a part of every day is yet another positive approach to improving overall performance, competence, and even morale. Using an event as a catalyst for discussion immediately following it has been done for years by the fire service and others. There is no reason why a dispatch supervisor can’t do the same thing on a smaller scale with their team after they handle a large fire or mass casualty incident for example. Taking it a step further, why not engage in a short discussion about a contemporary event or incident from the news that potentially impacts quality and professional growth from time to time? On the same thought, pointing out a positive or even an area in need of improvement right away to an individual dispatcher once in a while will also go a long way toward the overall goal of Quality Improvement.
John R. Brophy is an EMS Communications Supervisor, EMT Instructor, and Fire Department Lieutenant who also served 10 years as a US Navy Corpsman both at home and abroad. His insights are a culmination of his over 25 years of experience in emergency services. He can be reached at firstname.lastname@example.org