The Next Generation of EMS Guideline Development:

Clinical and Operational Guideline (COG) Teams

Presented by: Colleen Hayes, MBA, RN, EMT-P

CEO, Vertical Villages, Inc.

Editor-In-Chief, EMSvillage.com

September 6, 2001

The Presentation

Objectives & Program Outline

How do you presently research, develop and propose changes to your clinical or operational guidelines? Here’s a refreshing revelation: After years of being on the sidelines, EMS providers want to actively participate with medical control and collaborate with other medical disciplines to develop evidence-based patient care guidelines. Outdated clinical practices and EMS protocols based on belief rather than scientific evidence and those developed in a top-down managerial style are OUT! What’s IN? Developing changes in clinical and operational EMS practices through collaboration between field personnel, physicians, management and other stakeholders.

Learn how to put together a “Clinical & Operational Guideline” (COG) Team. COG Teams use the FOCUS-PDCA method and are charged with actively seeking out problems, areas for improvement and are an active part of engineering solutions, implementing them, evaluating outcome and promoting lasting change. We’ll also discuss tips on how to keep your COG Team effective, on schedule and motivated!

Agenda:

1. Introduction

1. Overview
2. Is your organization ready for a COG Team?
3. Common barriers to readiness.

2. Putting the Problem in Perspective: A Brainstorming Exercise

1. Based on an “Ask the Professor” question from EMSvillage.com
2. Brainstorm solutions and discuss the root of the problem

3. The Solution: A “COG Team”: What is it and why do we need one?

1. Define a COG Team
2. Define FOCUS-PDCA.
3. The Manager as mentor, coach and leader

4. Plan-Do-Check-Act: A Problem Solving Process

1. Discuss the value of PDCA as a systematic method for improving processes.

5. “COG Team” Case Study: Developing a Restraint Policy for EMS

1. Putting what you’ve learned into action

6. Appendix: Sample Forms for “COG Team” Project Management

Introduction

Welcome to “The Next Generation of EMS Patient Care Guideline Development”. During the next hour we’ll explore a new paradigm that is being used to create change in EMS systems. This paradigm converges the ideas of Continuous Quality Improvement (CQI), Total Quality management (TQM) and process improvement into what I like to call an “EMS Clinical and Operational Guideline Team” (or, COG Team).

How do you presently research, develop and propose changes to improve your clinical or operational guidelines? The “COG Team” method is designed to recognize that every person within the EMS System wants to be an active participant in and is capable of improving patient care guidelines and operational policies and procedures. The COG Team method of CQI empowers every single employee to be able to affect change.

COG Teams rely on a combination of mentoring, empowerment, teaching, research, collaboration and teamwork as the core principles to success. They use a popular method of process improvement called FOCUS-PDCA.

To successfully implement a COG Team management has to be able to take a leadership and mentoring role instead of a “managing” role. Mentoring is an essential ingredient helping the team succeed. Consider these common critical barriers organizations face when implementing a CQI program:

· Will your organizational culture be able to accept changes in work structure, role changes, power shifting and overcome resistance to change?

· Will management believe in and commit to the program? Will it maintain a presence and support the team? Does management empower and mentor employees to take charge and lead a project to its completion? Can management change its traditional role to one of leader, mentor and coach?

• Can the QA system be redesigned to collect different types of data so that specific outcomes can be evaluated? Are the materials, manpower and resources, skill, knowledge and guidance available to support quality initiatives and their measurement?

• What other barriers must be removed or controlled for the COG Teams to succeed? Will you be able to assemble the personnel to develop multidisciplinary teams? How will you plan to allow for sufficient time for the learning curve to be met? How will you deal with personnel looking to forward personal agendas through the team?

• Do you believe that your employees have it in them to take charge of process improvement…or is that management’s turf? Can you, the manager, let go of owning quality improvement projects?

• Are there budgetary or scheduling constraints? If so, how will you overcome them?

Putting the Problem into Perspective: An Exercise

To understand the scope of the problem from the field provider’s perspective please read the following problem. Can you come up with an answer for this troubled paramedic? What are the potential consequences of “Company A” not changing its current management practices? What can be changed in this situation to improve it?

Note: Reprinted with permission from EMSvillage.com’s “Ask the Professor” service:

Dear Professor:

I have a problem that is troubling me greatly. I am even wondering if I should stay in EMS…that’s how unhappy I am right now. I graduated paramedic school a year ago and have been working in two EMS systems.

The one I work for full time is a combination 911/private transport company and the other is a private 911-only not-for-profit system. I’ll refer to them as “Company A” and “Company B” respectively. I work full time at Company A and per diem at Company B. Company A is a busy system and I’ve seen lots of things in my short time there. They are very strict with protocols and I feel like a robot when I work there, but I’m getting lots of experience. The management tells me what I can and can’t do on a day-to-day basis. There is no way to suggest changes, or make things better. They are operating on old protocols. Basically, I’m working at Company A to get enough experience to be hired at Company B full-time. Company B doesn’t have a lot of employee turnover either, so for now I’m stuck at Company A.

Company B is really progressive and practices evidence-based medicine. The docs are progressive. When I work for Company B I really feel like I am part of a team and I can use the things I learned in paramedic school – like critical thinking, and advanced patient care. They respect my patient assessment and I can work with medical control to tailor care for the patient if it’s in his/her best interests or if the situation requires it.

OK, that’s the background, now here’s my problem. I was working for Company A when I was called to treat an 80-year-old female with acute pulmonary edema. I remembered the lecture I heard on managing pulmonary edema and the important role of nitrates. This lady was in bad shape and through her gasps, she made it clear that she didn’t want to be intubated…so I decided to be really aggressive with her care. I contacted medical control to get orders to “double dose” the sublingual nitro (since this is what is done at Company B and I’ve seen it work well) and repeat it very 5 minutes as long as her BP was over 110 systolic. I gave her Lasix and hit her early with a double dose since she was taking 40 mg twice a day at home. I even got blanket orders for Morphine so I didn’t have to call back again. I administered the meds as ordered, extricated her to the ambulance and reassessed her. Wow! It was working really well! She turned around so nicely…by the time we got to the ED she could talk in complete sentences, her sats were much improved, her skin dried up and where here lungs were full before and I could hear her without my scope, she now had crackles in the bases. I was so happy and pleased that I didn’t have to intubate her and the patient was so thankful to me that she could breathe and she wasn’t intubated. I was never so satisfied in my life! I’ve had good APE calls, but that was my first really “great” call where I felt I made an important difference in the outcome!

The next day my Operation’s Manager called me in. I was racking my brain trying to think what it could be about. When I arrived at the scheduled time, my Manager asked me about the case. He felt I was out of line and I was formally counseled and got a written warning for a “protocol deviation”. I shared my thought process, and even said there was research that backed up the “double dose” of SL nitro. Even though I documented that I called into Medical Control to obtain permission and the ED physician agreed with my approach (and I even got an “atta boy” at the ED) my Manager simply said, “It doesn’t matter – these are our protocols and this is what you do here. WE don’t do cowboy EMS here – WE follow the protocol.” He then proceeded to lecture me about legal liability, malpractice, knowing one’s place, practicing medicine without a license, and other “management” stuff. Frankly, I don’t agree with any of it…

I went to my Medical Director and he said my treatment was correct, but he didn’t want to make any changes to the guideline since it would take “too much of his time” to develop a new guideline. He disagreed with the counseling I received but said it was a “management issue” and he couldn’t do anything about it.

I’m very, very confused! I trained under the latest paramedic curriculum. My instructors taught me all kinds of things about critical thinking, leadership, doing the right thing for the patient, and the latest EMS treatments… We learned about practicing continuous quality improvement as part of our professional responsibility. I haven’t really seen this happen in most EMS systems, except the one that I mentioned. Most of the medics who have been around for a while laugh at the things I learned and say it was a waste of my time because they will never happen. Is all the stuff I learned really for nothing? How can things change if EMS companies and their managers are so far behind in their thinking? Was I supposed to let that patient deteriorate to the point where I had to intubate her against her wishes all for the sake of the almighty “protocol”? How can I call myself a professional if I can’t develop within my profession?? If I can’t do the best for my patient I don’t think I want to stay in this field much longer. Help!

-M.R.

What would you suggest to M.R.? Can you see any similarities to you organization in either Company A or Company B?

The Solution: A “COG Team”:

What is it and why do you need one?

FOCUS - PDCA is a systematic method for improving processes.

FOCUS-PDCA - A strategy that provides a roadmap for continuous process improvement when linked to a quality definition. It is an acronym meaning:

Find a process to improve,

Organize a team that knows the process,

Clarify current knowledge of the process,

Understand sources of process variation,

Select the process improvement,

Plan the improvement and continued data collection,

Do the improvement, data collection, and analysis,

Check and study the results,

Act to hold the gain and to continue to improve the process.

FOCUS - PDCA is an extension of the Plan, Do, Check, Act (PDCA) cycle sometimes called the Deming or Shewhart cycle.

Plan-Do-Check-Act: A Systematic Problem Solving Process

PLAN Step 1: Identify The Problem	Select the problem to be analyzed Clearly define the problem and establish a precise problem statement Set a measurable goal for the problem solving effort Establish a process for coordinating with and gaining approval of leadership
PLAN Step 2: Analyze The Problem	Identify the processes that impact the problem and select one List the steps in the process as it currently exists Map the Process Validate the map of the process Identify potential cause of the problem Collect and analyze data related to the problem Verify or revise the original problem statement Identify root causes of the problem Collect additional data if needed to verify root causes
DO Step 3: Develop Solutions	Establish criteria for selecting a solution Generate potential solutions that will address the root causes of the problem Select a solution Gain approval and supporter the chosen solution Plan the solution
DO Step 4: Implement a Solution	Implement the chosen solution on a trial or pilot basis If the Problem Solving Process is being used in conjunction with the Continuous Improvement Process, return to Step 6 of the Continuous Improvement Process If the Problem Solving Process is being used as a standalone, continue to Step 5
CHECK Step 5: Evaluate The Results	Gather data on the solution Analyze the data on the solution
Achieved the Desired Goal?	If YES, go to Step 6. If NO, go back to Step 1.
ACT Step 6: Standardize The Solution (and Capitalize on New Opportunities)	Identify systemic changes and training needs for full implementation Adopt the solution Plan ongoing monitoring of the solution Continue to look for incremental improvements to refine the solution Look for another improvement opportunity

COG Team Case Study: Developing a Restraint Policy for EMS

We need an example to illustrate how a COG Team can function so I’ve created a hypothetical team and a hypothetical problem.

Meet Joann Wright. She’s a paramedic who works in an urban EMS system. She is an excellent paramedic with top-notch knowledge and skills. She is knowledgeable and up-to-date on emergency medicine literature and trends.

She had been following some news stories on her favorite web site about patients who have died because of positional asphyxia. Positional asphyxia occurs when patients are improperly restrained and they suffocate due to a closed airway. She thought that there must be a better way to deal with violent patients. Then, the other day she had a case where a young man overdosed on PCP and was extremely violent. He was “hog tied” by the police and positioned on his stomach on the ambulance cot. Her mind drifted back to the cases she read about and became very concerned for this patient’s well being. She realized that she found an opportunity to develop a patient care guideline that can be used to safely restrain violent patients.

Joann approached her supervisor and obtained a COG Team Kick-off Form. She also approached the sponsor hospital’s Institutional Review Board (IRB) since she intended to publish the findings.

She then began to lead the team through the FOCUS-PDCA process. Throughout the project her supervisor was available to coach and mentor her through the process. They touched base with each other to ensure that project milestones were completed.

The project was completed on schedule. The Team used a free website that offered secure “groupware” to manage the project’s documents, maintain communication and share information and draft documents. This allowed the team to function and facilitate communication and stick to the timeline without having to meet in physical locations all of the time. This greatly facilitated progress!

What resulted was a patient care guideline that could be used by EMS and PD to guide them through a safer restraint process. The guideline coordinated efforts and provide each agency with the same baseline education. Acceptable restraint methods were developed, and a “rapid tranquilization” guideline was included for paramedics’ use.

A training program was developed and administered. Both paramedics and police officers participated in the teaching so that each agency’s perspective could be appreciated. Police officers gained insight about when it might be appropriate to use medications to rapidly tranquilize a patient –and when it would not be appropriate. Paramedics learned about the issues facing police officers.

For ongoing process improvement and data analysis, a notebook was put together into a compendia format. This notebook housed the COG Team forms and contact information, copies of the literature reviewed for the new guideline, and other supporting documentation. The Team continued to collect information and maintain the compendia with current information. The Team developed data points that were to be collected and analyzed.

Data was collected by team members and entered into a database for analysis and ongoing assessment of the guideline’s effectiveness. Education and training was ongoing to ensure compliance with the new guideline. Consistent feedback was provided to its users by the COG Team to hold the gain.

Sample Forms

COG Team Project

FOCUS-PDCA Performance Improvement Project
Project Kick-off Form

Please submit this form at the beginning of your project.

Enter Your Contact Info and E-mail Address:

F - Find a process to improve. 

Project Title:

Describe the problem/opportunity for improvement:

This project targets: (check all that apply)

□ Patient Care □ Operations □ Regulatory □ Customer Service □ Cost Reduction

□ Injury Prevention /Community Outreach □ Billing □ Improve outcomes □ Reduce Errors □ Enhance Revenue

Performance Functions/Dimensions: (check all that apply)

□ Pt. Treatment □ Pt. Assessment □ Education □ Continuum of care □ Performance improvement □Leadership □ Safety □ Human Resources □ Information management □ Infection Control

□ Respect/Caring □ Timeliness/Efficiency

Benchmark data to be used? □ Yes □ No If yes, enter source:

O - Organize a team.

Enter Name of Team Leader:

Enter Members Names & Departments:

1. 4.

2. 5.

3. 6.

Team will report to: (enter name of committee, director, administrator or medical director):

Project Time Frame:

Start Date:

End Date:

Click here to send, or fax to: 555-555-5555

Note: If you plan to publish the findings, use random assignment in data collection or any possibility exists that the subjects will be at risk you must obtain IRB approval.
Sample Forms

COG Team Project

New Project Proposal Summary Form

Project Number	555	556	557
Project Title	Documentation Improvement	Pain Management	START Triage
Leader	Colleen Hayes	Joyce Smith, RN	James Dean
Contact phone #	203-261-8580	555-888-5555	555-999-4555
Department	EMS	St. Joseph’s ED	EMS
Description	To improve standards and compliance in accordance with AMCE EMS policy. Particular problems include pt. Assessment, reassessment after treatment, mental status, RMA, spine clearance, and trauma MOI.	To develop a prehospital pain treatment guideline that meets current JCAHO and EMS standards.	To develop a standardized and simplified system of triage to use during a multiple patient scenario. To obtain agreement and acceptance of mutual aid communities to coordinate efforts.
Start/Target Date	5/1/01 – 8/1/01	8/1/01 – 10/15/01	9/1/01 – 11/15/01
Reports to	J. Blow, Supervisor	Dr. Turnbull	J. Blow and Dr. Turnbull

Project Number	558
Project Title	Restraint Policy
Leader	Joann Wright
Contact phone #	555-555-5555
Department	EMS
Description	To develop a patient care guideline that will allow for safer methods of restraining violent patients – including pharmacological therapy.
Start/Target Date	5/1/01 – 8/1/01
Reports to	J. Blow, Supervisor

Sample Form

COG Team Project

Project Management Form

Use this form to coordinate and track project milestones and project assignments. This can be used as a meeting agenda or as a project tracking form.

Agenda item

Preparation Required

Action to be taken

Discussion

Sample Forms

COG Team Project

FOCUS-PDCA Performance Improvement Project
Project Completion Form

Before completing this form, make sure you have submitted a Project Kick-off Form. Please complete this form at the end of your project. 

Project Title:

Team Leader:

Phone number

E-mail address:

Please complete the following:

C -- Clarify the process-- Describe how the team clarified the process/problem (send or e-mail supporting documents):

U -- Understand the process -- Describe the performance measures used and provide baseline performance data:

S -- Select improvements--What intervention(s) or change(s) did your team implement? Identify individuals, departments, committees or others who were responsible for implementation of the interventions (include time frames and other parameters).

P -- Plan the study to test the improvements-- What methods were used to study the effects of the intervention? Identify individuals, departments, committees or others who were responsible for conducting the study (include time frames and other parameters).

D -- Do/implement the plan -- Did the study go as planned? 

C -- Check/study the results-- What were the results of the study? Did performance get better, worse, or no change? (include performance data and send or e-mail supporting documents):

A -- Act on the findings -- What will the team do as a result of the findings? (e.g., continued monitoring, select alternative interventions to study, plans to communicate findings, spin-off ideas, lessons learned, etc.) Identify individuals, departments, committees or others who are responsible for each follow-up action (include time frames and other parameters).

Click here to send, or fax to: 555-555-5555