Grand Rounds
PETER CAMERON, MD // PRESIDENT OF IFEM
Applying the ‘Quality Framework’ Now that IFEM has published a quality and safety framework, EPI executive editor Peter Cameron turns the spotlight on his own facility in Qatar. How does his new department stand up under scrutiny?
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Following the successful launch of the quality and safety framework policy under the International Federation for Emergency Medicine (IFEM), now available on the IFEM website, I was stimulated to review
before, with different social and religious norms, made me a little nervous about my ability to interpret what I was seeing. Physically, we were in the middle of a renovation program, so the environment was suboptimal. There were cramped spaces, noisy building works, poor signage and “way finding”. I got lost just going from triage to the trauma room. In addition, there was significant overcrowding with patients pending admission cluttering the ED bays and little room for new patients. Patients were cranky to say the least, with a number of physical and verbal assaults evident. Staff were not communicating well and there was a lack of respect between professions exactly how I was going to measure quality in my own department and how we and also between services attending the ED. Further compounding the negawould know whether we were actually improving the department and its functive approach of staff was the fact that patients and their relatives showed little tions. The quality framework document asks some very simple questions: respect for the staff. There was a high commitment to working hard but a lack • Are the facilities adequate? of initiative to solve problems, especially amongst the junior nurses and doctors. • Are the numbers and quality of staff adequate? Observing processes, there was a lot of movement, much of which seemed • Is there a culture of quality? inefficient, with patients being moved backwards and for• Is the data support adequate? wards and poor handovers. There was a high level of noise • Are the key processes in place? and lack of coordination between doctors and nurses. • Is Access Block present? Gestalt vs. Metrics Communication was not efficient, with repetition and • Is evidence-based practice resulting in optimal results? I have noticed that misunderstanding. In spite of this, staff did smile and • Is the patient experience measured and acted upon? within minutes of greeted me with appropriate salutations. Doctors from • Is the staff experience measured and acted upon? entering an ED, most other units appeared to have little respect for ED decisions senior emergency and would frequently disagree with emergency physician By asking these questions and measuring as well as actdoctors will quickly opinions. ing upon the relevant parameters, it is likely that an ED decide whether the ED is Regarding culture, our department looked like it was in would function very well. functioning well or not. trouble. My gestalt, based on the “vibe” of the place, told I have always been a believer in the “gestalt” of medicine But what if the numbers me the ED processes and outcomes must be poor. So I tell a different story? at a clinical level – that is, by asking a few basic questions, looked at numbers to see if the quality indicators reflected a senior clinician can learn quite a lot. Is the patient sick? what I saw. Will they need to be hospitalized? Are they likely to die? Using typical indicators such as length of stay, the overall Usually, this clinician can give reasonably accurate answers numbers were good by any standard with a median time of about one hour for to these questions within minutes, approximating or even bettering elaborate total length of stay. Even patient satisfaction looked fairly good – over 90%. For decision rules with complex algorithms. Of course, there are some patient outlia department that sees over 1200 patients per day, figures such as mortality rates ers and we sometimes get it wrong… and complications also looked very impressive, with very low rates (not risk adWhen it comes to assessing the quality of an emergency department, simple justed). Even the indicators such as staff turnover were better than what I had questions give us a decent view of the ED as a whole. Is this a good department, been used to in Australia. Did this mean that my gestalt was wrong? somewhere I would bring my family to get treatment? Does attendance here reWell, not exactly. Statistics don’t always give the full picture. The length of sult in unnecessary morbidity or mortality? Is this a place I would like to work? stay numbers did not reflect the fact that there were a large number of minor paI have noticed that within minutes of entering an ED, most senior emergency tients that were handled very effectively, were managed by ED staff and turned doctors will quickly decide whether the ED is functioning well or not. There is a around within an hour. These patients were generally satisfied and received a “vibe” in a good department – people smile, they talk courteously to each other. reasonable service. However there was a small percentage of seriously ill patients It may be busy, but it looks like activity is coordinated. Clearly poor physical who were in the ED for many hours and a significant number waited for days facilities are immediately apparent and overcrowding is obvious with a quick for a bed. The time for admitted patients to reach an inpatient bed was averagwalk around. Outcomes are not obvious from quick observations, however, in ing more than six hours. Critically ill patients were receiving sub-optimal care. other industries there is good evidence that the right culture, or “vibe”, actually The low staff turnover was not necessarily related to satisfaction with the prescorrelates well with outcomes. ent job. Most staff were expatriates who came on fixed contracts and had limited So, getting back to my ED, what sort of vibe did I get walking around the ED options because of these contracts. In some cases they had no chance of returnwhen I first visited more than six months ago? Coming from Australia and being to their home country. This might bring stability, but it does not ensure an coming Chair of a very large department in Qatar, a country I had never visited
34 Spring July 2012 2013// // Emergency Physicians International