“You don’t know what you don’t know.”

Chaos of ED room

Our department’s ED Quality Assurance (EDQA) committee will celebrate its 4th  anniversary this September. By that time over 1,100 cases will have been reviewed by the roughly 10 individuals who make up this committee. Cases are obtained using both screening criteria (ED mortalities, return visits resulting in admissions) and open referrals from inside and outside the department.

While most referrals are internal, many come from other hospital departments, private attendings, and patients\families. EDQA is our major tool for barriers to providing optimal care and improving patient and staff safety.

standing out

The composition of the committee is key. It includes both ED nurses and physicians (including leadership) along with a representative from the hospital’s quality department. When appropriate,  representatives from other departments also attend. Commonly this includes psych emergency services, trauma, EMS, and neurology.

The actual case reviews center around a structured questionnaire that guides discussion and is completed for each case. The focus is on determining whether the care and clinical decision making were appropriate. The committee is asked to judge whether an adverse outcome occurred and to identify any documentation, patient care, or systemic (including cultural ) issues.

edqa breakdown

Most of the review is based on the ED electronic medical record (physician and nursing notes, lab results). At the conclusion of each case the committee provides a rating (0-6) of the ED portion of  care. Zero represents no individual provider concerns while a six denotes grave concerns related to avoidable severe morbidity or mortality.

The majority of charts reviewed receive a rating of zero. For the rest,  most are rated in the minor to  moderate range (1-3) . Severe concerns (4-6) are rare. When adverse outcomes or care\documentation issues are identified rapid feedback is also provided (usually electronically).  The main goal is to educate and achieve future risk reduction rather than to be punitive.

Just as importantly many system issues (human, computer, non-ED, and cultural) that act as barriers to optimal care are identified. The knowledge of these gaps and barriers is used to further reduce risk and improve the reliability of our systems (See Swiss Cheese Model).  Participation of ED leadership in EDQA  (See Collaborative Leadership in the ED) is an essential element for success.

swiss cheese model

Other benefits of EDQA include:

  • the ability to handle and control most issues within our department. Our process is recognized throughout the hospital as being effective and well constructed.
  • a vehicle to bring well defined concerns to other departments.
  • being a major source of information for the decision makers in our department.
  • identifying at-risk employees (though most of our energies focus on system concerns)
  • a great educational platform on patient safety and systems engineering (with CME\contact hours available).
  • being open to anyone who wants to refer a case. Provides a voice for all employee concerns.
  • the ability to learn from others’ mistakes instead of duplicating them.

Throughout the Spring I will be writing on the lessons we have learned in EDQA. I will be covering aggregate data on the  cases reviewed; where typical gaps exist in complex systems such as the emergency department; how we can put lessons learned to work; and tips for providing better and safer care. For those excited to get started I am providing a  set of lecture slides from two years ago (The Sharp End).

David