Participating in quality improvement for emergency care: Some principles and practical tips.

If we are not trying to go forward, we will go backwards. If we are not trying to improve the quality of emergency care, the quality of emergency care will regress. If we are not participating in efforts to improve the quality of emergency care, we are the barriers to improving the quality of emergency care. There is no perfection in emergency care quality improvement (QI); continually recognising opportunities to improve the quality of emergency care is essential if we wish to participate in emergency care QI. QI in emergency care is about paying attention to structure, process and outcome.1 Structure (i.e. physical ED space) can be slow and resource-consuming to change, and its benefits will only be realised if it is linked to improvements in process. Outcome improvements (e.g. mortality and length of stay) are the goal, but are dependent upon process improvements. Process is most linked to the whole patient journey; it is where QI in emergency care begins and ends. The following are a selection of principles and practical tips for participating in QI for emergency care. Participate. Identify opportunities in your setting (i.e. your ED). Start small, with a feasible aim, a short timeline, a simple intervention and an easily defined process and outcome. Hitch a ride on an existing project. Read. Search the literature. Develop your own taxonomy (i.e. understanding and classification) of quality, QI, a menu of metrics, a menu of opportunities and a menu of interventions. Build your own library of evidence-based interventions matched to potentially identified opportunities to improve emergency care. Observe. Look around. Observe a patient's journey. What are the consistencies? Where are the sources of variation? Observe the patient journey from the perspective of others: the doctors, the nurses, the allied health team, the managers, the clerks, the security staff, and, of course, the patients, their carers and their families. Observe with your eyes, but also with your ears. Listen to all actors in the patient's journey through the ED. Observe emergency care and observe how it is documented. Observe emergency care by arrival mode, by culture, ethnicity, language, age and gender, by presenting complaint, place in the journey (virtual [e.g. at home, a clinic or residential aged care facility], ambulance, triage, first cubicle, radiology department, emergency short stay and transfer out of ED), event in the journey (arrival, registration, triage, initial assessment, pathology tests, radiology tests, medication and fluid administration, other treatments, communication, monitoring, repeated assessments, referrals, multiple waits and disposition), by type of frontline healthcare worker providing the different parts of emergency care. Observe emergency care by how it is documented; by how it is communicated. Ask questions. Do not assume that whatever is the case, was always the case or needs to be the case, forever. Query the rationale for the way things are done. Talk to others who have tried to change the way things are done. What would they do differently if they tried again? Would they mentor you, if you tried to achieve where they feel that they fell short? And take notes; dedicate a notebook or folder. Champion. Find one, be one. Find many: a champion doctor, nurse, allied health professional, a consumer, a quality manager, and an electronic medical record expert. Ask them to be a mentor; but also use them as a mentor. Then multiply your impact: be a mentor. Evaluate. Measure. Measure before, during and after. Identify the best metrics which are already accessible. If it is worth evaluating, then it is worth measuring, and it is worth sharing the results of that evaluation. So, define your QI activity; generate a one-page protocol, submit an ethics application, secure local support and permissions, collaborate widely. Then write up and submit to a peer-reviewed health journal for publication. And close the loop: make sure that the planned intervention has been implemented and make sure that the planned intervention has had its intended impact and sustained that intended impact. So many projects are commenced with enthusiasm and then fade away or sharply cease, with no evaluation, no feedback, no report and nothing to inform the next time someone tries to address the same improvement opportunity by resuscitating the same improvement intervention. Sustain. This is hard. Staff move. Priorities change. Funding stops. Ensure there is a sustained memory, including that logbook and/or folder you started; maintain momentum and continuity with ongoing advocacy, measurement, feedback and celebrate the milestones, the successes and the improvements. Remember what, or rather who, all this is about. It is about the patient; do not forget this. Look back and reflect; then refresh and look forward again. If we are not trying to go forward, we will go backwards. Your PROCESS checklist for QI in emergency care P-articipate in QI activities in your setting; R-ead widely and build your library of resources; O-bserve the patient journey through your ED; C-hampion QI in emergency care; E-valuate at the start and at any junctions along the way; S-ystematise QI activities in patient care and associated meetings; S-ustain through advocacy and refreshing. Open access publishing facilitated by Monash University, as part of the Wiley - Monash University agreement via the Council of Australian University Librarians. GMOR is a section editor for Emergency Medicine Australasia.