Benchmarks Beyond Borders

Published on July 12, 2013
In November, London hosted a symposium on EM quality that opened the door for a global consensus

As part of IFEM’s role in promoting emergency medicine internationally, a decision was made to begin the work of developing a framework for measuring quality of care delivered by emergency departments to act as a catalyst for driving improvements in emergency department (ED) care.

Although the concept of striving to deliver the highest possible quality of care is a “no-brainer”, what we mean by this – and how we measure it – is a lot more complicated than it first seems. There are issues regarding the resources, geography, desired outcomes and processes that should be measured. Each country has different approaches to data collection, data definitions and funding – all of which make the aims of any framework for improving quality of care fraught with danger. Fortunately a decision was made by the IFEM executive to collaborate with the UK College of Emergency medicine to organise a symposium in London, England to explore how to go forward.

The UK College put on a fantastic show last November, hosting about 150 EM Safety and Quality experts and enthusiasts from around the world in the British Museum. Delegates were predominantly from the “founding societies” of IFEM – as many of the more recent members have not had a chance to develop a comprehensive quality framework for EM in their countries. The venue exceeded expectations with its grand architecture and treasured exhibits – there was even a little “spare” time to whip off and visit some of the magnificent displays. In addition (a real coup for the organisers) we had a brief visit from Her Royal Highness Princess Anne – the Royal patron of the UK College of Emergency Medicine. To top off the social/organisational highlights, we were treated to a dinner at The Royal Society of Medicine on the first evening of the conference.

Expert speakers included such emergency medicine luminaries as John Heyworth, Art Kellerman, Greg Henry, Pat Croskerry, Sandy Schneider, Jonathan Benger, Suzanne Mason, Michael Schull, Ian Stiell, Ellen Weber and Jim Ducharme. Importantly, some perspectives were heard from under-resourced countries such as Malawi and the West Indies, where Elizabeth Molyneux and Ian Sammy gave their views on what was needed to improve quality of care and what could be done. An equally important perspective was given by Suzanne Shale on the way patients see quality and how we should monitor patient perceptions of quality. The numerical or percentage patient satisfaction survey probably doesn’t give the necessary information to drive quality improvement – a more qualitative approach is necessary to understand patient and relative’s concerns. During the symposium, a range of quality initiatives in a number of countries were discussed and compared and a lot of discussion occurred about what was needed to progress towards a consensus on this topic.

At the end of the meeting Fiona Lecky (symposium convenor) and I had the unenviable task of “summing up” the learnings and attempting to define a way forward to facilitate international consensus. It was clear that despite differences in funding and policy between the various participating countries, there was a lot of commonality in approach and good reason to be optimistic that over the next 12 months we might be able to develop a framework for measuring quality in emergency medicine, that would drive improvements.

The main focus for quality measurement in emergency medicine has been the use of indicators of timeliness and efficiency. These are generally easy to collect, important for patients and liked by administrators. The use of these indicators has driven major change in the provision of care in the UK and other countries such as Canada, USA, Hong Kong and Australia. Waiting times to be seen by a doctor and total length of time in the ED are the most common measures. However many other process times are routinely tracked by individual EDs such as laboratory turnaround time, time for inpatient consultation and so on…

Many participants felt a much broader approach to quality should be adopted and measured and reported routinely. It was agreed that the domains of quality used by the Institute of Medicine (IOM) is a good starting point. Unfortunately, although everyone would agree that domains such as patient-centred care and patient safety are essential components – there is little agreement about how to measure and what data sources to use. It is likely that for many EDs routine collection of data that is not available on administration and tracking systems would represent a large clerical burden. For low resource countries, even routine data is difficult to access. It is probable that there will need to be several approaches to collecting data, depending on IT and clerical resources. In developing a flexible approach to implementation, it is essential that there are common data definitions and standards. Also, for benchmarking purposes, guidelines would have to be developed to enable a standard approach to sampling of ED populations – if data was not available through routine information systems.

Clearly targets and standards will vary according to local infrastructure – there can’t be one standard of care across the globe (much as one might want this an aspirational goal). However for EDs located in urban areas in high income countries, it should be possible to benchmark across regions. Equally for low/ middle income countries – by using standard data definitions, collection methods, population sampling techniques and analysis – it should be possible to compare quality of care for key indicators.

The participants at the symposium agreed to participate in a process of developing a framework for comparing quality of care internationally by commenting on an evolving document by email until the time of the Dublin ICEM conference in June 2012. At that time a forum will be held to discuss quality of care in EM, and hopefully a consensus document will be agreed upon.

The potential for this process of consensus building to enable benchmarking of quality of care across the global EM community is high. Where differences between jurisdictions are clear and result in poor outcomes or poor service to the community, it is likely that local emergency physicians can use these data to drive change to improve care. I am very excited by the involvement of key global opinion leaders and invite others to be involved – even if your involvement is limited to participation in the consensus meeting in Dublin or email commentary because of geography or resources constraints.

*This article originally appeared in issue #7 of Emergency Physicians International *

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