History of ACEP’s Section on Quality Improvement and Patient Safety (QIPS): A Personal View of the Early Years
David John, MD, FACEP
In my first year out of residency, my new boss thought it would be a great idea for me to do quality and risk management for our emergency department. He thought the best way for me to learn was through the mistakes of others. It also helped that the guy who was doing continuous quality improvement (CQI) for us was tired of doing it. I got really excited and went looking for literature. There was very little at that time, but Jim Espinoza, who founded ACEP’s Continuous Quality Improvement (CQI) Section, had got a section grant and wrote a book on CQI in the 90s. It became my bible.
Until 1999, interest in healthcare quality was limited (in spite of some important work including the Harvard and other malpractice studies in the early 1990s), but late that year, the Institute of Medicine published its landmark report, “To Err Is Human”, in which was stated “at least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year” from preventable medical errors. This generated lots of interest and concern about the issue, and public pressure led to responses from many stakeholders including government and organized medicine. One of ACEP’s actions was to change the name and focus of the CQI section to the Quality and Patient Safety Section (QIPS).
In 2000 and 2001, under the leadership of Sue Nedza, an ACEP Board member at the time, the College organized 2 Task Forces to recommend what actions the College should take in response to the IOM Report. Sue and Dave Meyers each chaired one of the Task Forces, which produced white papers on Patient Safety, which were presented to the ACEP Board. One of the recommendations was that ACEP create a new committee to focus on patient safety.
I was commissioned by Mike Carius, the president of ACEP at that time, to dissuade the Board from making this move. He believed that there were too many committees in the College. A lot of time and effort and money was spent on these committees that did not really do very much. He believed in empowering the sections and asked me to somehow incorporate Dave and Sue and the white paper into the newly named Quality Improvement and Patient Safety Section. After some contentious discussion on the Council floor, I convinced Dave Meyers to join the section and become the next chair. He agreed to only if I would stay on for a second term. He was very busy in his professional career at that time.
Marilyn Bromley, then the staff liaison for the College’s Emergency Medicine Practice Group, felt sorry for me and took me under her wing. She showed me the ropes of the College, got me in contact with the right people, helped me with my grants, and basically consoled me through the dark and lonely days before quality counted for anything. Marilyn has since been replaced in her retirement by Sandy Schneider, past-president of ACEP.
Around 2001, I went to the Scientific Assembly (SA) in Chicago where I attended the CQI Section meeting at Navy Pier. There were seven of us in the room, and Jim, who had been the Section chair for years, was stepping down. He asked for nominations from the floor, and two people raised their hands - a woman whose name I do not remember and Dan Murphy. She was made the Chair, and Dan was the Chair-elect. We never heard from this woman again. Dan and I managed to write enough articles ourselves to squeak out two newsletters. We essentially wrote about what we were doing in our EDs. We agreed that the next year, I would be Chair-Elect. I was uncontested.
I guess you could say the rest is history. There was not a lot of interest in the Section from the College or the membership. Courses on quality were poorly attended. Other courses like Pediatric Airway and Flesh Eating Bacteria were much more sexy and popular. In the early years, I spent many a December dipping into my bank accounts to pay for memberships for residents and my colleagues to get our Section membership up to 100, so we could have Council representation. I also spent a lot of time trying to convince people that quality was important.
Fortunately, my and the other’s efforts slowly began to bear fruit. I still went deep into my cash reserves every December to keep the membership at 100, but at least I had found a replacement. I spent the next several years trying to figure out ways to make quality sexy. We started getting out consistent newsletters with interesting pieces from all over the country. Dave and I wrote most of the newsletter articles. We then found Helmut Miesl who was a kindred spirit. With great effort, we convinced him to come out of semi-retirement to help us run the section.
I wrote three grants over the next four years. When they were funded, I opened them up to the membership of QIPS. Most of us were trying to push our careers along and getting on a grant was a good way to pad a CV. I had anywhere from 25 to 50 people on each of the three grants. This allowed us to network on a fairly regular basis and it allowed me to identify future leaders.
The first grant was called QTIPS, Quality To Improve Patient Safety. I always found it overwhelming when I went to the scientific assembly. I would learn lots of great things, but then would never really change my practice as a result. I got a group together including nurses, physicians, and PAs to attend all of the lectures at the Scientific Assembly in Boston in 2003 (the year the Red Sox lost to the Yankees in game 7 of the ALCS). Our goal was to have somebody in as many lectures as possible to come up with 3 to 4 tips from each lecture that people could bring back to their EDs and change their practice. The example that I always use was from a pediatric lecture called the Inconsolable Infant. After you have checked for signs of child abuse, hair tourniquets, and the other usual suspects, they suggested that you stain the eyes with fluorescein. I was still compiling the QTIPS list when I was faced with that infant screaming at the top of her lungs. I stained the eyes and bingo she had a corneal abrasion. Over time, we put about 400 QTIPS online on the ACEP website and they may even still be there. For a few years after that, the Education Committee requested the SA faculty put four or five practical take-home tips from each of their lectures in their syllabus. (I like to think that was the forerunner of the “Editor’s Capsule Summary” of articles in the Annals of Emergency Medicine).
The second grant was called The Chief Complaint Based Quality Indicators. We took the six highest risk chief complaints - headache, syncope, altered mental status, chest pain, shortness of breath, and abdominal pain - and tried to come up with at least 3 to 4 indicators that would help improve quality to providers in the field. We put a lot of time and effort into this grant and many of us in the section worked on this. It became so important to ACEP that we were asked to finish it six months early. They needed to be able to show the federal government that they had initiatives in quality after the 2006 Institute of Medicine report on the state of emergency care in America (Hospital-Based Emergency Care: At the Breaking Point). We got the grant in to the Board as requested.
The last grant I wrote was called the Quality Course. We decided to put together a three hour course as one of ACEP’s stand-alone courses. The first year we gave it at the ACEP Spring Symposium in San Diego. The next time we gave it as part of the International Emergency Medicine Conference in San Francisco. It was well received, and for a few years I threatened to update it and give it again.
Some luminaries from the Section in those early years included (here I am trying to go in chronological order): Dave Meyers, Helmut Meisl, Jack Kelly, Bob Broida, Dickson Cheung, Chris Beach, Azita Hamedani, Jay Schuur, Mike Phelan, Elaine Thallner, Shari Welch, Kevin Klauer, Jim Augustine, and Heather Farley. We all worked together on the content of the grants, and many presented at that International Emergency Medicine Conference.
I continued to spend a lot of time and effort trying to convince people to be part of the leadership track for the section. Many had just taken new jobs, had babies, and plates that were way too full to take on any more responsibility. As you know they became leaders at different times. Many like Jim, Kevin, Sheri, Azita and Mike contributed greatly to the section, but were too busy to take on a leadership position.
One interesting side note: Jay Schuur was doing a Robert Wood Johnson Fellowship in quality at Yale in the early 2000’s. He looked up “quality” in Emergency Medicine. The only person he found was me. I was still living in the New Haven area since my initial neurosurgical residency at Yale in 1988. We met for drinks and he became a section member.
I cannot take credit for all of the success that followed me. But we did get out four newsletters per year, had several successful grants, year after year service and newsletter awards from the College and a pipeline of exceptional leaders continuing to this day. My strongest contribution to the section was networking and getting to know all the amazing people that I have mentioned above. If you are not on the list, is not because I don’t love you, I am getting old and my memory is not what it used to be. Thanks to all of you for stepping up and making the QIPS section what it is today.