Reflections on being a QI Director for over 30 Years
Helmut Meisl MD, FACEP
Once upon a time many years ago, I was accepted as a new member at my regular ED. Following the custom at this department, the most junior member was assigned the task of QI person, Director was not the title. I readily accepted this position as I was keen on working at this ED, and the prior QI person was all to glad to rid himself of this chore. At that time the task was mainly to review charts, a large pile that somehow materialized at our ED meeting from various sources. At these meetings, we waded through the charts, engaged in lively discussions, and assigned some level of care.
My first special project identified an issue regarding care of pediatric epiglottitis, which was a significant concern at the time with the fear of airway obstruction (Hemophilus, does anyone remember this major pathogen in children?). ENT, Pediatrics, and Anesthesiology, devised a procedure and so the gradual start of collaboration between various departments and the ED began, which had previously operated in relative isolation. The position progressed further with more organized peer review and chart referral processes that included review criteria and standardized methodology. With time, several projects and issues were addressed involving the hospital and various departments, some were forced upon the ED, and others were initiated to truly improve patient care. One project in particular included obtaining approval from anesthesiology for ED use of thiopental for sedation prior to endotracheal intubation. I had to address anesthesiology’s concern that the patient may become too sedated and may require intubation, despite my repeated statements that intubation was already planned. This was part of the learning phase for many junior members who were starting to realize the constraints senior ED physicians experienced. Today, we have various agents, not just for intubation, but also procedural sedation. Variability still exists for the use of these agents in various hospitals, but this is just one example of our expanding scope of practice.
I found the job to be interesting and I stayed on as the QI person, despite the arrival of another junior member. The next new EDMD wanted to avoid QI work and the ED Director was happy for me to continue in this role. I flattered myself that this was due to my good performance in QI activities, but it is more likely that I was the only one foolish enough to even want this task. So as the years continued, I received the title of QI Director, rather than the person dedicated to QI at the time. QI went through various terms, including QI, TQM, CQI, depending on the term in style, with various reasons given why one system was better than the other, but essentially all were the same.
Mandates and surveys began to be developed and implemented. One mandate example comes to mind, a mandate to measure head circumference on all children presenting to the ED, which could be a tormented struggle on a child with a broken arm. The JCAHO, TJC or Joint Commission mandates evolved with time. There were the regular surveys, which involved the ritual of combatting the Commission’s latest priorities and hot issues. We planned carefully in advance to educate the EDMDs to prepare them for various questions. We also had elegant protocols in place in large, neatly indexed ring binders. When survey time arrived, all the Managers and Directors would follow like sheep after the surveyors, and then be asked the profound question of where the fire sprinklers were. After these surveys we were relieved, not because we had actually learned something to improve patient care, but because we had another 2 to 3 years of time before the next survey.
I recall the various hospital department meetings, which often produced somnolence. However, one always had to remain alert for when a medical staff member at a high-profile meeting would suddenly criticize the ED. For example, the thoracic aortic rupture that was “missed in the ED”, but on further review revealed that the condition was actually diagnosed in the ED. One of the ongoing jobs of the QI director was to be alert to rumors, investigate them, and try to mitigate and resolve them. The very important result of these interactions and meetings was the elevation of the status of the ED and its physicians. When I started out, EDMDs were characterized as people who had various levels of training, or rather lack thereof, much less any specialty status. Some viewed EDMDs as individuals looking for a part-time job or moonlighting and as individuals who had little to no commitment to the hospital. I remember one term referring to EDMDs as “Band-Aid Bandits”. Over time, both administration and other members of the medical staff recognized EDMDs as educated and devoted peers.
With the arrival of EMTALA, also came legality, paperwork and anxiety about this regulation. I found that transfers to and from my hospital even before EMTALA were quite appropriate. Various hospital accreditation, certifications “Centers of Excellence” or merit designations, that were popular at some time, included cancer, chest pain, stroke, or even infertility (long story). The arrival of the long overdue Patient Safety movement came along, with more hospital and medical staff emphasis on QI processes and safe medical care, issues that QI Directors had been addressing in some manner for years. There also were the lectures and Medical Grand Rounds, with one lecture being quite memorable as the projectionist dropped my tray of slides (does anyone remember the time before PowerPoint?) and quickly put them back into the tray, and I had to continue the lecture with the slides in random order.
QI Director is no longer the shunned chore, and fellow EDMDs now strive for this position. For me, it was all an interesting experience and journey; I learned from every chart and every project, and I do believe the process led to actual improvement in patient care. It also reflects the journey and progress of Emergency Medicine.
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