Quality Improvement in healthcare has a long history, but it officially entered the scene initially with the publication of the Darzi next stage review, the rise of the Healthcare Quality Improvement Partnership in around 2008, and the emergence of the NHS Institute for Innovation and Improvement in 2013. However, within this landscape, Quality Improvement in Ambulance Services has faced unique challenges.
Traditionally, Ambulance Services have primarily concentrated on learning from incidents, using them as opportunities to review issues and implement changes. Recent initiatives like Project A and the Ambulance Q network aim to promote Improvement in pre-hospital care while considering the distinct complexities of Ambulance Services.
Nevertheless, the conventional Quality Improvement model has struggled to gain traction in Ambulance Services for several reasons:
Organizational Culture Despite there being a recent pivot to looking at more proactive care and interest in the wider determinants of health, Ambulance Services are inherently emergency-focused organizations. The core mission revolves around immediate response, necessitating command-and-control leadership and a constant state of readiness for crises. The very nature of ambulance work demands a culture of swift, decisive action. The focus on ‘responding’ often overshadows long-term improvement efforts.[1][2]
Professional Standards Unlike Medical and Nursing professions, where Quality Improvement is deeply embedded in professional portfolios, Paramedics have less explicit guidance. While HCPC standards for Paramedic practice do mention Improvement in a general sense, they lack the specificity and emphasis on active participation and data collection seen in other healthcare professions. Paramedic standards hint at the need for Improvement but fall short of providing clear direction and expectations for Paramedic involvement.
Work Environment Ambulance personnel work in a dynamic and demanding environment with minimal downtime. They often lack dedicated time for personal and team development, let alone Quality Improvement activities. The work is characterized by constant movement and high-pressure situations. This leaves little room for contemplating broader changes or engaging in structured Improvement initiatives.[1][2]
So, if we were to draw a force field analysis of the situation, you’d see an epic tug of war with individual staff on one side and a massive, change-resistant squad on the other. It’s like trying to shift the immovable object with a feather duster, and it’s causing frustration, burnout, and even staff exodus.
Having worked in the Ambulance Service and with Ambulance Clinicians, the inability to make change is not through want of trying. They are some of the most competent, versatile professionals in the health care game but as described, the odds are stacked against them. These issues are not going to change overnight, but a movement is underway. Quality Improvement is transitioning from individual endeavours to a systemic approach that aligns with organizational goals and operates as a cohesive unit. This approach, emphasizing quality management systems rather than isolated Improvement efforts, holds promise for overcoming issues, especially the ambulance service barriers, yet is also likely to take many years to achieve.
But before you lay blame soley at the “System” you find yourself in, imagine a world…Where you didn’t have to rely on others to make change for you; where you were able to assume control, taking tiny steps towards “Better” for you and your team? Maybe there is a way?
In the challenging environment of Ambulance Services, where the need for Quality Improvement is paramount but often met with resistance. I think we need to think differently about micro-changes repeated every day, so that Improvement becomes reliant on habits, rather than traditional rigid methods. This is not a tried and tested approach, but maybe its worth a try. The principles of “Atomic Habits,” as outlined by James Clear, can provide a practical framework for driving and sustaining positive change. Let’s explore how these principles can be applied effectively:
Make it Obvious: In the context of Quality Improvement in Ambulance Services, making the desired change obvious is crucial. This involves clearly defining what needs improving and setting specific, measurable goals. For example, rather than a vague goal like “improve patient care,” it could be “try to reduce time on scene with patients by 5 mins per patient or make sure your vehicle is fully stocked before leaving your shift.” This clarity helps Paramedics and staff understand the focus and direction of their efforts.
Make it Attractive: Attractiveness plays a pivotal role in habit formation, associating action with positive emotions or rewards. In the Ambulance Service, making Quality Improvement attractive could involve gaining support from organizational leaders and emphasizing the positive impact on patient outcomes and job satisfaction. Rewarding and celebrating successful efforts can make the process more appealing, motivating individuals and teams to engage actively.
Make it Easy: Paramedics and staff in Ambulance Services have demanding schedules, leaving little room for additional tasks. To overcome this, the habit of Quality Improvement must be made as straightforward as possible. Simplify processes and provide tools and resources that facilitate Improvement initiatives. For instance, create user-friendly templates for documenting improvement projects, or introduce digital platforms that streamline data collection and analysis. I previously re-purposed an existing app which allowed all non-ED pathways contact details to be stored in one place, which instantly increased use of these pathways as they were easily accessible with no extra cost.
Make it Satisfying: One of the keys to habit formation is the sense of satisfaction that comes from completing a habit, even with modest gains. In Ambulance Services, implementing Quality Improvement projects can become satisfying by showcasing individual and team progress through data or patient feedback. Recognize those who actively engage in improvement efforts. Seeing the positive impact of their work on patient care and outcomes can be a powerful motivator. The opposite approach could be taken for unwanted behaviours, especially through feedback loops to support people to make the right decisions and understanding their reasons for current unwanted behaviours.
If there was one I might add in this situation it would be…5. Make it Important: In the context of Paramedic work, emphasizing the importance of Quality Improvement is essential. Link Quality Improvement to the evolving expectations in the profession and the broader healthcare landscape. Show how it aligns with the organization’s mission and vision, regulatory requirements, and the ultimate goal of providing the best possible patient care. We need to help others understand that Quality Improvement is not just a “nice to do” but a fundamental aspect of everyone’s role.
By applying the principles of Atomic Habits to Quality Improvement efforts in Ambulance Services, it may be possible to take repetitive microscopic steps towards Continuous Improvement. Rather than expecting individual Ambulance Clinicians to initiate and manage Improvement projects independently, the focus shifts towards a collective effort, supported by organizational structures and leadership.
In this way, Quality Improvement becomes an ingrained habit, a part of daily practice and a shared commitment. It moves from being a daunting challenge to a routine aspect of Paramedic work, ultimately leading to better patient outcomes and a more resilient healthcare system. So if you’re reading this, think about how you can help your teams by applying some of the atomic habits above or how you as an individual might develop Improvement habits using these tiny tools.
Let us know how this works for you
Join us next week for… “Getting to grips with hospital QI – avoid the pitfalls!” Podcast
References
-
Hobbs L, Devenish S, Long D, Tippett V. Facilitators, Barriers and Motivators of Paramedic Continuing Professional Development. Australasian Journal of Paramedicine. 2021;18:1-7. doi:33151/ajp.18.857
-
https://www.paramedicpractice.com/features/article/the-paramedic-profession-disruptive-innovation-and-barriers-to-further-progress
