The elusive nature of quality

Ten core principles are therefore identifiable for system success. The AEM Consensus Conference helped inform and advance these notions. In the collective wisdom of the conference day, notions of quality in emergency care progressed. The challenge is now to keep moving forward in an informed way. Perhaps the following core principles might anchor thinking, and help in our search for our elusive goal of quality: 1. Leadership at the highest levels is needed in order to effect enduring, meaningful change to improve the quality of emergency care. 2. Caregivers have to be expert at what they do. This comes through proper selection of personnel, training, attitude, work ethic, interpersonal skill, and ability to work as a team member. Expertise then comes through continued rigorous training and ongoing feedback. Experience without feedback leads to overconfidence. High numbers of encounters with feedback incorporated into future decisions create expertise. 3. The system capacity has to be sufficient to meet the patients' needs. Even the best system will break if demands too far exceed capacity. 4. The essence of quality, satisfaction, efficiency, safety, and cost - effectiveness is the patient - physician relationship. The clinician has to have time to spend with the patient, family, and key sources of information. When paper-work, regulations, administrative tasks, errands, hunts for equipment and supplies, inefficiencies, extraneous telephone calls, and interruptions interfere with sitting, listening, and communicating, danger is introduced. The most fragile part of the care process is the time spent with the patient. Physicians are often criticized for not adapting to poorly conceived technological solutions and for not obeying time-consuming regulations that have no demonstrated benefit. The greater danger might be that physicians actually do adapt. 5. Teamwork is essential. Receptive doctors and nurses must work well together, welcome input, offer supportive feedback, trust each other, and remain worthy of trust. 6. Effective central supports are at the core of ED quality. Completing laboratory tests, delivering medications from the pharmacy, and completing radiology studies and other diagnostic tests, along with timely results, are essential. 7. Continual improvement and innovation are an essential focus of every high-reliability system. Quality takes continual effort. It is not a series of tactics or fads. 8. Involvement of all personnel is optimal. In team construct and functioning, in system design, in continual improvement efforts, in the design of ongoing training programs, representation of front-line experts is required. 9. Consistency of the message, of the goal, of a vision, of clinical performance, of operating standards, is fundamental. In order to achieve quality, the definition must be clear, consistent, and shared. 10. All work must be infused with compassion, integrity, and sound ethics. Yet this raises the bar. With true commitment to compassion, the unit becomes unforgiving. It accepts no inefficiency, poor attitude, or ineffective behavior. Compassion does not forever forgive bad behavior, it recognizes the importance of every individual's every action, relentlessly supports good effort, but does not tolerate destructive action.