Towards quality emergency medical services. April 2021

BETTER HEALTH PROGRAMME SOUTH AFRICA

CASE STUDIES

MARCH 2021

TOWARDS QUALITY EMERGENCY MEDICAL SERVICES (EMS)

In early November, BHPSA went to the Western Cape accompanied by a top team of health officials. Their mission: to workshop the Ideal EMS Framework Tool and to discuss a range of the nationally-driven quality improvement efforts and how they can strengthen emergency services in the Western Cape Province. The team included members of the National Department of Health (NDoH) Emergency Medical Services, the Quality Assurance Directorate, as well as the Office of Health Standards Compliance. They conducted a two -day workshop, and spent a further day assessing one of the stations of the Western Cape Emergency Medical Services (EMS). The meeting was hosted at the EMS Communication Centre at Tygerberg Hospital, Cape Town. Attendees from provincial EMS services included the EMS Operations, District, Sub-District, Communication Centre and Information Managers from the Western Cape Province. The Western Cape Communication Centre is responsible for receiving emergency calls for medical help from the public as well as health facilities that come from across the four regions of the City of Cape Town. They must then dispatch the closest appropriate ambulance, crewed by paramedics and Intermediate Life Support Practitioners, as required.

The Centre Manager took us on a tour of the Communications Centre demonstrating their up-to-date technology that enables them to identify callers via their Computer Aided Dispatch System (CAD) and geographical location (by “What3Words”) and dispatch ambulances at speed. This centre co-ordinates 58 city emergency services which handle an average of 1, 000 calls a day, resulting in an average of 600 responses per 24 hour period. Approximately 80% of patients are treated and transported to a health facility. The ambulances that are dispatched to patients that are critically ill or injured are backed up by the Advanced Response Units as well as the Aeromedical Services.

Three interlinking quality improvement and quality assurance programmes were discussed in the workshop. These are the National Health Quality Improvement Plan (NHQIP); the Ideal Emergency Medical Service Framework and the OHSC quality assurance strategy. BHPSA is providing some support to the NHQIP and is engaged in ongoing technical assistance to strengthen the Office of Health Standards Compliance.

THE TOOLS AND FRAMEWORK

Days one and two of the visit were given over to presentations and discussions about the EMS Ideal Framework and the national quality improvement strategy. Raveen Naidoo, who heads the NDoH EMS, presented on the draft Ideal EMS Framework, which sets out norms and standards for services across the country. It covers six domains of health care which are: facilities and infrastructure, patient rights; clinical governance and clinical care; clinical support services; leadership and governance; and operational management (unique to EMS). This framework has been used to create a tool for assessment across the six domains which are in turn divided into vital, essential, important or aspirational. These will be measured by observation, interviews and document review.

After a lively discussion, this was followed by a presentation on the NHQIP by Catherine Mbuyane, Director of the Quality Assurance Directorate in the NDOH. The NHQIP is one of the key drivers of quality improvement at national level and aims to

establish at least two Quality Learning Centres in each province. These will include hospitals, primary care and EMS services (public and private) and form the focus for learning and disseminating skills for quality improvement. Best-performing facilities and personnel will be identified to lead the clusters.

The presentation outlined the phases in implementation of the NHQIP, including training of assessors to conduct selfassessment and peer review by facilities (using the Ideal EMS Framework in this case); the development of facilitybased quality improvement plans; and support and mentoring visits. After these phases have been completed an external evaluation will be carried out by the OHSC to assess whether the facility meets requirements for certification and accreditation for National Health Insurance (NHI).

PUTTING TOOLS TO THE TEST

On the second day of the visit, participants had the opportunity of working carefully through the Ideal EMS tool which enabled them to understand how it would work and how it would fit into the wider regulatory framework. Some gaps were identified by attendees including the need for measures around staff safety. This was of particular concern to Mitchell’s Plain EMS staff who have to work in extremely dangerous conditions, with staff being held up at gunpoint and ambulances stripped of equipment on a daily basis. These assaults have led to a situation where, at any given point, EMS workers are off with post-traumatic stress disorder, and the remaining staff are under additional pressure. EMS participants requested that the standards include Victim Support for EMS staff as well as measurements of security such as dashboard cameras for ambulances that work in areas of high violence. On day three, the team headed off to the Mitchells Plain EMS to test the tool in one of the busiest trauma regions of the city. They were warmly welcomed by staff members who were keen to get involved and to improve the quality of their services as well as the overall safety and cleanliness of their site.

A self-assessment was conducted with the final score of 75%, and achieved a silver status: the EMS station had scored well for a first go at the tool. Obvious areas were identified for improvement with assistance from NDoH EMS and Quality Assurance Team.

OBSERVATIONS

BHPSA noted that the need for improved communication around the OHSC and its role. Out of a working group of approximately 15 people, only one person had heard of the OHSC and participants were very surprised to hear that the EMS would have to be assessed and certified by OHSC before they would be eligible for NHI. This observation will be fed into BHPSA’s support for the OHSC communications strategy which is now underway. It was rewarding to see the interest and enthusiasm about quality improvement shown by the Western Cape Emergency Medical Services (EMS) participants. They were positive about implementing the Ideal EMS framework and excited to be part of a national initiative along with all the different health facilities in the country.

The UK’s Better Health Programme (BHP) is a global health system strengthening programme led by the UK Foreign, Commonwealth and Development Office and delivered in South Africa by Mott MacDonald