Pay for performance improves rural EMS quality: investment in prehospital care

To evaluate the effect of a system of financial reward for emergency medical technicians (EMTs) who meet selected quality marker goals.

This project was reviewed by an institutional review board (IRB) and was found to be exempt from IRB review. Two operational and four clinical markers were targeted for improvement. Baseline performance measurements were retrospectively measured for the preceding year, and challenging but achievable goals for improvement were established. Operational markers included completing run reports within three hours after completion of the run and call-to-en route ("out-of-chute") times of less than 90 seconds for emergency calls on our first-line ambulance. Clinical markers included the use of aspirin in adults with nontraumatic chest pain, electrocardiogram (ECG) performance in adults with nontraumatic chest pain, documentation of pain assessment and intervention in patients with traumatic hip pain, and documentation of the time of onset of symptoms in stroke calls. Each full-time EMT could earn up to $1,000 in addition to baseline pay, with part-time EMTs eligible for prorated amounts.

Postincentive run reports were completed within three hours 99.7% of the time, with 21 of 24 providers meeting the goal 100% of the time. Before the incentive, reports were completed within three hours 64% of the time, with only two of 23 providers meeting the goal 100% of the time. The out-of-chute goal of less than 90 seconds was met 98.7% of the time, compared with 90.1% before the incentive. Aspirin use in adult nontraumatic chest pain improved from 68% to 96.3%, and ECG performance in this group improved from 43% to 87.8%. Documentation of the time of onset of symptoms in stroke patients improved from 97% to 100%, and the assessment of and intervention for pain in traumatic hip pain patients improved from 56% to 100%.

Financial motivation improved targeted quality measures in this rural emergency medical service. It appears to be a useful adjuvant to traditional quality improvement mechanisms.