Characteristics of a High-quality Anesthesia Practice

Donald E. Arnold, MD Western Anesthesiology Associates Inc., and Mercy Hospital-St. Louis, St. Louis, Missouri

Steve Hattamer, MD Southern New Hampshire Medical Center, Nashua, New Hampshire

James S. Hicks, MD, MMM Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, Oregon



Practice Organization and Activities Quality Assurance (QA) Meetings and Minutes

Proper conduct and documentation of QA activities is the keystone of all institutional QA. In the United States, the Health Care Quality Improvement Act (also known as the Wyden Act, after Congressman Ron Wyden who sponsored the bill) made into law in 1986 provided limited protection for “peer review,” or the review of one physician’s actions by a panel of his/her peers. Before that time, culminating in a notable court case in Oregon (the “Patrick Case”), there was fear among physicians that any criticism of a colleague’s (especially a competitor’s) performance could be interpreted as self-serving. The protections granted peer reviewers were based on the premise that all such reviews were conducted in “good faith,” spurring many hospitals to engage outside reviewers for more egregious cases that could result in a practitioner’s loss of privileges if found warranted. Although the Health Care Quality Improvement Act did not directly address the nondiscoverability (the ability for attorneys to learn the discussion or results of peer review in a lawsuit), many states have subsequently passed legislation that protects formal peer review actions from becoming part of a legal action. Thus protected, the regular review of both generic data (ie, incidence of known complications such as postoperative nausea and REPRINTS: DONALD E. ARNOLD, MD, DEPARTMENT OF ANESTHESIOLOGY, MERCY HOSPITAL -ST. LOUIS, 615 SOUTH NEW BALLAS RD, ST. LOUIS, MO 63141. E-MAIL: [email protected] INTERNATIONAL ANESTHESIOLOGY CLINICS Volume 52, Number 1, 15–41 r 2014, Lippincott Williams & Wilkins

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vomiting, postoperative pain, etc.) and the result of reviews of specific cases becomes the first—and often the most educational—step in the QA process. Use of such tools as the root cause analysis technique to analyze a sentinel event can break it down into its components and isolate primary and contributory causative elements to have an effect on system or individual remediation. Minutes of QA meetings must be carefully recorded and preserved. There should be no individual attribution of opinions and remarks of reviewers or the involved physician made during review of specific cases. Minutes should identify the patient by medical record or other identifying number, a brief outline of medical history, the sequence of events being reviewed, and the findings of the reviewers. Generic screening data should be reported to the quality committee on a regularly repeating basis depending on volume—anywhere from monthly to annually. Anesthesiology departments are strongly encouraged to add their data to a larger pool such as the National Anesthesia Clinical Outcomes Registry (NACOR; see chapter 1 in this volume) to gain access to external benchmarks that can provide stronger statistical support for quality improvement actions. Reporting

Reporting of results from anesthesia QA/peer review activities should be conducted with full confidentiality of the minutes and access should be strictly controlled on a “need-to-know” basis. The services of a Certified Professional in Healthcare Quality are extremely valuable to organize peer review and reporting activities.1 Reports of recommendations ranging from not finding individual responsibility to systems failure to any greater level of concern are to be conveyed to the next higher body of review, usually the medical executive committee and subsequently the hospital board. Typically, the chair of the QA committee or designate should communicate this information upward personally to relate the extent of the discussions held and the basis on which recommendations were made. The Quality Cycle

Far too many departments conduct what they feel are highly organized QA activities, leaving extensive paper trails of their actions, yet never reassess the results of systemic or individual quality or performance improvement recommendations and actions. Real measurement of quality improvement only occurs when a “plan-do-checkact” cycle is completed, and, in some cases, repeated. System changes engendered by QA activities should require at the outset the setting of a time schedule and methodology for measurement of www.anesthesiaclinics.com

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the outcome variable expected to show improvement (the “plan”). The change is then implemented (the “do”). Depending on incidence, the intervening time might be as short as a few weeks or could be 1 or more years. An active tickler file should be maintained to allow for regular spacing of “check” reassessments to ascertain the extent to which the specific quality concern has improved (or not). Finally, the “act” cycle element is used to readjust procedures based on the results of the “check.” ’

Assistance from the American Society of Anesthesiologists (ASA) Overview

ASA has a long history of assisting members and their institutions in maintaining the highest quality of anesthesia care. In 1982, under the leadership of Dr Ellison (Jeep) Pierce, ASA created the Anesthesia Consultation Program to offer the services of expert anesthesiologists to the hospitals of ASA members to assist with the identification and rectification of a wide variety of quality concerns. Over the succeeding 31 years, ASA has performed hundreds of such consultation visits. An overwhelmingly high margin of satisfaction is evidenced by surveys conducted approximately 6 months after the receipt of the consultation report. Reasons to request ASA assistance are widely varied, but most commonly they center on concerns about group organization and leadership, communication issues among anesthesiologists, administrators, and/or surgeons, competence of one or more members, or the structure of the group itself. Occasionally, a hospital will be evaluating all in-hospital physician-contracted groups and acknowledges that ASA is by far the most appropriate organization to judge the performance of anesthesiologists. These consultations usually consist of a visit by 2 anesthesiologists experienced in quality matters, almost always current or former members of the ASA Committee on Quality Management and Departmental Administration (QMDA). The consultants will visit the facility for 3 days (occasionally 2 days in the case of very small facilities) and carefully examine all of the processes involved in the conduct of a high-quality anesthesiology department. In addition to extensive interviews with the “internal” and “external” customers of the department (administrators, surgeons, other physicians, and nurses), they will examine a representative sample of each practitioners’ anesthesia records for legibility (if hand written) and completeness, acknowledging the breadth of anesthesia techniques appropriate to the situation. Should a pattern of deficiencies exist in one or more practitioners’ charts, it will be included in the consultants’ report. In addition, the consultants will examine interrelationships between surgeons, anesthewww.anesthesiaclinics.com

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sia staff, nurses, and administrators. Evidence of an active and functional quality program will be sought, and department members’ participation in hospital affairs will be examined. After this rigorous examination, the consultants will jointly prepare a report on the state of the requesting department, addressing a number of standard areas as well as those specific issues that triggered the consultation request, and provide definitive recommendations for correction of any areas of concern. ’

The ASA/AQI Quality Matrix Could it be Used in my Practice?

Several years ago, the QMDA Ad Hoc Subcommittee on Quality Anesthetic Practice developed a matrix of questions and conditions that it felt could provide any anesthesia department worldwide with the ability to assess its level of quality and fill in any gaps to allow the department to elevate the quality of its care to the highest possible level. The matrix is formatted into a series of questions directed to each of several persons or groups within and external to the anesthesia department. In addition to the chair of anesthesia and staff anesthesiologists, it offers questions to nonphysician providers, preanesthesia, intra-anesthesia, and postanesthesia care nurses, administrators, anesthesia technicians, surgeons, obstetricians, and intensivists. Its questions can easily be tailored to the specific situation of any department. Many questions determine the availability of appropriate anesthesia equipment, policies, procedures, and practices, whereas others are more subjective and ask about the culture of safety, professionalism, interpersonal relationships, and willing participation by department members in hospital affairs and committees. The questions are further divided into “required” and “optional” categories. Every department should be able to demonstrate that it meets all of the “required” elements, whereas the degree of complexity of patients and types of service lines dictate which of the “optional” elements should be present. Can ASA Use the Quality Matrix to Help us Assess our Quality?

Recently, ASA has partnered with the Anesthesia Quality Institute (AQI) to offer a limited “quality check” 1-day consultation involving 1 or 2 consultants at a lower cost than the conventional consultation described above. The “quality check” is designed to allow higherfunctioning departments a review of their quality program with specific attention to benchmarking their performance against national norms as collected by AQI. This program is not designed to diagnose complex relational or clinical performance problems but instead gives the requesting www.anesthesiaclinics.com

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departments an individualized overview of their quality management programs. Limited interviews with surgeons, nurses, and hospital quality staff help to corroborate the reports of the department members and provide valuable feedback to anesthesia department leadership. The ASA/AQI Quality Matrix forms a significant element of this new offering. It is sent to the requesting department in advance of the consultant’s visit and the department uses it as a guideline to prepare for the onsite visit of the consultant several weeks later. By having this map of the standards expected to be demonstrated before the visit, the department is able to prepare for a successful “quality check” consultation. The ASA/AQI Quality Matrix is available to ASA members on the AQI website at http://www.aqihq.org/qmdaqualitychecklist.aspx.



Professionalism

Professionalism is enigmatic, situational, and (despite Webster’s Dictionary) difficult to define. However, with a nod to Justice Potter Stewart, you know it when you see it. The key to any successful department and leadership position is an ongoing attitude of professionalism and service. This attitude needs to be from the top down and imbued into staff at all levels. It is easy to do your best under good circumstances, but real professionalism is manifested during times of adversity and tribulation. Your kindergarten teacher’s voice may still ring in your head, “let’s act like ladies and gentlemen!” yet in our environment there are many stressors that test our professionalism. It is difficult to be at your best at 3:00 AM when you are looking for a third arm, trying to keep a critically ill patient alive. Nevertheless, professionalism (and the attitude that accompanies it) is the key to a “quality” department. It is easy to talk the talk, much harder to walk the walk. Sometimes it is the better part of valor to remove yourself (or another staff member) from a “no win” situation. It is up to each and every member of the department to foster this attitude and help others when they struggle. Anyone can have a bad day. The department must work as a “unit” with the goal to be viewed as the most “professional” department in the hospital. When all else fails, stop and listen to your kindergarten teacher. No matter the profession, dressing for success still matters. We put the white coat on for patients because it means something. How we dress is no less important for our colleagues and hospital administration. Sadly, physicians seem to be dressing “down” more every day. While waiting for the staff meeting to begin, one will see “cut-off” jeans, running outfits, and various forms of “nonprofessional” garb. When meeting with our colleagues, we need to project the “look” of professionalism. This is a special area of concern for anesthesiologists www.anesthesiaclinics.com

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as we are seldom seen outside the operating room (OR) and are, by nature, not interested in dressing up. However, we need to be more thoughtful about how we present ourselves. Keep in mind, the family practice physician sitting at the same meeting is wearing a coat and tie, as he does every single day. We do not want him to view us with contempt—as the guys lounging in our pajamas. Again, back to kindergarten—how you dress reflects your level of respect for the proceedings and those present. This may be subliminal, but the perception by others (ie, the family practice doctor) is very real. When we attend meetings, we should be in a coat and tie. If scrubs are necessary because of clinical obligations, go to the meeting in a crisp, white coat. Anesthesiologists are used to being dropped behind enemy lines, we do it every day. Remember, a successful infiltration into enemy territory requires you to dress like a native! A “quality” department studies “quality”y. always! A “good” department studies data, but a “great” department reports and acts on it. It you are not already doing this, follow these few, simple steps. First, appoint a “Quality Officer”—an individual who will take charge of the project, convene quality meetings, and perform case reviews. Now that you have a leader, you need data. Gather the department and decide what parameters you wish to study (ie, returns to OR, reintubations, wet taps, etc.). Include parameters that can and will indicate quality (or lack of it) within your department. If you are just starting, it does not have to be an exhaustive list and probably should not be; building a quality program will take time. Once you have your parameters, the department will need to create a form (paper or electronic) to be used for every case to track data and create reports. The quality officer should make reports to the department, but the real test is the ability of the department to adapt and change on the basis of the data gleaned. This is the mark of a great department. Another important dimension that separates good from great is “corporate citizenship.” If you want to have a department that is revered for excellence, clinical care is only a single facet. Anesthesiologists need to come out from behind the drapes and literally “work the room.” While it is good to be involved in hospital leadership, it cannot stop there. Activism and leadership must extend beyond hospital walls into your state capitol and the halls of the national legislature. Many, if not most, decisions that have the greatest effect on us, our livelihood, and our patients are political. A great department rolls up its sleeves and gets to know their legislative representatives at every level—local, state, and federal. To have influence on the decisions that affect our patients, we must have influence on those that make those decisions. Know your elected representatives, get involved in their campaigns, and contribute toward their reelection bids. Our professional organizations offer other avenues for involvement. A strong professional society is part and parcel www.anesthesiaclinics.com

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of a vibrant profession. Every member should contribute time and effort for the betterment of all. This investment will always offer a return to the department and individual as well. The exchange of information and ideas through our society provides a cross pollination that increases our depth and strength. Volunteerism should also be a consideration of corporate “citizenship.” Giving back to the community, whether it be through the local soup kitchen or repairing cleft palates on the other side of the globe, adds to the stature of your department. Without moralizing, volunteering elevates the individual. A department with the ethos of “giving back” is a department of quality, placing the needs of others above its own—that is true greatness. Teamwork is the key to a quality department and one of the hardest characteristics to embrace. Anesthesiologists are all-too-frequently rugged individualists. We are used to working on our own, making our own decisions, and taking care of our own patients. It is hard to move from total autonomy to working as a team, let alone becoming a well-oiled machine. However, this is exactly what we must do. Moving to make the department (and not the individual) the focus of success differentiates the great from the good. Paraphrasing the old saying “Imagine what we could accomplish if we didn’t care who got the credit”—imagine giving all the credit to the department. No one wants to be a cog in the machine, but you can still be a “standout” while working hand-in-hand with your colleagues for the betterment of the department. Too often we see insidious and pervasive problems in a department because a few individuals are driven to be glory hounds. Although strong leadership might seem an obvious necessity for a “great” department, it is too often neglected and taken for granted. Many of us have no desire to do the required administrative work. Even though necessary, it is looked down upon as a duty beneath most doctors. Many departments rotate this duty, some so often that those outside the department are never quite sure who is in charge. Leadership has to be consistent, known, and reachable. When it comes to anesthesia department leadership, the 2 most important qualities are access and consistency. Access is simply being available; people need to know who is in charge and how to find them. When a staff member is tossing towels on the floor, the chief must be available to hear the OR nurse vent her frustration. If he/she is not available, the nurse will stew and seethe, then go to administration, pull the nuclear pin, and explode. Then you will find yourself chairing a multidisciplinary task force on “towel management,” all because you were not there to hear the complaint and defuse the bomb before it went off. The consistency of speaking with “ONE” voice is vital. We have all been on the end of a surgeon who is “doctor shopping” because a colleague would not take a case to the OR. The surgeon wants to find an anesthesiologist who will push the risk envelope and then say to the www.anesthesiaclinics.com

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anesthesiologists who turned him down, “See, we can do it!” Approaches to the leadership of a department are no different. People, especially surgeons and hospital administration, want the answer they want. A great department will not allow fractionation and will not be bullied. The department must speak with one, clear voice. All staff members need to know that presenting a united front is vital for long-term success. That is a hard concept for the individualists who are anesthesiologists. However, conferring with each other, building consensus, and allowing a single person to present that opinion will only serve to strengthen the department and individual staff as well. Together, we are stronger—if we do not hang together, we will “hang” separately! Every great department has a “compliance officer.” It is often an unpopular position because the person becomes the departmental “beat cop.” No one likes having his/her case reviewed, and no matter how good the logic, no one likes being asked “why” he or she carried out care in a certain manner. How we deliver care varies widely. One of the most important tasks of the compliance officer is to “smooth” variation and develop standards for the department. We all recoil when told how to practice, but we will never make real and meaningful strides in quality until variation can be decreased and results studied. The compliance officer is integral to an outstanding department and its quest for continuous quality improvement. In this day and age, all departments should strive for 100% anesthesiologist certification by the American Board of Anesthesiologists, and up-to-date maintenance of certification. It is no longer enough to provide and demonstrate great care. The public, your colleagues, and third party payers are demanding it. Patients will ask whether you are “Board Certified” during the preoperative examination, families will call requesting care only by a board-certified anesthesiologist, and hospitals want to tout 100% board-certified physicians on their staffs. It is beyond marketing though. It has become, in and of itself, a mark of quality; an outward sign to all that a certain level of expertise has been obtained. In the not too-distant future, third-party payers may require this level of certification and maintenance to achieve the highest level of reimbursement. In our current generation, there are many that have “grandfathered” in and will likely never be certified or recertified. However, these individuals are quickly becoming as anachronistic as ether.



Communication

In the ASA’s Quality Seal Project (described earlier in this chapter) a group of anesthesiologists attempted to do one thing: define the attributes of a “quality” anesthesia department. Although we came up www.anesthesiaclinics.com

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with a lengthy rubric, “quality” as defined by those “outside” the department could be easily distilled to a single word—“communication.” For whatever reason, departmental communication (with those who are not anesthesia staff) translates into a “quality” department. Armed with this kernel of knowledge, one can transform a department virtually overnight. It starts within the department itself. Having monthly meetings and quality sessions is great, but things change quickly and information must be disseminated rapidly. “Slow” email is being replaced with texts. Modern departments have Facebook pages, websites, and even use Twitter to communicate to the group. Great departments must leverage modern technology and bring some of the more “mature” members along (sometimes kicking and screaming) into the modern age of communications. As mentioned above, to be able to speak with a “single” voice, there must be excellent communication within the department, not just from the top down, but in all directions. All must have a voice and be able to communicate their views within the structure of the department. Great departments need to provide consistent methods and access to department leadership. During ASA consultations, we have found hospitals where people had no idea who ran the department; therefore, they did not even know who to speak with if they had a problem or concerny or a great idea! A stellar department informs its customers, telling them who is in charge. They provide information on where and how to locate and engage department leadership. An isolated and insulated department cannot be viewed as high quality because it is a black box! If the group is viewed as cooperative, communicative, and transparent, the opinion of the outside world rises. One of the best things a department can do is meet with other departments. This does not have to be a joint meeting (although it can be). It is often easier and more convenient to send emissaries to other departments. The simple fact of offering the Chair of the department 10 minutes at the family practice meeting will purchase more prestige and goodwill than buying them donuts for a year. People like to be appreciated. Giving time to meet them shows a level of respect and collegiality that a great department wants to cultivate. Conversely, invite chairs of other departments to stop by your meeting and answer questions or give presentations on what is important to them. This simple networking will pay ongoing dividends. The same type of communication must go on with the hospital leadership. If you are not communicating, you will never know about a problem. How can you address and solve a problem you do not know about? A great department will make a point of meeting with hospital administrators and asking them how the department is doing and how the department is contributing to the hospital’s strategic plan. Keep in mind: if you are not part of that strategic plan, you are part of the www.anesthesiaclinics.com

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problem. A group that is part of the “problem” is not viewed as high quality and will likely have a very short lifespan. Just like the tough teacher you faced growing up, go to administration and ask them how to get a good grade. You may not always like the answer, but at least you will know where you stand! One of the easiest and yet most beneficial things a department can do to improve communications and solve problems is a 360-degree evaluation. Providing the staff and “customers” the opportunity to give feedback can be an enlightening and humbling experience. Some departments go along for years never knowing that there is an issue. They perform a 360-degree evaluation and realize there is a huge gap in service. This can be a very inexpensive means of departmental improvement. Any department can develop an evaluation form then disseminate it to everyone—nurses, surgeons, secretaries, etc. Assure all participants that their comments will be confidential and aggregated; have your secretary gather and collate results, and then present to the department. I have never been involved with a department that did a 360-degree evaluation and did not discover something important to improve. Even better, hire someone to come in for a day or 2 and conduct one-on-one interviews. This shows others that your department cares enough to bring an “impartial” person in to evaluate. It also yields 2 important by-products: (1) people always provide much more complete and honest answers to a (perceived) impartial person; and (2) having an experienced anesthesiologist do this helps protect the department from the invariable “ask” for a service that is far beyond what any department offers. However this evaluation is accomplished it is an invaluable tool to improve even the best anesthesia department. Anesthesiologists recognize that modern medical practice has been under increasing pressure to improve patient safety and optimize outcomes. This is particularly true within the hospital environment and other facilities where most of us practice. The Institute of Medicine’s 1999 report, “To Err is Human,” cited the medical specialty of anesthesiology as among the most successful specialties affecting improvements in patient safety. This validated the longstanding commitment of anesthesiologists to placing patient safety as the highest priority, but also raised the question of “How do we get better at what we do?” Recognition of the need for continuing improvements in practice has helped fuel an explosion of outcome research in areas of quality and safety in the practice of anesthesiology. From a more global perspective, the health care system in the United States has been under intense scrutiny because of increasing demands from various stakeholders such as patients, insurers, employers, government agencies, and advocacy groups, among others. Since the inception of the Patient Protection and Affordable Care Act (ACA) on March 23, 2010, health care regulation and delivery has undergone significant changes, many not without www.anesthesiaclinics.com

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controversy. The impact of the ACA on all stakeholders including anesthesiologists will continue. How does a department or practice ensure effectiveness and improvement in patient care and safety while the fundamental structure of medical practice undergoes change? How do departments get better at what they are organized to do? ’

Effective Leadership If you don’t know where you’re going, you might not get there. —Yogi Berra

If it is not clear where your organization is headed and roles that individuals must fill, clinical staff members have a hard time signing up for the trip. High functioning departments address this through different strategies and tactics; however, common purpose, organizational unity, and effective leadership are all needed. In a survey to determine factors that have an impact on quality in an anesthesiology department, a diverse international group of anesthesiology department leaders identified failure to define collective goals as having negative impact on quality.2 Intuitively this makes sense. Without knowing organizational goals and objectives, work priorities are individually defined or assumed and make less sense to the clinical staff carrying them out. As a result, organizational effectiveness is compromised, morale sags, performance deteriorates, and improvement is stifled. Clarity in purpose, and the energizing motivation that flows with it, occur when objectives and performance targets are so well specified that you can measure where you are, where you want to be, and your progress along the way during the journey. In revealing research of organizational dynamics, those companies that clearly defined who they are (values, mission) and their plans (vision and goals) outperformed the general stock market by 15 to 1 over a 50-year period of time.3 In addition, goal-setting research has long demonstrated that trying to “do your best” is not likely to achieve your best. Instead, specific, hard, measurable goals produce the highest level of effort and performance.4 Departments and practices should develop a culture that meets and adapts to their specific operational needs. In surveys of departments conducted by the ASA Consultation Program perceptions of “quality problems” are correlated with lack of alignment to goals and objectives of key external stakeholders including patients, surgeons, and facility administrative staff. Within your department, understanding shared values core to your members and your practice of anesthesiology, defining a mission or core purpose for your organization, and defining external stakeholders and what is important to them enables a department to create a guiding context. This may require decisions to delay immediate gain to attain www.anesthesiaclinics.com

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carefully planned development. The subsequent steps of defining strategic priorities, operational goals and objectives, and creating alignment within the department enable better management and improvement of quality. On the basis of locally defined needs, departments and department leaders must establish realistic department goals that should be consistently pursued. Specific operational goals and objectives may include essential national performance measures (eg, the Surgical Care Improvement Project measures) and disparate yet locally important goals/ objectives in areas such as patient care, patient and customer satisfaction, quality improvement, career development, research and education, and financial management. Strategic priorities, operational goals and objectives may be revised to adapt to changing circumstances or performance. Local performance goals and performance against these goals must be openly and consistently communicated. Dashboards or performance plots should be used to highlight results and facilitate communication of performance attributes and trends. Comparisons of successful and troubled departments suggest that adopting any specific brand-name structure for these tools is far less important than identifying an effective format for local use and a process that ensures effective communication. When performance information is not provided, departments become stagnant and separated. Staff may be unable to accurately and consistently articulate shared purpose and organizational goals. Health care organizations have been sharpening their focus on the critical behaviors necessary for success. To succeed in our changing and challenging health care delivery environment, staff alignment is essential. Intentional efforts to understand organizational behavior and taking steps to improve organizational effectiveness are required. Ensuring that practice staff members view their work through the prism of local department values and in the context of values, mission, and priorities for the health care organization is essential for department improvement.



Quality of Care

Quality is assessed internally on a department level and externally at the hospital/health care organization and public levels. In this context, 5 key goals of quality assessment have been identified5: (1) Anesthesia departments should adopt quality-improvement practices that meet their specific operational needs. (2) Quality-improvement efforts in anesthesia should be aligned with broad health care quality-improvement initiatives; efforts to improve patient outcomes, systems performance, and professional development should be linked. www.anesthesiaclinics.com

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(3) Avoid distortions in perceptions of quality by overemphasizing what is easily measurable at the expense of what is important. (4) Prioritizing quality over productivity and aiming for “better” is the key to “cheaper,” by avoiding costly errors. (5) Recognize the importance of the role of human relationships (between staff, and between staff and patients) in quality and safety. A couple of these items benefit from additional development. On a local level and in general terms, the operationally relevant needs of departments fall into a few broad categories. High-performing departments seek to actively assess and improve outcomes in these domains:  Patient-centered outcomes: postoperative nausea and vomiting, adequacy of pain management, patient satisfaction.  Other customer outcomes: surgeon/proceduralist service satisfaction, facility assessments.  Operational outcomes: case cancellations, procedure duration, intraoperative delays, post-anesthesia care unit time, hospital length of stay.  Major complications: mortality, intraoperative cardiac arrest, perioperative myocardial infarction, stroke or neurological injury, anaphylaxis, etc. The previously cited survey of international department leaders suggests that quality from a local viewpoint includes additional, more subjective factors (Table 1). Although these are not all easily quantifiable, they can be readily identified through survey methods. Items included here are frequently identified as items of concern during ASA Consultation Program visits. In contrast, practices in which a preponderance of positive factors and few negative factors are present are more highly valued in their home institutions. Seeking both affirming and problematic practice features can shine the light on areas in need of improvement. Measurement and improvement of quality on a local level is the hallmark of high-quality departments. When considering anesthesiology quality management in the context of broad health care quality initiatives, one recognizes 2 important forces, guideline development and outcome measurement. Since the early 1990s, there have been efforts to define and promulgate best practice recommendations.6 Anesthesiology has been in the forefront of specialties establishing guidelines for patient management. The ASA has promulgated a broad array of statements, guidelines, and standards. In addition, the National Guideline Clearinghouse has additional guidelines applicable to the practice of anesthesia. In practice, there are gaps observed between literature guidelines and physician decision making and complex reasons for this gap. Evidence that within a practice there is a systems-based approach to effective implementation of evidence-based best practices (with guidance for local adoption) is a marker for quality. www.anesthesiaclinics.com

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Table 1. Features Impacting on Quality in an Anesthesia Department Positive Impact on Quality Diverse skills and interests Department that is valued within an organization Sufficient measures to prioritize quality (inpatient outcomes, technologies, pain, and perioperative services, research, education, training) over productivity Staff who are valued within a department

Negative Impact on Quality

Indication of High-quality Department

Indication of Lowquality Department

Failure to define Good morale, High staff turnover collective goal collegiality Failure to performance Excellent patient Trainees not wanting outcomes to stay manage difficulty personalities Insufficient resources Positive feedback Difficulty attracting senior staff from trainees, to deliver consistent, surgeons, sustainable quality operating room staff, etc.

Insufficient resources High pass rate in Unhappy staff examinations to support nonclinical activities including quality improvement (eg, no mechanism to collect and manage information) Excessive sick leave Open communication Reduced educational Research productivity opportunities for about call/leave trainees and arrangements, consultants due to clarifying and service managing requirements expectations Motivated, committed Overstretched, Committed, Inability to meet staff with an interest overworked staff caring staff standards (eg, The in patient outcomes Australian and New Zealand College of Anaesthetists staffing requirements for a teaching department) Inability to meet Inability to take leave Good working Good working clinical service relationships relationship with demands; onerous with other administration, eg, working conditions disciplines departmental involvement in strategic operating room and/or hospital management, being consulted on decisions material to anesthesia services Support for individual Inequitable division of Stable workforce staff to achieve privileges and/or personal and labor collective goals

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Table 1. (continued) Positive Impact on Quality

Negative Impact on Quality

Indication of High-quality Department

Indication of Lowquality Department

Sense of Leader who believes in Resistance to change collective price quality and is willing in to work for it (eg, achievements sees quality improvement as a genuine opportunity to improve the performance of the department and the hospital as a whole) Stable, respected, and “Noncontributors,” ie, responsive staff who do not leadership have a collective vision for the department and whose only interest is to pursue personal goals Complacency Understanding of differences in intergenerational workplace traits Succession planning Timely problem solving and implementation of change (in the interest of progress) Sharing of nonclinical tasks (Head of Department does not need to do everything) equitably between staff Reprinted with permission from Mcintosh and Macario.5 Copyright Wolters Kluwer Health/ Lippincott Williams & Wilkins. All permission requests for this image should be made to the copyright holder.

Outcome measurement is increasingly important but occurs within an environment that is complex and unwieldy at best. Perhaps the most visible measurement processes has been the American Medical Association Physicians Consortium for Process Improvement development and Centers for Medicare and Medicaid Services (CMS) approval of the Physician Quality Reporting Initiative [now Physician Quality Reporting System (PQRS)] measures as a method to improve overall care. It is important in this regard to recall that anesthesiologists have only 3 PQRS measures available for routine reporting:  Adherence to infection control measures when placing central venous catheters. www.anesthesiaclinics.com

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 Maintenance of normothermia in cases longer than 1 hour.  Appropriate administration of prophylactic antibiotics. Furthermore, it is widely recognized that these process measures are poor indicators of anesthesia practice quality and the longevity of these measures is unclear. The performance gap for high-quality departments between actual performance and complete compliance should be negligible. Looking forward, attention is directed to the National Quality Strategy and its importance for health care organizations and accordingly all internal stakeholders including anesthesiologists. The Triple Aim of simultaneously improving population health, improving the patient experience of care, and reducing per capita cost was first described in 2008.7 Through the enabling legislation of the ACA, CMS has defined the National Quality Strategy that targets realizing the Triple Aim through monitoring and improving 6 priorities: clinical care, patient experience and engagement, population and community safety, care coordination, and cost and efficiency. The National Quality Forum is a nonprofit, private-public collaboration responsible for approving and recommending measures for reporting programs. Moving forward, the National Quality Forum Measures Application Partnership will be identifying measures for reporting in both the public and private sectors. Prominent anesthesiologists are emphasizing that the future of measure development will increasingly focus away from process measures (eg, the current anesthesiology PQRS measures) toward performance measures and shared accountability teambased outcome measures involving both anesthesiologists and surgeons. The ASA Committee on Performance and Outcomes Measurement’s (CPOM) essential duty is to define measures of quality of care that may be used by anesthesiologists. Practices should monitor the work of ASA CPOM, with a goal of improving performance in areas of practice that may be impacted by developing measures (Table 2). It is critically important that all anesthesiology practices participate as members of the AQI and contribute data to NACOR. With discrete data from over 15 million anesthetics (and growing rapidly), AQI NACOR will provide data for anesthesiology practices to perform more robust quality management and demonstrate improvement through benchmarking of outcomes with comparison with similar practices. It is noteworthy that contributing data to NACOR advances efforts of a department to improve PQRS performance by meeting the requirements of the CMS PQRS measure #321, Participation by a Hospital, Physician or Other Clinician in a Systematic Clinical Database Registry that Includes Consensus Endorsed Quality. Although not yet certain, it is possible that CMS may turn to specialty societies and specialty registries to serve as the mechanism for quality reporting. These are among the reasons that participation in AQI NACOR has accelerated and is common for leading practices. www.anesthesiaclinics.com

Characteristics of a High-quality Anesthesia Practice

Table 2.



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Performance Measures for Public Reporting by Anesthesiologists

2013 PQRS Measures for Reporting Anesthesia Care Services #30 Perioperative Care: Timely Administration of Prophylactic Parenteral Antibiotics #76 Prevention of Catheter-related Bloodstream Infections (CRBSI): Central Venous Catheter (CVC) Insertion Protocol #193 Perioperative Temperature Management Measures Submitted to PCPI for Development AND to CMS for 2015 PQRS Consideration (1) Postanesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU) (2) Prevention of Postoperative Nausea and Vomiting (PONV) in High-risk Patients—Combination Therapy (Adults) (3) Prevention of Postoperative Vomiting (POV)—Combination Therapy (Pediatrics) (4) Continuation of Preoperative Use of Aspirin for Patients with Coronary Artery Stents 2013 PQRS Measures for Anesthesiologists Reporting the Designated Services #109 Osteoarthritis (OA): Function and Pain Assessment #131 Pain Assessment and Follow-up #148 Back Pain: Initial Visit (148, 149, 150, and 151 are in a measures group) #149 Back Pain: Physical Exam #150 Back Pain: Advice for Normal Activities #151 Back Pain: Advice against Bed Rest #226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention #276 Sleep Apnea: Assessment of Sleep Symptoms (276, 277, 278, and 279 are in a measures group) #277 Sleep Apnea: Severity Assessment at Initial Diagnosis #278 Sleep Apnea: Positive Airway Pressure Therapy Prescribed #279 Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy #312 HITECH: Low Back Pain: Use of Imaging Studies 2013 PQRS Measures Being Adapted for Anesthesia Care Services #44 Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery #164 Coronary Artery Bypass Graft (CABG): Prolonged Intubation #166 Coronary Artery Bypass Graft (CABG): Stroke #167 Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure #321 Participation by a Hospital, Physician, or Other Clinician in a Systematic Clinical Database Registry that Includes Consensus Endorsed Quality Measures National Quality Forum-endorsed Measures Being Adapted for Anesthesia Care Services #0119 Risk-adjusted Operative Mortality for CABG #0120 Risk-adjusted Operative Mortality for Aortic Valve Replacement (AVR) #0534 Risk-adjusted measure of mortality or one or more major complications within 30 d of a lower extremity bypass (LEB) #1790 Risk-adjusted Morbidity and Mortality for Lung Resection for Lung Cancer PQRS-Clinical Registry #321 Participation by a Hospital, Physician, or Other Clinician in a Systematic Clinical Database Registry that Includes Consensus Endorsed Quality Reprinted with permission of the Anesthesia Quality Institute. All permission requests for this image should be made to the copyright holder.



Customer Satisfaction

A service organization’s most precious asset is its customers’ confidence in the service it renders. www.anesthesiaclinics.com

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Table 3. Measuring Quality from the Surgeon’s Perspective

Measures Timeliness

Examples On-time starts

Target (Examples)/ Measurement Technique

< 10% cases start late Turnover times Turnover times

Characteristics of a high-quality anesthesia practice.

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