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August 1997
Volume 61 |
Number 8
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PRACTICE MANAGEMENT
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| Setting Up a
Quality Improvement Program |
Karin Bierstein,
Practice Management Coordinator
J.Kent Garman, M.D., Chair of the Committee on Quality Improvement
and Practice Management, regularly receives inquiries on how to
set up a quality improvement program for an anesthesiology department.
The ASA Washington Office fields the same question almost as frequently.
A good starting point for information on continuing quality improvement
(CQI) is Chapter IV of the 1997 Manual for Anesthesia Department
Organization and Management, available from the ASA Executive
Office in Park Ridge, Illinois. The manual provides a summary
of the traditional elements of CQI, a bibliography, a checklist
of steps in the CQI process and sample charts.
Dr. Garman and several experienced members of his committee are
willing to assist colleagues needing information on CQI programs.
Dr. Garman can be reached at <jkgarman@jkg.com>.
Committee member Jerry A. Cohen, M.D., at the University of Florida
has written several book chapters on the topic and has provided
consults to other anesthesiologists. His e-mail address is <cohen@anest1.anest.ufl.edu>,
and his telephone number is (352) 395-0301. Another anesthesiologist
who is willing to share his considerable expertise in implementing,
expanding and upgrading a CQI system is Hugh L. Flanigan, M.D.,
at the Brigham and Women's Hospital in Boston. Dr. Flanigan's
telephone number is (617) 732-7330, and his e-mail address is
<flanigan@zeus.bwh.harvard.edu>.
A number of departments have well-developed programs in place.
One that came to my attention recently was designed (and is under
continuous improvement) at the University of AlabamaBirmingham.
Arthur M. Boudreaux, M.D., Professor of Anesthesiology and Vice
Chair for Education, and W. Greg Green, Executive Administrator
of the Department of Anesthesiology, provide an introduction to
the QI process in their department in the article below. If you
would like to know more about the UAB program, please contact
Mr. Green by telephone at (205) 934-9650 or by e-mail: <greg.green@ccc.uab.edu>.
Continuous Quality Improvement in Anesthetic Practice: Is It
Worth the Effort?
Arthur M. Boudreaux,
M.D.
W. Greg Green
Is there a need for development of continuous quality improvement
(CQI) programs for individual anesthesia practices? American industry
is now embracing the movement espoused by W. Edwards Deming, J.M.
Juran and other quality improvement experts because of the success
of Japanese industry in the worldwide marketplace. This is obvious
in the U.S. auto industry, which frequently boasts of its quality.
In 1987, the Joint Commission on Accreditation of Healthcare
Organizations initiated programs directed at requiring hospitals
to develop quality assurance (QA) programs for continued accreditation.
Most anesthesiologists have participated in such hospital-administered
QA programs and are aware of the lack of specificity of these
programs for anesthesiology-related QI activities.1
Effective quality improvement systems are process-oriented, proactive
and supportive of self-reporting. In contrast, QA approaches evaluated
individual performance, were reactive, defined a minimum standard
and were often punitive.2 An effective CQI program
collects data about a practice that may be utilized to benchmark
performance, track and validate indicators thought intuitively
to impact outcome and recognize problems in processes of care
and practice management. Utilizing the CQI database, information
regarding severity of illness of patients, frequency of procedures
performed, complication rates, techniques employed in patient
care and many other variables can be gleaned. If cost data is
combined with this information, a practice will have the tools
to evaluate cost-effectiveness. All of this can improve quality
and give a practice a competitive advantage. CQI is a mechanism
to add value to your practice.
What is quality? Quality in health care is hard to define. Is
it patient satisfaction, success of treatment or length of stay
for a particular illness? Each practice and health care organization
can devise its own definition. We prefer to define quality as
the maximum opportunity for uncomplicated recovery with minimal
intervention.2
The essential elements of a CQI program include data acquisition
and incorporation into a database, followed by data verification
and analysis. Problems that are identified and verified then lead
to modification of the system or process involved. A CQI Committee
is responsible for this activity. Follow-up monitoring assesses
improvement.
Data acquisition and self-reporting of indicators or complications
involving patient care may be problematic. Sanborn et. al.3
compared an automated anesthesia information system tracking physiologic
deviations from preset limits to a voluntary, manual entry, electronic
reporting system. Only a small fraction of incidents identified
by the automated system were reported by the anesthesiologists.
Automated information systems do not circumvent the need for data
entry by anesthesia providers. They can capture physiologic data
from electronic monitors, have a small but significant artifact
rate and will not automatically record complications (a postoperative
respiratory arrest after discharge from the postanesthesia care
unit, for example). These data must be entered.
Why do anesthesiologists fail to report incidents in the QI process?
Cooper4suggests that better incentives
are needed such as demonstration of the value of reporting and
change of the culture that attributes error to negligence. If
we consider that CQI permits evaluation and modification of the
overall patient care process, is proactive and is supportive with
the goal of providing more cost-effective care, there is every
reason to participate. The key to wider acceptance is to lower
the barrier to data entry. An electronic anesthesia information
system or, less expensively, a scannable data entry system will
accomplish this objective.
Using a system developed within our department by Gilbert Ritchie,
Ph.D., Dennis Doblar, M.D., Ph.D., and John Taylor, preoperative
risk factors, intraoperative and postoperative procedures and
events are documented using scannable data sheets for entry into
a relational database [Figure 1]. The data are analyzed periodically
for trends and outlier events. We routinely analyze indicators
such as aspiration, death, myocardial ischemia, persistent hypoxemia,
unanticipated intensive care unit admissions, PACU discharge times
and others. A wealth of information concerning our practice may
be rapidly retrieved by database query. A Pareto diagram displays
the relative frequency of problems in a process or operation.
An example of a Pareto diagram showing cumulative risk factors
from the database appears in Figure
2.
Other information can be obtained from the database for benchmarking
and practice assessment. Most practices are currently considering
cost reduction strategies. For example, if the department instituted
a policy recommending the use of certain less expensive drugs,
direct and indirect effects of this change can be assessed by
data analysis. A query of the database for complications anticipated
as a result of the change in practice (perhaps nausea, awareness,
postoperative ventilation, PACU discharge times) will reveal valuable
information. Changes in the frequency of these events, both positive
and negative, will determine whether the policy change is beneficial
or detrimental. The database is also effective in tracking compliance
with the policy change.
Confidential information concerning quality of care issues may
also be brought to our CQI Committee outside of the database by
submission from personnel, patients or the hospital CQI Committee.
Each problem identified is analyzed by an individual, peer-review,
case-analysis protocol and is discussed at a CQI meeting. A recommendation
for change of a patient-care process, protocol or treatment algorithm
is made. Clinical conferences are used to disseminate information
about the process changes. Follow-up evaluation continues after
implementation of a process change to assess effectiveness. Additional
information about individual personnel activity can be used if
necessary for recredentialing information.
The system has worked well in our department. We are armed with
the data necessary to effect change when needed. Continuous quality
improvement does indeed work. Is it worth the effort? Absolutely!
References:
- Doblar DD, Ritchie G. Quality Improvement
in Anesthesiology, Principles and Practice of Anesthesiology.
Longnecker DE. ed. Philadelphia: Mosby Yearbook (in press).
- Lell W. Chair, UAB CQI Committee, personal
communication.
- Sanborn KV, et. al. Detection of intraoperative
incidents by electronic scanning of computerized anesthesia
records: Comparison with voluntary reporting. Anesthesiology.
1996; 85:977-987.
- Cooper JB. Is voluntary reporting of critical
events effective for quality assurance? Anesthesiology. 1996;
85:961-964.
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