May 2001
Volume 65 |
Number 5
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VENTILATIONS
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| Anesthesiologists:
Architects for Bridging the Quality Chasm |
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Mark J. Lema, M.D., Ph.D. Editor
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At 4:30 p.m. on April 2, 2001, I received a strange telephone
call. If it had occurred one day earlier, I surely would have
considered it an April Fool's joke. The evening news producer
for a local television station asked if I was available to speak
with the news anchorwoman about the anesthesia shortage. I was
stunned that our personnel shortage would reach the television's
radar screen. As I commenced discussing our undersupply, he interrupted
me to ask about the anesthesia drug shortage presented on CNN.com.
However, he became interested in both stories and sent a news
team to our hospital.
After a pleasant exchange with anchorwoman Victoria Hong, I watched
the late news broadcast to see how my conversation was edited.
For those who have yet to give a statement to the media, I can
tell you it is always a surprise to learn what comments the editors
deemed important. The report was accurate, informative, nonsensational
and truly credible. It notified viewers that anesthesia personnel
were in short supply (largely due to the report by Abt Associates
in 1994) and that a likely increase in resident physicians will
continue for the next five years. With regard to the shortage
of commonly used anesthetic drugs (e.g., fentanyl, succinylcholine),
a balanced approach as to the possible causes and the impact on
patient safety was voiced. If I were a layperson, I would have
been appropriately apprised of the shortage in both personnel
and supplies, told that the concerns were significant but not
an immediate crisis and informed that some action on my part (e.g.,
calling my congressional representatives) is needed to reverse
these trends.
Over the past year, I have discussed personnel shortages, dismantling
of the academic structure, dissatisfaction by professionals, assault
on our practice by nurses, over-regulation by administrative bodies
and the mass exodus of doctors away from clinical practice. This
newscast represents the early understanding by a few perspicacious
television news reporters that U.S. citizens are standing on a
burning health care platform with no clear directive to act. To
delay is to succumb to inferior, unsafe health care.
The Institute of Medicine (IOM) is very concerned. In their newest
monograph titled Crossing the Quality Chasm: A New Health System
for the 21st Century, they call for a fundamental change in our
health care delivery system.* In the executive summary, the authors
state:
The frustration levels of both patients and clinicians have
probably never been higher, yet the problems remain. Health
care today harms too frequently and routinely fails to deliver
its potential benefits Between the health care we have and the
care we could have, lies not just a gap but a chasm.
Medical discoveries and technology continue to expand rapidly
while, ironically, the health care infrastructure is crumbling.
The awesome medical advances that people see on television are
not what they receive after they become ill. With shortages in
both nursing personnel and physicians added to 40 million uninsured
Americans plus continued reductions in reimbursement the current
path leads directly into catastrophe. Imagine for a moment that
health care was similar to the restaurant industry. If there were
no servers, bartenders or chefs, if customers demanded the best
service, but could not pay, if credit card companies only partially
paid for services or food delivered, the business would file for
bankruptcy and close. How do we shut down health care in America?
In the executive summary of the IOM report, the authors succinctly
describe the last quarter-century of health systems development
as the Era of Brownian motion in health care. What most physicians
find insufferable is the abject shortsightedness displayed by
those orchestrating mergers, acquisitions and affiliations, seemingly
in a vacuum. Millions of dollars previously used to deliver and
pay for direct patient care are squandered on uniformly unsuccessful
partnerships. Most physicians believe that excellence is driven
by being as good as the outcome of one’s last procedure. How do
we judge CEOs in the health care industry who apparently judge
their success by the magnitude of their severance package? With
no obvious solution to correcting the current American health
care system, IOM believes that a totally new system must emerge
one that will be able to seamlessly incorporate future medical
technology into a cost-effective practice paradigm.
IOM has developed an agenda for crossing the quality health care
delivery system chasm. Among its early recommendations, they propose
six aims for improvement. Health care should be:
- Safe – avoidance of injury in the attempt to cure
- Effective – provision of services based on scientific
knowledge
- Patient-centered – provision of respectful, responsive
and individualized care Timely — reduction in waiting time and
harmful delays in care
- Efficient – avoidance of waste in equipment, supplies,
ideas and energy
- Equitable – provision of equal quality care to everyone
Anesthesiology, despite our anticipated shortage in personnel
concomitant with an increased demand for services, can once again
lead the way for medicine. We are safe, effective, patient-centered,
timely, efficient and equitable. Our challenge then is to not
only market our accomplishments to the public, but to maintain
and further improve on these six aims. Each physician must develop
a code of practice and conduct that espouses these concepts whenever
interacting with patients. Patients should not bear the brunt
of our frustrations by receiving anything less than our best efforts.
I reflected on these six aims and derived an action plan in the
form of six questions for interacting with patients. I would like
to share them with you in the hope that collectively we can begin
to develop a standardized nationwide code of professional decision-making
and conduct for patient care. Once again, we can show medicine
how it should be practiced.
Suggested Code of Conduct
1. Safety – Would I want someone to do this (procedure,
block, technique) on me or my family?
2. Effective – For what reason am I doing this (procedure,
block, technique)?
3. Patient-centered – Am I acting in a manner that I would
want someone to act with me or my family?
4. Timely – How can I minimize the time spent (on this
procedure, block, technique, assessment)?
5. Efficient – What do I REALLY need (to perform this assessment,
procedure, block, technique)?
6. Equitable – Is this what I would want (do) for me or
my family?
As anesthesiologists, we are among the best physicians medicine
has to offer. We demonstrate it daily by being safe, effective,
patient-centered, timely, efficient and equitable. IOM has “certified
us as being the best. Now, amid the drug and personnel shortages,
we must do it all, with one hand tied behind our backs.
No problem, because we are the best!
– M.J.L.
*Crossing the Quality Chasm: A New Health System
for the 21st Century; 2001. A full report can be obtained on the
Internet from National Academy Press at www.nap.edu/books.
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