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April
2002
Volume 66 |
Number
4
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PRACTICE
MANAGEMENT
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| Postgraduate
Medical Training in Anesthesiology at Kilimanjaro Christian
Medical Center |
Mark J.
Lema, M.D., Ph.D.
Editor
Lessons From
ASA's Anesthesia
Consultation
Program
Karin
Bierstein, J.D.
Assistant Director of
Governmental Affairs
(Regulatory)
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Mark J. Lema, M.D., Ph.D. Editor
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One hundred
and forty-one hospitals around the country have availed themselves
of ASA's Anesthesia Consultation Program in the 20 years since
the program was launched. A consultation involves a two- or three-day
site visit by a team of two trained anesthesiologists who follow
a detailed protocol and prepare a written report. Most of the
recommendations are based on ASA policy statements, guidelines
and other materials reproduced in the ASA Manual of Anesthesia
Department Organization and Management. The hospital administrator
and the head of the anesthesiology department (or the chief of
the medical staff, if the anesthesia chief is unwilling) both
must sign the request for the consultation. The average on-site
consultation costs $21,000. A very small hospital with limited
issues may be satisfied with a two-day visit and a fee of $17,000.
The most commonly
given reason for a request for a consultation is "overall
quality," followed by "department leadership" and
"quality management." Other factors are listed in Table
1.
Other issues
mentioned with decreasing frequency include:
- Intraoperative
care
- Relationships:
surgeons, registered nurses, other physicians and nurse anesthetists
- Equipment/physical
plant
- Disruptive
physician
- Call coverage
- Controlled
substance management
- Economic
issues/competing groups
- Staffing
levels
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Table
1: Incidence of Stated Reasons
for ASA Consultations
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These were
some of the findings reported by James S. Hicks, M.D., Vice-Chair
of the Anesthesia Consultation Program for the Committee on Quality
Management and Departmental Administration, at the ASA Conference
on Practice Management held in Phoenix, Arizona, on February 1-3,
2002.
The title
of Dr. Hicks' presentation, "No, Everyone Does Not Practice
That Way – Lessons From the Anesthesia Consultation Program,"
suggests the variety of practice and management styles in anesthesiology
departments as well as the specific problems that the consultants
are asked to address. In the area of clinical care, for example,
88 percent of participating hospitals scored "outstanding"
or "acceptable" [Table 2]. Intraoperative care was satisfactory
in no fewer than 94 percent of the hospitals. In the 12 percent
rated "deficient" in overall clinical care, Dr. Hicks
wrote in his monograph that: "Common reasons for such an
assessment included 1) severe, group-wide interpersonal conflict
that reached such a level that it had a measurably deleterious
effect on patient care, 2) conduct by an individual anesthesiologist
that was so egregious that it warranted such a rating and 3) a
subspecialty practice situation that fell seriously below the
standard of care in a number of areas."
"Deficient"
ratings were common in the area of preoperative evaluations, according
to Dr. Hicks. "Most often, hospitals falling below the mark
had no formal area, protocol or practice established for the preoperative
assessment function, and frequently the first contact between
anesthesiologist and patient occurred moments before the patients
were to undergo anesthesia and surgery." Twenty-five percent
of the consultations revealed problems with obstetrical anesthesia,
resulting largely from the unpredictable nature of obstetric practice
and the shortage of anesthesia personnel.
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Table
2: Clinical Care Results
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Quality management was found to be deficient in 59 percent of
the hospitals. (It also was o
ne of the top three reasons for requests for consultations.) Despite
some effort to report sentinel events and to review clinical cases,
systems that would allow completion of the corrective loop were
inadequate. Policy and procedure manuals were substandard in 46
percent of the institutions, consisting of what Dr. Hicks called
"a mishmash of unorganized and frequently irrelevant materials."
Twenty-nine percent of the consultations revealed inadequate anesthesia-record
preparation and documentation of preoperative and postoperative
care.
Personal factors
such as leadership, performance and interpersonal relationships
were behind a huge proportion of the consultation requests and
revealed problems in a significant proportion of the hospitals.
Anesthesiologists are frequently unwilling to assume leadership
responsibilities without support from the group or members of
the department (which is reasonable enough) and without recognition
that administrative work is a service that must be compensated.
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