Several recent health care studies have focused on quality and found the need for improvement. The Institute of Medicine reports, “To Err Is Human” in 1999 and “Crossing the Quality Chasm” in 2001, found evidence for suboptimal quality and injury-causing errors.¹ The subsequent transplant of an incompatible heart, causing the death of the recipient, at a first-class medical center dramatically confirmed for the public a need to do better.² Groups as disparate as the Agency for Healthcare Research and Quality of the Department of Health and Human Services, the Veterans Administration Hospitals, the Joint Commission on Accreditation of Healthcare Organizations and a consortium of large businesses known as the Leapfrog Group have responded with quality initiatives.

Organized anesthesiology, long interested in improving quality, also is responding. The Anesthesia Patient Safety Foundation has identified electronic anesthesia records as a future standard, begun infrastructure work for the construction of a national anesthesia database and promoted the concept of the “high-reliability organization” to improve patient safety.³ The American Board of Anesthesiology is developing a maintenance of certification program to promote lifelong learning and professional competence. Despite tight funding, ASA is continuing its support for patient safety legislation, clinical practice guidelines and the development of useful performance and outcomes databases and benchmarks.

Anesthesiologists support these national programs because they promote patient safety as well as provide performance and outcomes measures to gauge and improve individual effectiveness, group productivity, patient satisfaction and public health. Anesthesiologists easily learn to apply performance and outcomes measurements because their applications mimic the anesthetic process of adjusting anesthetic drug doses according to observed physiologic parameters. Other aspects of this metaphor that anesthesiologists naturally understand include the selection of pertinent information from the overabundance available, comparing the information to normal or preceding values and making adjustments.

What to Improve, What to Measure
Anesthesiologists deliver care both individually and as groups to the breadth of patients and pathologies present in today’s hospitals. They use complex technologies based on ever-advancing knowledge, often involving computerized controls. Multiple opportunities exist for measuring and advancing quality. What to measure is important because time and resources are insufficient to measure and work on all available data. Whatever practitioners and groups focus on will get better, so an effective strategy is to pick a few areas and look for key indicators of quality in these areas.

Some anesthesiologists divide their quality programs into three areas: patient, professional and business. Table 1 labels these areas as clinical care, professional competence and practice management and suggests two parameters to assess individual and department performance in each area. As groups advance in their uses of quality measurements, they tend to employ more outcomes than process measurements because outcomes are more comprehensive. Process evaluation looks at the rates at which anesthesiologists adhere to evidence-based or expert-consensus guidelines. Outcomes evaluation compares anesthetic care results to goals. Table 2 lists a process and outcomes measure for four anesthesiology subspecialties.

Table 1: Anesthesia Measurement Variables   Clinical Care Professional Competence Practice Management Individual PACU temps Charting errors Educational credits Committee participation Clinical days available Peer rating Department Satisfaction ratings QA participation Leadership roles Compliance maint. RVU/O.R.-site Turnaround time PACU temps: patient temperatures on arrival in the PACU Committee participation: hours of participation on department and institutional committees Clinical days available — number of days an anesthesiologist is available for clinical assignment QA participation — percentage of cases with quality assessment forms completed Compliance maint. — percentage of department members meeting all regulatory and educational goals before deadlines RVU/O.R.-site — total relative value units of anesthesia care billed per day divided by the average number of daily anesthetizing sites

Table 2: Process and Outcome Measurements in Four Anesthesia Subspecialties Subspecialty Process Outcomes Obstetric Wet-tap rate Delayed parturient discharge rate Cardiac Carotid artery punctures Cancellations on day of surgery Pediatric Caudal rate during urologic surgery Patients without postoperative pain Ambulatory Treatments for emesis Patient satisfaction

Assessing occurrences and measured rates requires a source of perspective. Few desired results or undesired complications occur at 100-percent or 0-percent rates. Two ways to judge these measurements are by comparisons with large databases or previous results. Using databases usually requires innovative adaptations⁴ or acceptance of less-than-global data.⁵ Few national benchmarks based on aggregate measurements exist, so most groups examine their trends or compare their results with agreed-upon goals.

Table 3: Sentinel Events Death in preoperative or postoperative areas Wrong drug administration Patient temperature below 34ºC in PACU Surgery canceled after anesthetic induction Anesthetic drug syringe found outside operating suite Legal request for anesthesia records

In any performance and outcomes measurement program, anesthesiologists also may detect unusual occurrences. Some of these, whether catastrophes or not, may signal a special need for review. Such sentinel events may indicate the need to redesign processes or build extra safety into them. Table 3 lists some possible sentinel events for anesthesiologists.

What to Do With the Measurements
Just as data without analyses are merely numbers, analyses without feedback to the originators of the measured actions are ineffective exercises. To improve performances and outcomes, individual anesthesiologists should learn their results and how they compare to group and benchmark performances. Particularly helpful is to identify high performers because others may be able to copy their styles and duplicate the results. Leaders may want to reward the high performers through public recognition, financial incentives or group perks, which will accelerate the improvement process.

Some departments post performance and outcomes results on a department bulletin board, list them in the minutes of regular group meetings or publish them in an internal newsletter. Academic departments may devote one weekly grand rounds time slot each month to a review of outcomes results and discussions of how to improve quality. Emphasis on systems instead of people and rewarding success instead of punishing failure builds a culture of quality. Anesthesiology departments measuring performances and outcomes often find that most aspects of quality care improve even as productivity and the ratio of medical direction increase.⁶

Routine and robust measurements of multiple parameters of performances and outcomes with identification of best performances and the frequent reporting of all relevant information to practitioners is the most effective model for improving anesthesiology quality.

References:

1. Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: Institute of Medicine, National Academy Press; 2001.

2. 60 Minutes. Anatomy of a mistake. <www.cbsnews.com/stories/2003/03/16/60minutes/main544162.shtml>. Accessed September 23, 2003.

3. Gaba DM. Safety first: Ensuring quality care in the intensely productive environment — The HRO model. APSF Newsletter. 2003; 18(1):1-4.

4. Dexter F, Wachtel RE, Yue JC. Use of discharge abstract databases to differentiate among pediatric hospitals based on operative procedures. Anesthesiology. 2003; 99:480-487.

5. Abouleish AE, Prough DS, Barker SJ, et al. Organizational factors affect comparisons of the clinical productivity of academic anesthesiology departments. Anesth Analg. 2003; 96:802-812.

6. Posner KL, Freund PR. Trends in quality of anesthesia care associated with changing staffing patterns, productivity and concurrency of case supervision in a teaching hospital. Anesthesiology. 1999; 91:839-847.

Robert E. Johnstone, M.D., is Professor and Chair, Department of Anesthesiology, West Virginia University, Morgantown, West Virginia. He is the District Director from West Virginia and a Colonel in the United States Army Reserve.