The ASA Consultation Program has been in existence for 22 years. It was created in 1982 by the ASA House of Delegates to provide a consistent and sanctioned response to hospitals and anesthesiology departments that requested assistance in evaluating the quality of their anesthesia services. The program, which is an integral component of the ASA Committee on Quality Management and Departmental Administration (QMDA), owes its success to the combined experience of ASA members who have served as consultants and program directors. The assistance of the ASA Washington Office and program objectives that are mandated and regularly reviewed by the ASA House of Delegates help to maintain the quality of the program. The consultation protocol is comprehensive and covers every facet of a department’s performance that relates to the quality of anesthesia care. The consultation does not deal with economic issues except when such factors clearly have an impact on the quality of anesthesia care.

Inquiries about a consultation are initially received by the ASA Assistant Executive Director who provides detailed information about the program to the requesting institution and simultaneously refers the inquiry to the program director. The program director then contacts the inquiring institution or individual and further discusses the services the program can provide. Once an institution or department chooses to proceed with a consultation, it is asked to formally request a consultation by letter, which must be signed by representatives of both hospital administration and medical staff, preferably the chief of anesthesiology. The letter of agreement includes acknowledgement of the cost of the consultation as well as indemnification of the consultants and ASA.

Consultants are chosen who have demonstrated by training and experience that they have the expertise to analyze and provide rationale solutions for the problems that triggered the consultation.

During three days (occasionally two for very small hospitals) on site, the consultants meet with and interview members of the anesthesiology department (physicians and nonphysicians), hospital administration (including quality management staff), nursing staff who work regularly with anesthesiology department members and as many surgeons and other physicians as possible who interact with or use the services of the anesthesiology department. Consultants review organizational documents and multiple, randomly selected charts from each anesthesia provider, specific charts of concern regarding anesthesiology care, all credentialing files, policy and procedure manuals and any other contracts or correspondence considered germane to the provision of anesthesia care. They also examine anesthesia equipment and visit all perioperative areas.

A consultation report is then prepared that covers every aspect of the visit and includes the perceptions of all those who have been interviewed, although extreme care is taken to avoid direct attribution of perceptions by any individual. The consultants analyze the issues that initiated the consultation and make feasible recommendations based on ASA standards, materials contained in the Manual for Anesthesia Department Organization and Management, or MADOM, and their own extensive experience. The consultation report is then carefully reviewed by the program director and ASA legal counsel (in conference with the consultants) for consistency with program standards and receives further review by the QMDA chair and ASA Assistant Executive Director. After these reviews, it is professionally edited for presentation, bound and provided to the two original requesting parties, generally within 30 days of the consultation. Six months later, ASA sends a follow-up questionnaire requesting an evaluation of the consultation.

Demographic Information:
Two surveys have been done on the consultation program results. William L. Collins, M.D., published the first in 1994,¹ and a second was completed by James S. Hicks, M.D., encompassing data from 1994 to the present (total of 34 consultations).² The surveys are similar in their overall conclusions regarding program demographics [Figure 1].

To date the consultation program has served 141 hospitals ranging in size from 40 to 458 beds [Figure 2].

Staffing levels of anesthesia providers varied between facilities with only one anesthesiologist to the largest with 39 anesthesiologists.

Reasons for a Consultation:
Overall quality of department leadership and quality management concerns are the most commonly stated reason for a consultation. Other reasons are listed in Figure 2. In many instances, it is only after the consultants have established a rapport with the hospital personnel that other concerns emerge regarding the competence of practitioners or anesthesiology leadership. The consultants’ findings were grouped into five general categories, and the following deficiencies were commonly found:

A. Clinical care: Individual and groupwide interpersonal conflict that had a measurably deleterious effect on patient care; substandard subspecialty practice; lack of innovation in a hospital; inadequate preoperative assessment due to lack of protocols, practice or dedicated area resulting in a poor operating room utilization and management; less than optimal obstetric anesthesia coverage.

B. Quality management and documentation: Inadequate follow-up of sentinel events; disconnection of the “plan-do-check-act” quality cycle between “do” and check” (i.e., failure to implement change based on documented findings); failure to use “root cause analysis” or similar means of investigating poor outcomes; poor organization and content of department policy and procedure manuals; unreadable anesthesia records and poor preoperative and postoperative care documentation.

C. Leadership and organization: Inadequate leadership (often as a result of poor selection, motivation or poor interpersonal and leadership skills).

D. Operating room utilization and physical facilities: Inadequate numbers of anesthesia practitioners (which may be reflective of the national anesthesia workforce situation); older anesthesia machines; failure to accept and integrate newer agents, techniques and equipment into the practice of anesthesiology; inefficiencies in operating room scheduling.

E. Performance and interpersonal relationships: Reluctance in dealing with aging, inadequate or disruptive practitioners and poor documentation of these problems.

The ASA Consultation Program provides on-site consultation by experienced anesthesiologists skilled in assessing hospital and anesthesiology departments. Recommendations for correcting problems utilize ASA documents, including policy statements, guidelines, practice parameters and materials found in ASA publications. For questions or for more information about the program, contact the ASA Executive Office at (847) 825-5586.

References:

1. Collins WL. When someone cares enough to send for the very best. ASA Newsl. 1994; 58(3):10-14.

2. American Society of Anesthesiologists. 2002 Conference on Practice Management. Park Ridge, IL. 2002:119-132.

Zeyd Y. Ebrahim, M.D., is a staff anesthesiologist and Vice-Chair, Department of General Anesthesia, Cleveland Clinic Foundation, Cleveland, Ohio.

James S. Hicks, M.D., is Associate Professor, Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, Oregon.