Orin F. Guidry, M.D.

would like to tell you a political story about awareness, but for a change, Aspect Medical is not the central character.

About a year ago, ASA leadership began to hear rumors that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) was contemplating developing a standard on awareness monitoring. We thought that JCAHO developing such a standard was a really bad idea.

JCAHO is governed by a 29-member Board of Commissioners, which includes seven members each appointed by the American Hospital Association and the American Medical Association (AMA); six public members; three representatives each from the American College of Physicians, the American Society of Internal Medicine and the American College of Surgeons; one representative appointed by the American Dental Association; and an at-large nursing representative. Because seven of the commissioners are AMA appointees, it seemed logical to take this issue to AMA.

AMA listened attentively to ASA’s concerns, and in January 2004, sent a letter to JCAHO that included the following language: “The American Medical Association (AMA) and the American Society of Anesthesiologists (ASA) share concern regarding the suggestion that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) will soon seek to develop a standard with respect to use of monitoring devices purportedly designed accurately to detect patient awareness during the course of sedation and anesthesia.” Naively we thought the issue was put to rest.

On Monday, September 13, 2004, JCAHO sent ASA a draft Sentinel Event Alert on patient awareness under anesthesia and requested comments by the following Monday. ASA requested eight revisions, six of which were not included.

On October 6, JCAHO issued a news release that began with this sentence: “Tens of thousands of patients undergoing surgery each year experience the helplessness of being partially awake while under general anesthesia during surgery, but being unable to communicate their distress to caregivers.”

Also on October 6, JCAHO conducted a telephone news conference that included JCAHO President Dennis S. O’Leary, M.D., 2004 ASA President Roger W. Litwiller, M.D., and American Association of Nurse Anesthetists Immediate Past President Tom McKibban, CRNA, M.S. The distinct implication of these actions was that ASA actively participated in the production of the Sentinel Event Alert when, in fact, just the opposite was the case.

You can read the transcript of the news conference, the October 6 news alert and the actual Sentinel Event Alert at <www.jcaho.org/news+room/press+kits/se_32/se_index.htm>.

In addition to its “marketing,” a couple of things were particularly disconcerting about the alert.

The first is the following sentence: “Contributing factors to the risk of anesthesia awareness include the increasing use of intravenous (I.V.) delivery of anesthesia over inhalation to help manage patient care and the lightening of anesthesia at the end of procedures to facilitate ‘turn over’ in the O.R.” As far as I know, there is absolutely no data to support such an assertion. How many of you have deliberately lightened an anesthetic near the end of a case and risked awareness to facilitate efficiency? I consider that implication to be an insult to me personally and to my profession.

The second was the unprecedented step of specifically referencing a branded product (the bispectral index monitor) in such an alert. This paragraph was an addition to the final version and was not seen by ASA during the review process.

If carefully read and interpreted, most of the Sentinel Event Alert is a very reasonable document. I do not think that it is necessary for anesthesiologists because awareness has been a serious concern in our specialty for a good while. It is ironic that the Sentinel Event Alert was published on the 10th anniversary of the publication of an ASA NEWSLETTER devoted to the problem of awareness. A positive outcome of the Sentinel Event Alert may be a heightened appreciation of the importance of anesthesiologists by others in the hospital. My concerns are more about process than the actual language.

ASA again took its concerns to AMA, this time in the form of a resolution presented at the AMA Interim Meeting last December. The text of the entire ASA resolution is available at <www.ama-assn.org/ama1/pub/upload/mm/465/827i04.doc>.

The AMA House of Delegates currently consists of delegates from both state medical societies and from specialty societies. The number of society delegates is determined by the number of AMA members who elect to be represented by a specialty society. All of anesthesiology is represented in the AMA House by ASA. Because many ASA members are also AMA members, ASA has nine delegates. This makes it the third largest specialty society delegation behind the American Academy of Family Physicians with 16 and the American College of Obstetricians and Gynecologists with 10. Only eight state medical societies have delegations larger than ASA’s. Our AMA Delegation consists of the nine delegates and nine alternate delegates. In addition the Delegation has worked diligently to network with anesthesiologists who are delegates from state medical societies. There are even two other specialty societies who are represented by anesthesiologists (the Society of Critical Care Medicine and the International Spinal Injection Society). There are 39 anesthesiologists in the AMA House representing other organizations. Much of ASA’s political clout within AMA is the result of anesthesiologists who are active in these other organizations.

The Delegation leadership (past and present, including Richard Johnston, M.D., Susan L. Polk, M.D., James F. Arens, M.D., John B. Neeld, Jr., M.D., and others) has put a lot of effort into making this an effective political organization, and this political force was put into high gear to garner support for the resolution.

Testimony at the Reference Committee last December was overwhelmingly in favor of the resolution. ASA President Eugene P. Sinclair, M.D., along with Dr. Neeld and Mark J. Lema, M.D., Ph.D., were our articulate spokespersons. Pathologists spoke up with similar concerns about a previous Sentinel Event Alert on blood banking.

ASA’s efforts were a resounding success. The resolution was approved in principle with editorial revisions. Perhaps more important, the AMA Reference Committee added a second resolve: “RESOLVED, That our AMA advocate to JCAHO that Sentinel Event Alerts should not be interpreted to be equivalent to practice guidelines, given that practice guidelines should be developed and vetted by physician professional organizations, which have expertise in interpreting relevant scientific evidence regarding practice, outcomes, and safety.” The AMA House’s action on the resolution is available at <www.ama-assn.org/ama1/pub/upload/mm/465/refcomfk_annoti04.doc>.

The hidden agenda here is that the next Medicare initiative is innocuously termed “pay for performance.” In a nutshell, so-called “pay for performance” (also know as PFP or P4P) is a method of linking reimbursement or pay to some measure of individual, group or organizational performance. Ideally bonuses would be paid to motivate physicians and others to improve the quality of care and achieve better outcomes. A key to how this will affect you and me is the composition of the standard-setting body. Therefore it is critically important to ensure that there is as much physician input as possible into the process by which standards are developed. Legislation that further develops these ideas is expected in Congress early in 2005.

A cynic would say that JCAHO is positioning itself to be the standard-setting body, and JCAHO has already published a document titled “Principles for the Construct of Pay-For-Performance Programs” at: <www.jcaho.org/about+us/public+policy+initiatives/pay_for_performance.htm>.

What are the take-home messages from this political tale?

We must keep our eyes and ears open. (Vigilance must be our motto in the political arena as well as in the operating room.)

We must be politically active and politically astute in medical politics as well as governmental politics.
AMA is important (really important!).



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