Why a consultation program?
America can be proud of its hospitals and those who staff
them. However, modern times have brought about a climate of
change. Hospitals and their staffs are making new demands
on anesthesiologists. They seek different services. They ask
for increased services. As hospitals have faced increasing
demands by government, by their insurance carriers and by
the Joint Commission, physicians have been called upon to
provide a variety of medico-administrative services in such
areas as quality assurance, credentialing, delineation of
continuing education and the management of a department.
Economic pressures also have been a major problem for both
hospitals and physicians as government and third-party payers
struggle to cope with ever increasing demands for high-quality
health care. In addition, medical staffs are changing as
our educational institutions continue to produce younger
physicians who seek to practice newer techniques based on
their recent experience and training.
These and many other issues are not easily managed, and
often a neutral party may be the best resource to a hospital
before deciding on a course of action.
History
The ASA Anesthesia Consultation Program came into existence
as a result of the Society's need to respond to calls for
help from medical staffs concerned with the quality of anesthetic
care in their hospitals. Accordingly, the ASA Committee
on Quality Management and Departmental Administration developed
an innovative national program whereby it would make available
experienced, practicing anesthesiologists to conduct on-site
consultations at requesting hospitals.
The Anesthesia Consultation Program became operational
in 1982 following approval by the ASA Board of Directors
and House of Delegates. Since that time, the Committee
on Quality Management and Departmental Administration
has been asked to assist more than 180 U.S. hospitals
and their medical staffs to improve their quality of anesthetic
care.
Follow-up questionnaires have reported excellent satisfaction
with the consulations performed.
What is the Anesthesia Consultation Program?
The ASA Anesthesia Consultation Program consists of a group
of Board-certified anesthesiologists who are mostly past or
present members of the Committee on Quality Management and
Departmental Administration . Included are several Past Presidents
of ASA, and many are chiefs or former chiefs of anesthesiology
departments. They come from all parts of the United States
and work in institutions ranging from a 100-bed community
hospital to a 1,000-bed medical teaching center.
Many of these consultants are well known as speakers at
anesthesia meetings across the country, and each is actively
involved in patient care. All are thoughtful, experienced
clinicians who bring years of experience to the program.
It is from this group that two of these individuals are
appointed as an Ad Hoc Subcommittee to perform an Anesthesia
Consultation. Of course, no one serves as a consultant when
such service would involve even the appearance of a conflict
of interest.
How does the program work?
Though the first contact may be an informal query by letter
or telephone, an Anesthesia Consultation requires a written
request from both a hospital administrator and either the
chief of the medical staff or the chair of the department
of anesthesiology. This official request is sent to the
ASA Executive Office in Park Ridge, Illinois, and is then
forwarded to the Chair of the ASA Committee on Quality Management
and Departmental Administration for appointment of an Ad
Hoc Subcommittee.
Prior to an Anesthesia Consultation, the requesting parties
must enter into a formal, written agreement with ASA, providing
for the payment of the consultants' fees and expenses and
also indemnifying ASA and the members of the Ad Hoc Subcommittee.
In turn, the Society agrees to perform a careful, unbiased
on-site evaluation of the quality of anesthesia care rendered
in the hospital and to hold confidential any information
obtained in the course of the consultation.
What type of hospital requests an anesthesia consultation?
ASA has consulted for all types of hospitals, ranging from
small rural institutions to big urban medical centers. The
smallest to date has been 40 beds, the largest more than 1,200.
Approximately 45 percent of our requests come from medium-sized
institutions with between 250 and 500 beds. About 35 percent
of the requests are made by hospitals with less than 250 beds,
and 20 percent by large institutions. About half of the hospitals
give less than 5,000 anesthetics per year; a quarter give
more than 10,000.
View graph through this link
Institutions with less than 400 beds account for the majority
of the total on-site consultation visits conducted since
the program began.
What are the duties of the consultants?
Basically, they observe, they review, they recommend. They
interview administrators, all anesthesia staff, physicians,
nurses and other hospital employees. They inspect patient
records, anesthesia charts and other relevant institutional
and departmental documents. They quietly observe the work
of the anesthesiology department in operating rooms, delivery
suites, postanesthesia care units and intensive care units.
They constantly question those they meet, and make it a
priority to interview people with a variety of viewpoints.
They are particularly careful to try to understand conflicting
views of any controversy.
Following the Anesthesia Consultation, the members of the
Ad Hoc Subcommittee draft a report. This report is then
reviewed by the Chair or Vice-Chair of the Committee on
Quality Management and Departmental Administration and also
by the Society's legal counsel to ensure that the final
document addresses the concerns raised by the hospital and
its staff and clearly reports the Subcommittee's findings,
as well as the basis for these findings. More importantly,
the report includes feasible recommendations on how to address
any deficiencies.
In keeping with ASA's pledge of confidentiality, copies
of the final report are furnished only to those who sign
the official request from the hospital, i.e., a representative
of the hospital corporation, usually the administrator,
and a representative of the hospital medical staff, usually
its Chief of Anesthesia or President.
What has been found in previous consultations?
Upon reviewing the consultations that have been performed,
what is found? Usually, we encounter good anesthesiologists
working in hospitals that are providing high-quality care
to patients across the country. It is most rare to find an
institution where everything is negative. When weaknesses
are found in one area, they are usually offset by strengths
in other areas.
The consultants have encountered a variety of problems
relating to the practice of anesthesia. Sometimes these
center on issues of competence. Are the anesthesiologists
practicing with appropriate, up-to-date knowledge? Are there
issues of an anesthesiologist's ability to perform various
technical procedures? Are there problems with the preoperative
evaluation of patients or with the provision of postoperative
care? What is the appropriate coverage for anesthesia needs
of patients? Sometimes it appears that obstetric anesthesia
is not given proper coverage or that epidural anesthesia
is not available. Occasionally, there are problems with
night, weekend, holiday or in-hospital emergency coverage.
At times, it appears that the department leadership could
be improved, specifically in such areas as competency evaluation,
delineation of clinical privileges or a chief's ability
to lead the department in providing contemporary anesthesia
practice. Can the chief deal effectively with issues of
safety, quality assurance and continuing education, and
the provision of the appropriate resources for a department?
Issues about the use of nonphysician anesthetists to provide
technical assistance in an anesthesiologist's practice often
arise. Common issues include the adequacy of medical direction,
the ratio of physicians to nonphysician anesthetists and
the use of anesthetists to perform functions that are more
properly the practice of medicine.
A major problem continues to be quality assurance. Indeed,
only 15 to 20 percent of the time is it found that a department
has an effective quality assurance program. Sometimes there
is no program, or there may be one in name only.
Also, the quality of the anesthesiology department's leadership,
organization and management has become an issue in the changing
environment of health care.
How long is the overall process for a consultation, and
what does it cost?
It is customary for the complete process of an Anesthesia
Consultation to take approximately 12 weeks. The Ad Hoc Subcommittee
usually visits the requesting hospital within six weeks of
the receipt of the request, and the confidential written report
is forwarded not more than six weeks later.
The cost for an Anesthesia Consultation is: One day consultation $6,850; Two day consultation $23,700; Three day consultation $28,500. The number
of days on site depends on the size of the institution and
the complexity of its problems. The cost to the requesting
institution is the cost of operating this program. ASA does
not seek a profit.
If you are interested in requesting an Anesthesia Consultation
or would like further information, please write to:
American Society of Anesthesiologists
Committee on Quality Management and Departmental Administration
520 N. Northwest Highway
Park Ridge, Illinois 60068-2573
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