Quality and Regulatory Affairs

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March 1, 2014 Volume 78, Number 3
Quality and Regulatory Affairs William H. Montgomery, M.D., Director, Anesthesia Consultation Program

Richard P. Dutton, M.D., M.B.A., ASA Chief Quality Officer

Mark Singleton, M.D., FAAP, Assistant Director, Anesthesia Consultation Program

ASA Consultation Program: A New Quality Component Added to Traditional Program


One of the most useful benefits to ASA members and their departments is the availability of the Anesthesia Consultation Program (CP). Reports from this program appear periodically in the ASA NEWSLETTER to update the membership on issues confronting departments and hospitals. William Montgomery, M.D. and James Hicks, M.D. published the last such report in January 2010. Since that time, the CP has undergone several changes. This article will update readers on these changes and outline services available when an experienced consultant team from your ASA is requested to help improve quality and promote excellence in your department or hospital. Have the reasons for consultations changed? What about the process? How much does it cost? Has the program been a success? And who are these consultants, anyway?


The program began in 1981 as a result of the efforts of the California Society of Anesthesiologists and the ASA Committee on Peer Review. The CP was established by the ASA House of Delegates in response to inquiries from hospital administrators, medical staff governing bodies and departments of anesthesiology. The inquiries at that time related to concerns regarding peer-review and quality-of-care issues. The CP now resides within the Committee on Quality Management and Departmental Administration (QMDA). The road from 1982 up to 2014 has been consistent both in the conduct of the consults and the reasons for the consultations.


A Welcome Addition to the 2014 Consultation Program

In 2013, the QMDA committee and Anesthesia Quality Institute (AQI) collaborated to offer a new program: the Anesthesia Quality Consultation. This product is intended for high-functioning anesthesia practices seeking an objective external assessment of their performance in the areas of care delivery, patient experience, and continuous improvement and stakeholder engagement. The deliverable is a comprehensive, confidential report, which summarizes the group’s work in these areas, benchmarks them to similar practices in other parts of the country and suggests goals for future improve-ment. The report includes an executive summary, which is suitable for sharing with external stakeholders such as hospital administrators, payers, and surgical and procedural practice partners.


An Anesthesia Quality Consultation is conducted by experienced experts in anesthesia quality management and practice organization, typically members of the QMDA committee. The consultation begins with a series of conference calls between practice leaders and the consultants to define specific topic areas for focused consideration. The consultants provide the practice with a template for the review based on best practices outlined in the ASA Manual for Anesthesia Department Organization and Management (MADOM) and the Anesthesia Department Quality Checklist www.aqihq.org/qmdaqualitychecklist.aspx. The practice is expected to provide the consultants with documentation on policies and practice, examples of quality management activities, and physician credentialing and educational activities. The National Anesthesia Clinical Outcomes Registry (NACOR) is queried for both data from the practice and creation of a “benchmark group” of similar practices. The AQI provides the consultants with a comprehensive report of how the practice compares to its peers, showing metrics and trends across demographic data, efficiency and clinical outcomes. Once this background information is digested, the consultants make a one-day visit to the practice to interview key leaders and external stakeholders, and conduct a face-to-face visit to the facilities. The consultants meet following the visit to review key findings and draft the final report, which includes both their expert opinions and the objective data from NACOR. This document is reviewed by QMDA and ASA leadership and then officially submitted to the practice. A final activity, six to nine months later, is a return query to the practice by QMDA to determine the impact of the consultation.


How Does the Program Work?

Consultation requests – typically through cooperation from a member of the requesting organization administration, chief of the medical staff and chief of the department of anesthesiology – come to the ASA staff, which in turn notifies the director of the CP program. The director then contacts the requesting organization and speaks with those making the request. Subsequently, the CP director then selects two consultants based on the reasons for the consult and the availability of the consultants with the right skill set to address them. The consultants are Board-certified anesthesiologist members of QMDA who have maintained an interest and proficiency in conducting a consultation. The consultants are from large and small private practices or academic centers with a wide variety of practice and leadership experience over many years. It generally takes six weeks to arrange and conduct the consultant site visit and four weeks for the consultation report to be returned to the requesting organization. The site visit itself lasts from one to three days, depending on the issues to be addressed.


The final report is sent to the requesting parties and is formatted in a way that is easy to read. It addresses both the formally stated initial concerns and those subsequently uncovered when on site, with assessments and recommendations. They are supported by and referenced to ASA standards, guidelines, practice parameters, practice advisories, external regulatory agency policy, “best practices,” and the institution’s own medical staff bylaws, rules, regulations, and policies and procedures (medical staff and department). Many problems are addressed in the MADOM publication, available free online to any ASA member, which provides useful templates and references. The consultation report recommendations provide a road map for the requesting institution or department to address its own issues. While not endorsing any company, QMDA may provide the names of private consulting firms that can provide further ongoing guidance and advice.


Prior to the on-site visit by the consultation team, the two consultants review a considerable amount of requested information sent by the hospital. This includes demographic information about the hospital and community, hospital medical staff bylaws, rules, regulations, and surgical and obstetric volume statistics. Once on site, additional information is obtained from many sources and by several means.


The first day of the consultation is usually dedicated to a comprehensive record and document review consisting of several charts from each anesthesia provider, credentials files, departmental minutes, peer-review and quality assurance data, incident reports, narcotic reconciliation reports, exclusive contracts, medical staff minutes, and specific case reviews that are brought to the attention of the consultants.


The second day consists of an exhaustive interview schedule of individuals in administration, medical staff members who interact with the anesthesia department, members of the anesthesia department, other physicians as determined by the organization or consultants, nursing staff, including the PACU, preoperative testing areas, surgical admission centers, and the operating room staff. Any person wishing to be heard is given an interview with the consultants.


The third day is typically used to observe clinical areas and complete information gathering. Unless the consultants have found a behavior that threatens patient safety, no opinions are shared on site. There is considerable data to analyze before the final report and recommendations can be rendered. However, an informal exit interview is conducted to be sure that all concerns have been addressed.


The cost of a three-day consultation is $33,500, which is all-inclusive. There are no additional costs to the requesting institution. Six months after a consultation, the hospital is sent a follow-up questionnaire regarding its satisfaction with the consultation. Eighty three percent report being very satisfied and indicate that a majority of the recommendations have been or will be implemented.


Reasons for a Checkup and Findings of the Consultation Program

Analysis of the program and the reasons for consultation have previously been reported1-4: the total as of November 2013 is 215. The majority of hospitals surveyed have between 200-400 beds; however, smaller (<200 beds) and larger hospitals (>700 beds) have been visited, and community, private and academic centers are included in the mix. The number of anesthesia providers has been as high as 122 in a department. The major reasons for a consultation are as follows: overall clinical quality, departmental leadership, peer-review, competency, departmental organization, specific case reviews, preoperative care, obstetric anesthesia, departmental M.D. relationships, CRNA supervision and postoperative care.


A recent and increasingly common reason for a consultation, perhaps reflecting current economic conditions, is the request by hospital administration to examine staffing levels. The increasing emphasis on ambulatory surgery and anesthetizing locations requiring anesthesia personnel has stressed both administration and anesthesia departments to service the needs and yet maintain balanced staffing and optimal personnel utilization. There is not an easy answer for this increasing problem; however, the ASA Consultation Program can assist the organization in determining whether or not it is configured properly and if staffing levels are appropriate.


Next Steps for You

If you or your institution have questions or want to learn more about the ASA Consultation Program, request information about the program contact Deborah Novi at d.novi@asahq.org or contact the Program Director (William Montgomery, M.D.) at bmont@aloha.net.

William H. Montgomery, M.D. is in private practice in Honolulu, Hawaii. He is a member of the ASA Committee on Quality Management and Departmental Administration and ASA Board of Directors.


Richard P. Dutton, M.D., M.B.A. is Clinical Associate, University of Chicago Department of Anesthesia and Critical Care. He is Executive Director, Anesthesia Quality Institute.


Mark Singleton, M.D., FAAP is Adjunct Clinical Professor, Stanford University Medical School, and community practitioner, San Jose, California.



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

2. Hicks JS. No, everyone else does not practice that way – lessons from the Anesthesia Consultation Program. 2002 Conference on Practice Management. Park Ridge, IL: American Society of Anesthesiologists; 2002:119-132.

3. Ebrahim ZY, Hicks JS. Finding help in troubled waters: an update on the ASA Consultation Program. ASA Newsl. 2004;68(3):12-13, 20.

4. Montgomery WH, Hicks JS. ASA Consultation Program: a member benefit, and could you use one? ASA Newsl. 2010;74 (1):14-16.