By: Jamie Sparling, MD; Tal S.M. Levy, MD, MBA; Spiro G. Spanakis, DO; Luis E. Tollinche, MD
updated May 5, 2020
Measuring Performance and Quality
Establishing a patient safety and quality program is an integral part of an anesthesia department. Departments must develop these programs to optimize safe patient care, to satisfy reporting requirements at the federal, state, and local levels, and to comply with regulatory authorities such as CMS and the Joint Commission. For information and assistance in developing your department’s program, we refer you to the ASA’s Guide to Anesthesia Department Administration, developed by the ASA’s Committee on Quality Management & Departmental Administration (QMDA) and the ASA’s Department of Quality & Regulatory Affairs.
- Reporting quality measures at federal, state and local levels
Given that most practices have contracts with multiple payers, review of reportable quality measures must occur at least annually for each practice. Familiarity with institutional quality measure reporting will also be necessary.
- Establishing a department quality improvement program
Improving the system and clinical environment in which we practice should be an iterative process led by department leadership with feedback from practitioners. Understanding root causes of adverse events and establishing corrective actions plans are necessary to prevent future errors and patient harm.
- Using quality assurance and performance improvement practices to meet federal requirements
A robust established quality improvement and quality assurance program is required to meet federal requirements ensuring quality of care, patient safety and outcomes.
- Understanding quality measure development
Quality measure development can include process or outcome measures including: assessing clinical actions, examining patient outcomes (or other features of patient care) with the purpose of care delivery improvement. Quality measure development may occur both at the national level with recognized measures or at the local level with less robust intramural benchmarking. It is recommended that institutions establish a system for implementing and reviewing quality measures in their daily practice.
- Data collection and capture
Data collection and capture requires a basic understanding of quality measure structure and data requirements. Data collection methods are numerous and each method has a nuanced risk and benefit.
- Using quality metrics for process improvement and feedback
To effectively utilize quality metrics for process improvement and feedback institutions must first identify sources and tools for collecting quality metrics. A necessary next step includes defining a structured peer review process. Aggregated quality metric data can serve the mission of anesthesiologists.
- Peer review considerations
Examination of both the individual and the system are integral to the peer review process. Of course, there are legal considerations inherent in this process. There are two federal laws that contain relevant provisions as well as state level processes and protections that vary widely.
- Reporting sentinel and other patient safety events
The Joint Commission defines a sentinel event as “a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in any of the following: Death; Permanent harm; Severe temporary harm (critical, potentially life-threatening harm lasting for a limited time with no permanent residual, but requires transfer to a higher level of care/monitoring for a prolonged period of time, transfer to a higher level of care for a life-threatening condition, or additional major surgery, procedure, or treatment to resolve the condition).” All sentinal events must be reviewed by the hospital and reported to a national repository.
- Anesthesia Quality Institute (AQI) services
The Anesthesia Quality Institute (AQI) is a resource for members that includes registries and repositories of information that can be used to report data. For example, NACOR is a registry used to help report data that can be utilized for participation and payment through the Centers for Medicare & Medicaid Services (CMS) Merit-based Incentive Payment Systems (MIPS) program. The Anesthesia Incident Reporting System (AIRS), a database of information about perioperative adverse events, is also housed at AQI.
- Differentiating the role of clinical registries
A variety of medical registries exist for the purpose of collecting and sharing information on a specific condition or procedure, with the goal of improving patient safety and quality. Participating in these registries helps departments comply with mandatory reporting, identify additional meaningful metrics to improve care, benchmark care amongst peers, and form the basis of clinical research projects.
- Defining quality and quality improvement
A number of definitions exist for “quality”. In the clinical sense, a quality improvement approach focuses on dissecting the factors that contribute to errors, and addressing issues on a systems level that contribute to those, as well as reducing variability throughout the process.
- Elements of Benchmarking
Benchmarking is used in healthcare to achieve both business and quality goals; benchmarking is a continuous process by which an organization can measure and compare its own processes with its peers and leaders in the field.