Setting Up a Quality Program: Starting the Journey

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January 1, 2014 Volume 78, Number 1
Setting Up a Quality Program: Starting the Journey Shubjeet Kaur, M.D., M.S., HCM
Committee on Practice Management

Spiro Spanakis, D.O.

“Quality is never an accident. It is always the result of high intention, sincere effort, intelligent direction, and skillful execution. It represents the wise choice of many alternatives.”

– William A. Foster


What Is Quality?

Dr. Joseph Juran, often called the “father” of quality, defines it as “features of a product that meet customer needs and thereby provide customer satisfaction” and “freedom from deficiencies ... higher quality usually ‘costs less’.”1 It is astounding that these concepts, which were first published in 1951 along with the Juran Trilogy of Quality Planning, Quality Control and Quality Improvement, can be the foundation of a successful quality improvement program even today.


Quality Assurance vs. Quality Improvement

Quality assurance is an approach based on establishing a threshold/standard and taking action when that threshold is crossed or a standard not met. It has its roots in finding the “bad apples” and corrective action is aimed at improving individual performance.2 In contrast, continuous quality improvement focuses on process rather than individuals with an emphasis on data collection and analysis to drive process improvement efforts while valuing the needs of the customers, both external and internal.3 This difference is highlighted in Figure 1.2

Figure 1


Why Now?

Over the last decade, there has been a movement toward value-based purchasing in health care.4 Two landmark reports published by the Institute of Medicine (IOM) set the direction for quality improvement in the health care field. To Err is Human, published in 1999, highlighted that as many as 98,000 patients die each year as a result of preventable medical errors.5 In March 2001, the IOM called for a fundamental change to close the quality gap in health care with its report Crossing the Quality Chasm: A New Health System for the 21st Century.6 This set the direction toward a focus on quality and value by policymakers, regulators, payers and purchasers of health care. “Value” as defined by Michael Porter is Quality divided by the Cost of creating a quality product.7 When the Porter paradigm is applied to health care, value is added when quality outcomes are achieved at low cost8 (Figure 2).

Figure 2


External Forces

With the passage of the Affordable Care Act and the adoption of the “triple aim” of better care, better health, at lower costs by the Centers for Medicare & Medicaid Services (CMS), reimbursement has been linked to performance measures and patient satisfaction and public reporting (e.g., PQRS: Physician Quality Reporting System, HCAPHS: Hospital Consumer Assessment of Healthcare Providers and Systems, and NSQIP: National Surgical Quality Improvement Program).9-11 Quality programs have to be established to be in compliance with regulatory requirements (e.g., OPPE: Ongoing Professional Practice Evaluation, FPPE: Focused Professional Practice Evaluations, and MOCA®: Maintenance of Certification in Anesthesiology).12,13


Internal Forces

In addition to the patients, as physician anesthesiologists we have internal customers: our peers, surgeons, nursing staff and hospital administrators. Hospital leadership can exercise the option of choosing who provides anesthesia coverage. A quality program based on benchmarking, both internal and external, can make a strong business case for retention of an existing anesthesiology group.


What Should Be Measured?

In the past, providers have looked to themselves to determine what should be measured rather than what is important to customers. The recent paradigm shift is driving what elements need to be an essential component of a successful quality improvement program. There are four broad categories: performance outcome measures, patient satisfaction measures, process measures, and practice measures (Figure 3).

Figure 3

Performance outcome measures in anesthesia have been recently defined by the Anesthesia Quality Institute (AQI) and the Multicenter Perioperative Outcomes Group (MPOG). They have developed a consensus document outlining the core measures related to outcomes in anesthesia related to the intraoperative, PACU and postoperative phase of care. These were posted on the AQI website in May 2013.14 Some key examples are highlighted in Table 1.


Table 1


Excludes ASA 6 for Organ Harvest



Cardiac Arrest

Pulmonary Edema

Myocardial Ischemia







Unanticipated Difficult Airway

Inability to Secure an Airway

Respiratory Arrest






Malignant Hyperthermia

Medication Error


Delayed Emergence




High Spinal

Local Anesthetic Systemic Toxicity

Failed Regional

Vascular Access Complication


Examples of practice measures include day-of-surgery case cancellation, unplanned ICU admission, unplanned admission of outpatient, surgery on incorrect side or incorrect patient. Documentation and data collection about maintenance of normothermia, antibiotic administration, central line bundle, and beta-blocker continuation are examples of process measures that also ensure compliance with SCIP and participation in PQRS. The ASA Committee on Performance and Outcomes Measurement developed recommendations for a set of survey questions to measure patient satisfaction, for use by anesthesia practices. This white paper and appendices (sample surveys) are posted on the Anesthesia Quality Institute (AQI) website14 and are an excellent resource that can be used as a part of a quality improvement program.


Setting Up a Quality Program

There are eight key steps14 to setting up an effective quality improvement program that have their foundation in the Plan-Do-Study-Act (PDSA) cycle popularized by quality guru W. Edwards Deming.15 A critical “first step” to a successful start is a clear commitment of the department leadership to starting the quality improvement journey.


Step 1. Identify a Physician Champion: Identifying a physician champion within the group and giving him or her the nonclinical time, training and resources needed to be successful is the first step of setting up a quality program.

Step 2. Building a Quality Improvement Team: Establishing a patient safety and quality improvement team (may be a multidisciplinary team for a specific QI project).

Step 3. Communication and Agreement on Indicators: Communicating the QI plan and agreeing on what will be measured fosters transparency, buy-in and fosters trust.

Step 4. Gather Data: Data can be collected prospectively, automated or manual, and by self-reported or retrospective focused chart review to look at a specific area of practice. The mechanism for data collection and tabulation and analysis can be driven by the local practice environment (e.g., availability of anesthesia information management systems, or AIMS). Process maps can be used to clearly define key steps and highlight opportunities for improvement.

Step 5. Report Regularly: Timely, clear feedback to key stakeholders with a focus on a non-punitive peer- review data-driven approach aimed at seeking process improvement/system solutions with the goal of preventing future adverse events and improving outcomes is crucial to the success of the program.

Step 6. Make Improvements: The best solutions come from those at the frontlines of providing patient care. Build consensus and implement a change aimed at quality improvement.

Step 7. Re-measure: Assess the impact of your quality improvement intervention by re-measuring the agreed-upon indicators. Review unusual events and “near misses” to prevent harm from occurring.

Step 8. Benchmark: Comparison of metrics within the group as well as benchmarking with regional and national practices can help us learn from our peers. Participating in AQI databases and the ASA Critical Incidents Reporting System can help achieve these goals.


Quality is a journey not a destination: Start planning your journey today.

Shubjeet Kaur, M.D., M.S., HCM is Executive Vice- Chair and Clinical Professor of Anesthesiology, Director for Perioperative and NORA Service, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, Massachusetts.


Spiro Spanakis, D.O. is Director of Quality and Assistant Professor of Anesthesiology, University of Massachusetts Medical School, Worcester, Massachusetts.


1. Juran JM, Godfrey AB. Juran’s Quality Handbook. New York: McGraw Hill; 1999.

2. Carey RG, Lloyd RC. Measuring Quality Improvement in Healthcare: A Guide to Statistical Process Control Applications. Milwaukee, WI: ASQ Quality Press; 2001.

3. Berwick D. Continuous improvement as an ideal in health care. N Engl J Med. 1989;320(1):53-56.

4. Bohmer RM, Lee TH. The shifting mission of health care delivery organizations. N Engl J Med. 2009;361(6):551-553.

5. Kohn LT, Corrigan J, Donaldson MS. To Err is Human: Building a Safer Health System. Washington, D.C.: National Academy Press; 1999.

6. Institute of Medicine, Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press; 2001.

7. Lee TH. Putting the value framework to work. N Engl J Med. 2010;363(26):2481-2483.

8. Porter ME. What is value in health care? N Engl J Med. 2010;363(26):2477-2481.

9. Welcome to ACS NSQIP. American College of Surgeons website. Accessed November 15, 2013.

10. Physician quality reporting system. Centers for Medicare & Medicaid Services website. Accessed November 15, 2013.

11. CAHPS Hospital Survey. Hospital Consumer Assessment of Healthcare Providers and Systems website. Accessed November 15, 2013.

12. Standards. The Joint Commission website. Accessed November 15, 2013.

13. Maintenance of Certification in Anesthesiology (MOCA). The American Board of Anesthesiology website. Accessed November 15, 2013.

14. Anesthesia Quality Institute website. Accessed November 15, 2013.

15. The W. Edwards Deming Institute website. Accessed November 15, 2013.