A New Quality Tool for Anesthesia Departments

Editor's note: This article by Tony Mira, president and CEO of Anesthesia Business Consultants, an anesthesia & pain management billing and practice management services company, originally appeared in Anesthesia Business Consultants eAlerts, a free electronic newsletter. Sign-up to receive this newsletter by clicking here.

Do you check your professional association's web site regularly? There is more practice-related information there than you may realize. One recent addition to the resources on the American Society of Anesthesiologists web site (www.asahq.org) is worth your special attention. The ASA Committee on Quality Management and Departmental Administration (QMDA) has produced a comprehensive set of questions for anesthesiologists and others involved in perioperative patient care that can guide the development of a quality program tailored to your own department.

The QMDA Anesthesiology Department Quality Checklist is a "compendium of anesthesia safety and quality measures suitable as a reference for anesthesiology departments of any size as they develop a comprehensive set of quality standards." It consists of separate sets of questions for these individuals and offices:

• Chair of Anesthesia
• Staff Anesthesiologist
• Surgeon
• CRNA and/or AA
• Perioperative Nursing Manager
• Operating Room Nurse
• PACU Nursing Manager
• Obstetric Nursing Manager
• Quality Management
• Administration
• Anesthesia Technician

as well as for office-based anesthesia facilities. The questions, and the answers received, can serve a number of purposes. They can show the chair (or anesthesiology group president) where the department is doing well, and where it can be improved. They can provide evidence to the hospital administration — particularly important at contract renewal time — of the high quality achieved and maintained by the anesthesiology group. The questions on their own indicate the clinical quality, operating room management and efficiency, and the customer satisfaction and good citizenship activities considered meaningful by the members of the committee on QMDA, who include a number of leaders of the specialty.

Some of the recurring questions that appear on most or all of the lists, and that the Committee considers required elements of a quality program, are as follows:

1. Is safety the top priority in the anesthesia department?
2. Would you allow any member of this anesthesia department to anesthetize you or a family member?
3. Is there open and effective collegial communication between your [department/service] and the anesthesia department? [Between you, the chairman, and other members of the anesthesia department?]

There are also recurring elements that can be considered optional "but desired in appropriate circumstances," such as:

1. If requested, does the anesthesia department assist in providing educational opportunities for [your staff/for you and/or your colleagues?], and
2. Is there a culture of professionalism in the department?

A look at the relatively short questionnaire for surgeons will provide an understanding of how the tool might be used, not just in a quality improvement program but also in developing a surgeon-satisfaction survey.

Questions for: Surgeons
The tenth question for surgeons reflects a theme that runs through most of the Anesthesiology Department Quality Checklist:  the role of anesthesiologists in managing the OR and improving efficiency.  Thus the Chair's list of questions includes "does the department track: start time delays, turnover times, unexpected ICU admissions, PACU backlog/stay-overs, and unplanned admissions?;" and both the OR nurse's and the Administration's lists include "Is the anesthesia department actively engaged in running the operating room, improving efficiency, and providing adequate access to the operating room?"
Among other common themes are:

• Adherence to ASA's Basic Standards for Pre-anesthesia Care, Standards for Basic Anesthetic Monitoring, Standards for Post-Anesthesia Care and Guidelines for Ambulatory Anesthesia and Surgery;
• Verification that anesthesia machines and OR equipment are available and are used (e.g., "Is an oxygen analyzer with a low oxygen concentration limit audible alarm is use at all times?"— Question for Staff Anesthesiologist);
• Clinical personnel have, or are in the process of obtaining, professional certifications:  American Board of Anesthesiology certification, CRNA or AA certification, ASATT certification for anesthesia techs, and ACLS/PALS certification. (As an incentive, consider Medscape's Physician Compensation Report 2012, summarizing survey results showing that, across all 25 specialties and 24,216 physicians who responded, the average income without certification was $125,000, while the average with certification was $236,000. The report has a great deal of other information on physician compensation trends by specialty, job satisfaction, etc.);
• Standard anesthesia quality measures are recorded and reported:

o "Are policies or guidelines in place for management of perioperative glycemic control, including the availability of bedside glucose testing equipment?" (Chair)
o "Do you track perioperative temperature management as a part of the SCIP process? (if applicable)" (Chair)
o "Are pencil-point needles the usual spinal needle utilized in OB regional anesthesia?" (Obstetric Nursing Manager)
o "Is the department actively involved in achieving and documenting SCIP protocols?" (Quality Management)
o "Do patients on chronic beta-blockers have their medication continued through the perioperative period?" (Quality Management)
o "Is a policy in place (and followed) to assure maximum sterile barrier technique (MSBT) and the use of ultrasound for the placement of invasive lines?" (Quality Management)
o "Is perioperative temperature tracked per ASA standards?" (Quality Management);
• "Does the department have processes in place to allow for feedback from patients, nurses, surgeons, and/or administrators (i.e., surveys, peer review evaluations, 360° feedback)?" (Chair)
• Compliance with The Joint Commission standards, e.g., "Does the department provide Continuous Professional Performance Evaluations?" (Chair);
• Anesthesiologists and CRNAs willingly participate in surgical time-outs/performance rate of 100% (Chair, CRNA/AA, Perioperative Nursing Manager);
• Is there a standard procedure for hand-offs? (PACU Nurse);
• Good citizenship:

o Do anesthesiologists participate in the governance and committee work of the hospital? (Administration)
o "How regularly does the group membership meet? Is attendance greater than 75%?" (Chair)
o "Is the response time to most pages to the department of anesthesia timely?" (Obstetric Nursing Manager)
o "Is the anesthesia department actively involved in "Clinical Quality Value Analysis" and/or other cost effectiveness measures?" (Administration).

The Quality Checklist tool contains many more questions, in multiple domains.  It represents a massive amount of very thoughtful work on the part of the Committee on QMDA, which has brought to life such other important resources as the Manual for Anesthesia Departmental Organization and Management (the "MADOM"—must be an ASA member to download).  We congratulate the Committee (and ASA, while noting that the Checklist is a "committee work product" and does not set forth ASA policy), and commend this latest resource to our readers.  ABC's own commitment to capturing quality data means that we will be happy to work with clients to integrate any items of interest from the ASA Checklist into their individual reporting systems.

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