Continuous Quality Improvement for Non–Operating Room Anesthesia Locations

Quality

Quality in health care means doing the right thing for every patient every time. The Institute of Medicine (IOM) defines quality as the “degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” To accomplish the desired goals, the IOM focuses on the following six principal areas of achievement:

• 1.

  Safety: Avoiding preventable injuries, reducing medical errors

• 2.

  Effectiveness: Providing services based on best clinical evidence

• 3.

  Efficiency: Using innovative strategies in allocation of limited resources; avoiding waiting time

• 4.

  Patient-centered: Individualizing care to the patient’s unique needs

• 5.

  Timely: Reducing delays in delivery of care

• 6.

  Equitable: Providing consistent care regardless of patient characteristics and demographics

Quality improvement encompasses efforts to improve patient outcomes (health), system performance (care), and professional development (learning and teamwork). CQI is a scientific approach to quality management that builds on traditional quality assurance methods by emphasizing the organization and systems of the health care system. CQI employs a systems approach to identifying and improving quality of care. CQI continually evaluates medical care to identify systematic problems and implements strategies to prevent their occurrence by a plan-do-study-act approach ( Figure 5-1 ). By focusing on processes of care rather than individuals, latent system failures and errors are identified and corrected. Objective data are used to analyze and improve processes. Accurate and sensitive quality indicators, presented as a dashboard, are necessary to monitor performance according to benchmarks and improvements over time. When areas are identified for improvement, their current status is measured and documented. Changes are implemented, and the outcome is again measured after an appropriate time to determine whether improvement actually occurred.

Inspired by the Donabedian clinical indicators, CQI programs are oriented toward defining the structure, process, and outcome of health care delivery. Following the Donabedian Quality-of-Care Framework, this model sees health care as a cyclic transformation mechanism. In this mechanism, patients are inputs entering a health care organization’s structure. In this structure, these inputs undergo a process of care through which they will become outcomes or outputs. These outcomes/outputs will further inform the feedback loop back to inputs.

Selecting Indicators

Structural indicators refer to the setting in which the care takes place. It describes the type and quantity of resources used by a health system or organization to deliver programs and services. Examples include organization, ownership, accreditation of facilities, ratio of practitioners to patients, qualifications of medical staff such as board certification, and technological complexity. Structural characteristics are considered necessary but insufficient elements in the delivery of health services. They are indirect measures of quality in that their presence enables but does not ensure the provision of quality health services, whereas the absence of these structural characteristics decreases the probability of quality outcomes.

Process indicators assess medical activities performed by the provider to ensure the “best” patient care and prevention, continuity of care, and physician–patient interaction. In the actual practice, process measures often imply compliance with standards of care such as the following:

• ▪

  Was an adequate preanesthesia evaluation performed?

• ▪

  Did the patient provide informed written consent before the procedure?

• ▪

  Was the antibiotic administered in a timely manner?

• ▪

  Was central venous access obtained under strict sterile technique following established guidelines?

• ▪

  Was hyperglycemia in a patient with diabetes treated according to an insulin protocol?

Although process indicators are considered more proximal indicators of quality than structural indicators, they cannot guarantee a quality outcome; they can only increase its probability.

Outcome indicators refer to the impact of treatments on patient well-being, including mortality, morbidity, disability, length of hospital stay, and patient functional status and satisfaction.

Validity of Continuous Quality Improvement Indicators in Anesthesiology

To confirm the validity of a quality indicator, the metrics must be connected to the accomplishment of a better outcome. Process indicators that evaluate care delivery paradigms, rather than patient outcomes, may be easier to measure and implement and can provide important insight into care. Furthermore, process indicators might yield to positive or negative inputs concerning performance and consequently influence efficient improvement in patient care. Structural indicators are valuable only if they demonstrate an increase in either a good outcome or a process previously shown to yield better outcomes.

Because the outcomes of anesthesia care are so intertwined with surgery or procedural outcomes and patient comorbidities, choosing outcome measures sensitive to variations in quality of anesthesia care is difficult. Improvement in quality of anesthesia care was traditionally measured by a reduction in mortality and morbidity. However, mortality and serious morbidity attributable to anesthesia have decreased significantly over the last several decades to the point that they cannot currently be accepted as valid CQI measures. In their review of 108 current anesthesia quality indicators, Haller et al concluded that traditional perioperative morbidity and mortality data lacked criteria of sensitivity and specificity. Nearly half of the anesthesia quality indicators also measured surgical or postoperative care. Most indicators were either outcome (57%) or process (42%) indicators; only 1% of them were related to the structure of care. Patient safety (83%) and effectiveness (68%) were the two dimensions of quality of anesthetic care most often addressed, usually by outcome indicators. External benchmarking (comparison with other hospitals) and peer review by health care professionals were the primary methods used to identify possible quality issues.

Despite these limitations, current quality-of-care indicators still measure processes of care, perianesthetic morbidity and mortality, and patient satisfaction for anesthesia care within both operating room and NORA settings. Because many severe adverse events in anesthesia are sufficiently rare, rates of more frequent outcomes such as nausea or vomiting, pain control, and critical incidents are often used as quality indicators. The Anesthesia Quality Institute (AQI) created a national clinical outcomes registry to capture data specific to anesthesia care, including quality of care. Relevant quality indicators include rare outcomes ( Table 5-2 ) (e.g., death), major adverse events (e.g., myocardial infarction and aspiration of gastric contents), minor adverse events (e.g., delirium and dental injury), administrative events (e.g., delays and documentation issues), and process events (e.g., difficult intubation and use of naloxone or flumazenil), as well as patient experience ( Figure 5-2 ). These indicators are relevant to both operating room and NORA locations.

Methods to Improve Quality of Care: Quality Improvement Model Descriptions

Mishaps in anesthesia care are discovered through a variety of mechanisms. Historically, medical errors were revealed retrospectively through morbidity and mortality conferences and closed claims malpractice data.

Review of a randomly selected or targeted sample of medical records has been used to identify problem areas and to collect data on adverse events. Although collection of data in this manner may yield important epidemiologic information, it is costly and provides little insight into potential error reduction strategies. Moreover, chart review detects only documented adverse events and often does not capture information regarding their causes. Important errors that do not result in patient harm may go undetected by this method.