Chapter 26. Approaches to Quality Improvement in Anesthesia Care

1. In the United States there is significant public dissatisfaction with the level of safety associated with medical care. This issue has been taken up by many legislative and governmental regulatory bodies at both the federal and state level.

2. The demand for greater patient safety (ie, error reduction) has created multiple new levels of regulation and demands for accountability that go well beyond the traditional.

3. The traditional approach of practitioner accountability is giving way to approaches that additionally emphasize systems redesign and group-managed processes.

4. The demands for accountability require that individual practitioners, groups of practitioners, hospitals, and entire health systems implement methods that allow documentation of outcome and process.

5. The reliance of review systems such as case conference and focus on the individual patient is not adequate for the level of error remediation demanded. New approaches that allow examination of aggregate performance across a hospital or health system need to be developed and implemented. This is particularly challenging for perioperative anesthesia care, considering the already low level of adverse outcome.

6. For many practitioners, reimbursement will be linked to both outcome and the demonstrated compliance with process variables such as perioperative antibiotic administration. Systems that allow documentation at the individual patient level need to be developed or reimbursement and accreditation may be compromised.

7. The level of sophistication with respect to outcome and process evaluation in the intensive care unit has undergone much greater development than that for the operating room. A significant body of work exists to guide the improvement of care and to decrease the error rate in this area of anesthesia practice.

8. Safety and evaluation of outcome for acute pain therapy lags. Part of this may be related to the fact that decisions about acute pain therapy are often split between multiple groups. In addition, there is little definition of what adequate levels of acute pain relief are, how to accurately measure adequacy of pain relief, or how to monitor to prevent the complications of opioid-based pain therapy.

Since the publication of the Institute of Medicine monograph To Err Is Human in 1999, there has been a dramatic increase in the public's concern about the quality of patient care and the determination of the extent with which errors occur during the provision of that care.1 This concept of quality includes ensuring that the care is both beneficial and cost-effective and has placed unprecedented demands on all health care providers to prove the safety and value of the care they deliver.

Until recently, the autonomy of the individual practitioner to provide care in a manner in which they deemed best was paramount. In the hospital setting, the quality of care was ensured by preemployment credentialing with casual periodic renewal and episodic case conferences with the primary reliance on the individual professionalism of each practitioner. This no longer suffices. Groups, regardless of specialty, are being asked to identify potential sources of error both within their practices and the entire health care system. ...