QA and CQI In Current Anesthesia Practice

Zhang@LA

Quality Assurance andContinuous Quality Improvement In Current Anesthesia Practice (Part 2)

XiaoyanZhang, MD.

Chair,Patient Safety and Quality Committee, CASA

SeniorPartner, South Bay Anesthesia Group, PLCMMC. Torrance, CA USA

Inpart 1, I introduced some basic concepts of QA and CQI from Dr. Deming.  Now I will discuses these quality concepts incurrent anesthesia practice and healthcare system.

1. Healthcare SystemTransformation

Thoughhealthcare, as an industry, has been relatively late to come to the qualitymovement in the 1980s, the current healthcare reform is more active than anyother fields.

"ToErr is Human, Building a Safer Health System!” was brought up by the IOM (the Institutionof Medicine) in 1999, because medical errors were the 8th leadingcause of death in the United States.

Sincethen, "Quality Outcomes and Patient Safety" have become the priorityof quality improvement in medical care. Meanwhile, the health reform hasstimulated participation of all other fields in America, and then in the wholeworld as well. We can no longer accept the fact that annually almost 98,000people died from medical errors!

Nowadays,the system of QA and CQI is forcing an unavoidable transformation in American healthcare.The myriad of changes focus on "patient-centered" and "value-based"payment health system. We can no longer accept the traditional"volume-based/fee-for-service" model. This reform will result in bettercare, reduced cost, and higher quality of service.

2. The leadershipof Anesthesiologists in Perioperative Care

Asanesthesiologists, we are at the forefront of perioperative care. It'sindisputable that we have led all other medical specialties in the category ofpatient safety initiatives.

Inthe operating room, it’s our daily life that we handle all kinds of patients fromall other services. Thus, we are the only specialty who has to be well familiarwith other specialty’s work. No doubts, we are already the leader of criticalcare when OR emergency happens.

"Surgeonsknow just their patients – but we know them all", says Richard Dutton,M.D., M.B.A., chief Quality Officer, Anesthesia Quality Institute (AQI). “We are already at the front, andwe need to get to the next level first” added Dutton.

3. Anesthesia QA and CQISystem

Anesthesiaquality system should encompass several components as a network.

1)    Intradepartmental Collaboration

Peer review: This is the first lineof quality control at the primary level. The departmental QA and CQI should includecase presentation, discussion, and education, according to the standard care ofthe hospital, the community and the ASA. The review should be on routine and regularbasis to maintain self-monitoring, immediate response, problem solving andtimely communication.  

Peer Review is considered the most important and effective method toreduce complications and prevent medical errors for continuous qualityimprovement.

2)    The Hospital QA Office / Performance Improvement Department

At the hospital level, the office will establish the monitoring criteria forall services including anesthesia department. And they will evaluate ourperformance regularly and closely. For example, the Performance ImprovementDept at PLCMMC Torrance, California defines 4 items for our department, tomonitor and to report. These are 1. Death; 2. Stroke; 3. MI, and 4. RespiratoryFailure, during surgery and within 24 hours after surgery.

They also receive complaints from patients and hospital floors, and thenbring them up to the anesthesia department for case reviews.

The QA office is also responsible to the hospital medical staff andexecutive offices, to submit all anesthesia performance information requested.  The hospital will use its administrativepower to delineate physician’s privileges and adjust departmental contracts toensure quality.

3)    The State Medical Board

The State Medical Board ensures the quality of licensed practitioners tothe public. It also reviews the complaints from patients and consumers, who maycomplain directly to the Board. The anesthesiologists reported on have torespond with written explanations in a timely manner.

Here I’d like to share a knowledge that In California, the liabilityinsurance companies will not coverthe physician if he/she needs an attorney for the defense of the board cases.

4)    The Liability System

None of us wants to go so far to this step for quality control, butliability system is the most powerful system for risk management.

We win, we lose and we learn.

The good news is the anesthesia specialty has done so well in QA and CQIfor years. And our professional malpractice has dropped significantly. Asreported recently in the Los Angeles Area in 2013, the average frequency oflegal claims for anesthesiologist is 1:14.3 years, as low as the 2ndlowest, pathology; and just higher the lowest pediatrics. 1:33 years.

      5) The Credentialing System

In the United States, there are multiple institutions and organizations forhospital accreditation and compliance. They play very important role in qualityand continuous improvement in the healthcare system. The best-known ones forhospitals are the Joint Commission on Accreditation of Hospitals (JCAH), and the Center for Medicare andMedicaid Services (CMS).

6)    ASA QA Organizations

As mentioned earlier, our specialty and the ASA have worked on qualityfor many years through the leadership of several committees. These include the Standardand Practice Parameters (SPP), andQuality Management and Departmental Administration (QMDA), the Anesthesia Patient Safety Foundation (APSF), and most recently, the AnesthesiaQuality Institute (AQI).

4. Data, Measurable and Reportable

"Whatgets measured gets done". This is an all-too-familiar doctrine inWashington, D.C., among health policy experts. It’s further strengthened by CMSin 2013, when its 2014 Physician Fee Schedule (PFS) was released. Its focus on quality reporting has far-reachingimplications for anesthesia practice.

Inthe past 5-7 years, the Anesthesiology has reported 3 measures to the PhysicianQuality Reporting System  (PQRS),as requested:

1.Timely administration of prophylactic antibiotics;

2.Perioperative temperaturemanagement;

3.Prevention of catheter-relatedbloodstream infections.

Seemingly,the current measurements are very limited for anesthesia outcomes. Abx timinghas achieved near 100% compliance, and become "tapped out". Moreimportant new measures are needed.

Recently,ASA successfully submitted 4 measures to CMS for 2015 PQRS consideration. Theyare:

1.Aspirin for patients with coronary artery stent;

2.Post-anesthesia transfer of care;

3.PONV prevention in adults;

4.PONV prevention in pediatrics.

Thoughwe are not yet convinced that measurements, such as mortality and majorsurgical complications truly measure anesthesia performance, we may have toaccept accountability for surgical outcomes such as perioperative MI, stroke,kidney injury, and death. Otherwise, we will lose the opportunity to join oursurgical colleagues as equal partners in the new healthcare delivery andpayment system.

PatientSatisfaction Measurement is the last reportable data, though its value and reliabilityrise some concerns.

Aqualified electronic health records (EHRs)is necessary for the data measurement.

5. Value-Based Payment

Accordingto data measured and reported, the insurance company will evaluate the qualityof services. Now, the patient-centered and Value-Based payment system hasstarted, first by CMS. Here are somefacts.

InFY 2013, physicians participating in the reporting program are eligible toreceive up to an extra 0.5% of their total physician fees. Importantly, Itchanges. In FY 2015, PQRS will impose an adjustment (reduction) of 1.5% tophysicians who do not satisfy quality metrics. And the penalty will increase to2.0% in 2016.

From2013, all hospitals have a withhold of payment from Medicare beginning at 1%,and will rising up to 2% by FY 2017. The money will be redistributed tohospitals based on their Total Performance Scores. A hospital may earn back avalue-based incentive payment, less than, equal to, or more than the withhold. Inthe future, payment reduction may happen also to the physicians who do notsatisfy specific quality metrics or do not participate in the measurement.

Webelieve, this performance-based payment system would spread quickly to otherhealth insurance companies, beyond Medicare.

6. Education

“Knowledgeis not replaceable by information”, and education is always key to qualityimprovement.

Anesthesiologyprofessional education is approached at all levels: CME (self-study),Departmental Education Forum, ASA meeting, and Simulation Training.

Adepartment should consistently review updated ASA Protocols and Guidelines; anddevelop processes and systems to implement them. Study Emergency Manual withSimulation Training to improve management during critical and rare events.

Asthe leader, anesthesiology should contribute to the education to otherdepartments whom we work with outside of main OR, such as GI lab, Angio/ Radiologysuites and L/D, and promote the “sub-standard” anesthesia care to the ASAstandard. We should also teach them how to help us under emergent situations.Update the OR staff with pertinent knowledge to maintain better coordination atwork.

Conclusions

Currently,an all-new QA and CQI concept in anesthesiology focuses on the PerioperativeSurgical Home -- to shepherd the patient throughout the entire surgicalcontinuum, from decision to undergo surgery to discharge and beyond.

Allof us will be well prepared to achieve the better outcomes at lower cost, asleader in this quality transformation of healthcare reform.

Reference

1.   To Err is human: building a safer health system. Washington, D. C.National Academy Press, 2000, p 1

2.   Anesthesiologists and the transformation of the healthcare system.Anesthesiology, Vol 120. No 2. Feb. 2014

3.   Taking a lead on quality. Newsletter, ASA. Feb. 2014 Vol 78 No 2

4.   Patient safety and risk management. CAP-MPT insurance Company, 2013

Note

Thisarticle will be submitted also to the Chinese New Youth Magazine inAnesthesiology, on request, as introduction to American quality system for ourChinese colleagues. Some contents may be “routine” for our AmericanAnesthesiologists. Thank you!