The Evolution of Anesthesia Quality Management

  • Jain, Uday, MD
| Sep 06, 2016

Measures of anesthesia quality were initially developed by various anesthesia departments for quality management activities mandated by The Joint Commission. These measures of quality were not standardized across different institutions. In 2009, the ASA Committee on Quality Management & Departmental Administration (QMDA) compiled a list of critical incidents for quality reporting of anesthesia care.1 It was the intent of the ASA that this quality reporting list could be used by any of its members. 

CMS Quality Reporting
A major impetus for further evolution of quality management came from the Centers for Medicare and Medicaid Services (CMS), when its Physician Quality Reporting System (PQRS) program started incentivizing payees across the country to report quality data to CMS. Standardized measures of quality are utilized by CMS. These measures are applicable nationally and to all specialties. For the first time this has led to a large national database of quality data. 

The CMS-utilized measures of quality have been undergoing evolution. The complete 2016 list of measures for all specialties is available.2 Each measure corresponds to one of the following six U.S. National Quality Standard (NQS) health care quality domains: communication and care coordination; community, population and public health; effective clinical care; efficiency and cost reduction; patient safety; person and caregiver-centered experience outcomes. 

There are several ways to report quality data to CMS.3 These include routing via qualified registries (QR) or qualified clinical data registries (QCDR). Multiple QRs and QCDRs are available for reporting PQRS data to CMS.4  

Anesthesia Quality Institute
The ASA created the Anesthesia Quality Institute (AQI) to handle quality matters relating to anesthesia, perioperative care, and pain management.5 As a Patient Safety Organization (PSO), AQI is exempt from legal discovery. This removes a reason for withholding sensitive clinical data from AQI. The National Anesthesia Clinical Outcomes Registry (NACOR) of AQI is a QR and a QCDR. It is optimized for use by anesthesiologists. In addition to reporting data to CMS, NACOR also accumulates data for analysis. NACOR contains data on millions of anesthetics and is growing rapidly.  

PQRS quality measures data are supplied to NACOR via the eligible provider’s anesthesia information management system (AIMS), or billing software for practices not using AIMS. AQI also receives data from various organizations including CMS, the Anesthesia Patient Safety Foundation (APSF), and the American Board of Anesthesiology. These organizations and the contributing eligible providers also receive data from AQI. Data are also provided to The Joint Commission and government regulators. 

CMS Quality Measures
Of the 2016 PQRS measures, the ones that have relationship to anesthesia and are supported by the AQI qualified registry are listed below6 and have been described in detail:7 

  • #44:  Pre-operative beta-blocker in patients with isolated coronary artery bypass graft (CABG) surgery
  • #76:  Prevention of central venous catheter (CVC) - related bloodstream infections
  • #404:  Anesthesiology smoking abstinence 
  • #424:  Perioperative temperature management
  • #426:  Post-anesthetic transfer of care measure: Procedure room to a post-anesthesia care unit (PACU)
  • #427:  Post-anesthetic transfer of care: Use of checklist or protocol for direct transfer of care from procedure room to intensive care unit (ICU)
  • #430:  Prevention of post-operative nausea and vomiting (PONV) – combination therapy

For a specific patient, if the anesthesiologist has a reason for non-adherence to any of these measures, the reasoning behind such a decision should be documented.

ASA Quality Measures
CMS has approved additional measures proposed by various qualified registries, including NACOR. The additional measures proposed by ASA and accepted by CMS include:

  • ASA #8:  Prevention of post-operative vomiting (POV)—combination therapy (pediatrics)
  • ASA #10:  Composite anesthesia safety
  • ASA #11:  Perioperative cardiac arrest
  • ASA #12:  Perioperative mortality rate
  • ASA #13:  PACU reintubation rate
  • ASA #14:  Assessment of acute postoperative pain
  • ASA #15:  Composite procedural safety for central line placement
  • ASA #16:  Composite patient experience
  • ASA #20: Surgical safety checklist – applicable safety checks completed before induction of anesthesia
  • ASA #23: Coronary artery bypass graft (CABG) prolonged intubation
  • ASA #38: New corneal injury not diagnosed in the PACU/recovery area after anesthesia care

Patient Satisfaction 
Patient satisfaction has become an important component of quality. The most important measures of patient satisfaction are the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys,8 sponsored by the Agency for Healthcare Research and Quality (AHRQ) of the US Department of Health and Human Services (HHS). Consumers and patients can complete the surveys to report on their health care experiences. These surveys were developed in cooperation with CMS, and results are posted on the CMS website.9 Many organizations utilize the results of these surveys. 
There are different versions of CAHPS surveys for different providers. H-CAHPS is the version of CAHPS for assessing hospitals. The surgical S-CAHPS survey was developed by the American College of Surgeons (ACS) and the Surgical Quality Alliance (SQA) in conjunction with the AHRQ. Of the 45 questions in this survey, eight are related to anesthesia. These eight questions are not endorsed by ASA. 

Maximizing patient safety and satisfaction is a critical part of quality management. AQI provides resources for this purpose.10 Improving patient satisfaction requires improving bedside manner, easing anxiety, improving communication, respecting privacy, and ensuring comfort.10 AQI also provides guidance on measuring patient satisfaction,11 and provides an instrument for recording patient satisfaction after PACU discharge.12 Unlike the CAHPS survey of AHRQ, AQI does not collect and publish patient satisfaction data. AQI provides resources for patient education, which contributes to safety and satisfaction. 

Local Quality Management
Each institution may utilize PQRS quality measures for its own quality management activities. Doing so streamlines local quality management activity with PQRS reporting.  Whereas data are difficult to retrieve from CMS, participating providers can access data about their practices on demand from NACOR. They can compare their data with aggregate data from the entire country or a subset of the data. This facilitates benchmarking of outcomes. Trending over time can be performed. Outliers can be identified, and areas for improvement can be selected. Remedial action is facilitated by the educational resources provided. 

The national approach fostered by AQI can greatly enhance quality management, in addition to performing the service of submitting eligible providers’ data to CMS. The anesthesiologists who are utilizing AQI’s resources are at a substantial advantage compared to those who are not, and are also contributing to process improvement in anesthesiology. 

Other Quality Data
In addition to quality measures utilized by CMS, AQI has proposed templates for perioperative process and outcomes data.12 Templates are available for the intraoperative period, PACU stay, and for one week post-operatively. A template for pediatric outcomes is also provided. Data recorded in these templates are useful for institutional quality management. They are currently not being accumulated in a national database. 

To assess the quality of delivery of care, AQI recommends collection of indicators concerning business, process, and clinical outcomes.13 Business indicators include cases done, number of providers, total minutes billed, top ten cases done, and average durations of anesthetics. Process indicators include on-time starts, case cancellations, documentation compliance, and patient complaints. Clinical outcome indicators include the number of cases in which various critical events occurred. Patient experience indicators include postoperative nausea, vomiting, pain, patient complaints and satisfaction. 

Anesthesia Incident Reporting System (AIRS)
AIRS is the second registry of AQI. It records unintended events with significant potential for patient harm. It accumulates reports of adverse events and near misses from across the country, facilitating their analysis. Although this is especially useful for rare adverse events, a majority of events in the registry are not rare. Currently there are specialty modules on respiratory depression, drug shortage, obstetrics, and pediatrics. Data aggregated from NACOR and AIRS registries (after removing patient and provider identifiers) are being utilized for research.  This leads to newer approaches to quality improvement. AQI also maintains the anesthesia awareness registry. 

Surgical Quality Alliance 
The Surgical Quality Alliance was created by the ACS to bring together surgical specialties and anesthesiology for perioperative quality management.14 The surgical specialties have a number of clinical registries that closely interact with AQI. 15 These can be very useful for identifying approaches to quality improvement.

Other Quality Resources
ASA has developed a number of standards, guidelines and practice parameters for providing quality care.16 The Quality and Regulatory Affairs (QRA) group is part of the ASA Advocacy Division.17 It provides resources for quality management, reporting, and patient safety. QRA engages in advocacy on behalf of anesthesiologists and their quality management activities.

Patient safety is an integral part of quality. The APSF was established by ASA to promote safety research, education and dissemination of information.18 It conducts patient safety programs and campaigns.

Some state component societies of ASA also provide quality management support to their members. As an example, the CSA provides practice resources on its website.19 Similarly, some subspecialty societies publish guidelines for quality management.20, 21 Some of the many quality management resources for other specialties including surgery, internal medicine, cardiology, pediatrics, and obstetrics are relevant to anesthesiologists. Various regulatory agencies and government organizations are also excellent resources.22 Anesthesiologists may choose the most relevant resources from the myriad available.


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