Why You Need a Quality Management Program
Richard P. Dutton, MD, MBA
Executive Director, Anesthesia Quality Institute, Park Ridge, IL
The Anesthesia Quality Institute (AQI) is a non-profit corporation created to improve outcomes in anesthesia, based on aggregating, analyzing and reporting electronic data. Over the past three years AQI has recruited more than 220 anesthesia practices, from 44 states, to contribute data to the National Anesthesia Clinical Outcomes Registry (NACOR). The aggregate data has provided a unique and valuable perspective on the specialty of anesthesiology: What we do, what we know, and how we do it. At the same time, a picture is emerging of the other side of our national practice: What we don’t know and what we don’t do.
The widest performance gap in anesthesia today is our collective lack of insight regarding outcomes of the care we provide. Even among the participating groups in NACOR—a self-selected ‘choir’ of early adapters—fewer than 1 in 5 have the infrastructure to recognize and respond to the following event:
Mrs. Smith, an otherwise healthy 42 year old woman, undergoes laparoscopic tubal ligation in your outpatient surgery center. She is discharged after an uneventful anesthetic and recovery. On the way home she experiences severe nausea and vomits repeatedly.
In a perfect world, of course, Mrs. Smith’s anesthesia providers would know this adverse outcome had occurred. They would know how often patients like Mrs. Smith experience severe postoperative nausea and vomiting (PONV). They would know how their practice compared to their peers on this measure, and they would know if their outcomes were getting better or worse.
Chances are, they already know that ASA guidelines exist for managing PONV, and have read some of the thousands of scientific papers on this topic written. They know that educational resources exist to help reduce the risk of PONV, including recommendations for screening, for intraoperative management, and for postoperative treatment, and they know how to access this body of work. In short, they know that PONV is a major patient dis-satisfier, but a solvable problem. But they don’t know how often it happens!
In most anesthesia practices today no one follows-up with Mrs. Smith to discover this problem. In many others the information is sought through a phone call from the Surgery Center nursing staff, but the information itself never reaches the anesthesia practice or the specific providers. It is never linked to her electronic medical record, never presented within the group, and never reported to a national registry. While PONV might seem like a trivial problem (except to Mrs. Smith), the same data gap applies to perioperative myocardial infarction, peripheral nerve injury, and many other serious complications that are only apparent after the patient has left the PACU. Not seeking to identify these outcomes is a failure of our professional obligation to advance patient safety, and in the brave new world of healthcare reform it will not be tolerated.
A Quality Management (QM) program exists to provide your practice with data. Mrs. Smith’s outcome is one piece of information, but there are countless others. How many cases you do, and what sorts. How long each case takes. How often a case is cancelled or delayed. The satisfaction of your surgeons and your patients. How many patients your pain service sees. How many hours of critical care coverage you provide. How long your patients stay in the hospital after surgery. These are all data points that can help you improve patient outcomes, run a more efficient practice, or demonstrate your value to others. Increasingly, this information is also required by the government, private payors, certifying bodies, or the hospital itself.
“Lack of resources” is the most common barrier to effective QM, especially in small private practices. “We can’t afford to collect the data.” But is this really true? In fact, much of the data you need has already been collected. The facilities you work in and the services you interact with already have a wealth of data that you could be sharing. All you have to do is ask for it. Not only will you get the data, but you’ll also start a conversation that will lead to other easy wins. In the example of Mrs. Smith, it may be that a PACU nurse already called to talk with her on the day after surgery. Can you get that information? Can you add a question about PONV to the phone script? Can you work with the PACU to analyze and report this data? Collaborative collection efforts will lead to collaborative improvement efforts, and trends over time that benefit all stakeholders.
Once you’re looking at the data you can get for free, you will have a better idea of what’s missing. If you’ve been putting the data to work you will create evidence in your practice that QM is important, and you will be earning buy-in for when the going gets tough. Your colleagues won’t want to fill out new paperwork or electronic forms, but they’ll be more compliant if they can see the benefits the data produces. Here are some examples of how a QM program can help your practice:
Improving patient outcomes: As described above, a system for tracking and reporting patient outcomes is required to facilitate improvement initiatives. Whether reported at the group or individual level, in a public or private format, QM data will be the measuring stick that motivates individuals to alter their practice, and lets us prove as a profession that we are getting better over time at what we do.
Improving patient satisfaction: Patient-centered outcomes are the new focus of federal requirements for performance measurement, and ‘patient-centeredness’ is at the heart of healthcare reform. Every group and agency in Washington that is working on performance measurement has one or more consumer representatives, and their voices are influencing future requirements. Even the Maintenance of Certification in Anesthesiology (MOCA) program will soon require anesthesiologists to document patient satisfaction, despite little understanding of how best to measure it or how to analyze the results. Very few AQI participants track this metric now, although those that do have shown that it can be improved over time, and that this data can be useful in contract negotiations and public communications.
Building practice efficiency: QM data is not just about patient safety and satisfaction. Central to the data collected will be a description of the numbers and types of cases done, the resources committed, the financial returns achieved, and the main disrupters of efficient care. Every practice reporting outcomes to the AQI includes measures for same-day case cancellations, significant intraoperative delays, inability to move patients out of the PACU, and other important management indicators. Understanding and reacting to this data will make your practice more efficient.
Negotiating contracts: In the past, most anesthesia practices were centered on a single hospital, and worked under an exclusive contract for services. With the proliferation of ambulatory surgery centers, the rapid growth in office-based procedures, and the rise of very-large anesthesia practices, there is more business competition in the specialty than ever before. Data gathered by the QM program is essential to these negotiations, and can help to indicate which contracts will be valuable and which will not. Further, demonstration of an effective QM program is itself a selling-point for the group. Hospitals and payors are more likely to contract with a group that can present data on its own performance, and can demonstrate that it has improved its outcomes over time.
Meeting regulatory requirements: Data collected by the QM program will be essential for meeting the requirements of the Physician Quality Reporting System (PQRS), the Surgical Care Improvement Project (SCIP), and emerging pay for performance standards. MOCA Part IV now includes a requirement for anesthesiologists to document patient outcomes as part of re-certification. All of these needs can be met through the QM program, often in a way that reduces the burden of redundant data collection and reporting efforts.
Promoting academic careers: A robust QM program creates outcome information that can be combined with clinical data to produce new knowledge. Comparative effectiveness research is the study of medical interventions in actual clinical practice, facilitated by the ability to capture outcomes in large populations. Many important questions in anesthesiology will be answered with data collected by QM systems and archived in local, regional and national registries. Examples already developed include risk factors for postoperative visual loss, comparisons of regional vs. general anesthesia, and guidelines for prophylaxis against nausea and vomiting (something Mrs. Smith might appreciate …); examples in the future might include optimal approaches to sedation, the best way to reduce metastatic risk during cancer surgery, and even such far-reaching questions as the impact of anesthesia on future cognitive function.
Advancing the profession: Contributing QM data to a national registry enables development of national outcome benchmarks— something that already benefits AQI participants. Aggregated national information serves ASA leadership in its efforts to represent anesthesiologists, and influences discussions with information technology vendors, practice management companies, and drug and equipment manufacturers. By developing local QM systems and interacting with the AQI, anesthesia providers contribute to national efforts to advance the profession, ultimately benefiting all patients and providers.
If your practice is one of the majority that do not yet have a robust QM program, there are resources available to help you. The AQI website at www.aqihq.org lists dozens of companies that can help with data collection, analysis or reporting. ABC offers many of these services as well, in a variety of models to suit the logistics of any practice environment. Every practice and every provider should know the outcome of their work, as we are soon reaching a day when not knowing this information will be a profound competitive disadvantage.
Richard P. Dutton, MD, MBA is Visiting Professor of Anesthesiology, University of Maryland School of Medicine and AQI Executive Director. To contact Dr. Dutton or the AQI, visit www.aqihq.org.