The ‘Whys’ and ‘Hows’ of Starting an Anesthesia Quality Program, Part 1
It has never been more important for anesthesia practices to demonstrate the quality of their care. We review some of the key ingredients of an effective anesthesia quality program from a presentation at PRACTICE MANAGEMENT™ 2019 and will explore quality measure selection and definition in a future eAlert.
The need for anesthesia departments to show value to their institutions, payers and patients will only intensify in the coming years. As anesthesiologist Spiro G. Spanakis, DO, of UMass Memorial Medical Center articulated it in a presentation at PRACTICE MANAGEMENT™ 2019 in Las Vegas, quality measurement and reporting, far from being a one-shot measure, "is a cycle we're going to be going through until we retire."
In our view, the need to demonstrate quality has become virtually as important for anesthesia providers as getting paid for services.
As we've also observed in Communiqué articles and eAlerts, Dr. Spanakis pointed out that "insurance companies are putting the onus on providers to save money and to help provide efficient and safe care in a variety of ways. Quality reporting will definitely be a part of that."
At the same time, though anesthesia providers may eventually move toward alternative payment models (APMs), away from MIPS, MACRA is definitely here to stay. The shift from fee-for-service delivery to APMs and population health management that are hallmarks of MACRA will definitely take anesthesiologists with it, he said.
"Some of you, as anesthesiologists, may say we don't have a population of patients, but actually, we do," Dr. Spanakis said. "We care for patients that are having surgery. We are responsible for their care in the preoperative clinic, intraoperatively, and postoperatively in the recovery room, the ICU and the pain services to which we contribute."
Add to these forces the current financial pressure on healthcare organizations, many of which are operating on razor thin margins; the breathtaking pace of change in medical science; reports showing medical errors as the third leading cause of death in the United States; the expectations for hospitals to reduce surgical site infection rates, Medicare spending per beneficiary and other metrics through the Hospital Value-Based Purchasing Program; the growing importance of showing patient satisfaction through the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores; and the increasing transparency of performance data through government reporting systems and electronic health records, and the need for an anesthesia quality program becomes convincingly clear.
Dr. Spanakis referenced the Patient Safety and Adverse Events Composite (PSI 90), a list of quality indicators developed by the Department of Health and Human Services' Agency for Healthcare Research and Quality (AHRQ) to help hospitals identify potential for hospital complications and adverse events following surgeries, procedures and childbirth. "As anesthesiologists, there are a lot of opportunities for us to help our hospitals improve their rates here," he said. Dr. Spanakis's institution targets areas where improvement is needed and shares PSI 90 performance with quality officers organization-wide.
The rest of this eAlert gleans some of the key takeaways from Dr. Spanakis's presentation on setting up an anesthesia quality program. We'll explore additional messages from Dr. Spanakis's talk, including selecting and defining quality measures, in a future eAlert.
Identify a physician champion and give this person resources and training. It's important to identify someone within your department who is interested in quality work and to educate them, whether that education comes through local university and business school physician leadership training programs, quality and other meetings sponsored by the ASA and other medical groups, or free courses offered by the Institute for Healthcare Improvement.
Dr. Spanakis's institution has adopted the Lean process improvement methodology and incorporated Lean principles into the orientation for new employees "so we have a common language for the work we're doing," he said. Contrary to common belief, Lean is not about doing more with less, but about doing more with the same. "It focuses on looking at waste," he said.
Realize that you can't do it on your own. "As physicians, we see ourselves as leaders of the anesthesia care team and as leaders in the OR, and we sometimes think we can do this all on our own. We really can't," Dr. Spanakis observed. An effective quality program requires a commitment from anesthesia department leadership and hospital leadership. "As important as it is to identify a physician champion, this is not work that one physician can do alone. It's going to require a culture change in your department, and that change is going to have to start with leadership that is paying attention to the quality of the care you're providing your patients," he said.
The triad—nursing staff, surgeons and anesthesia providers—will need to understand the benefits of a quality program and be involved in it, especially if they are directly involved in improving patient outcomes and improving the scores for your institution, Dr. Spanakis noted.
Create an environment and culture that is supportive and non-punitive. It's very hard for people to admit they've made a mistake or that they didn't do something that they should have. "If you don't set up the right culture and approach this the right way, no matter how much time you spend on your program, it's not going to be successful," Dr. Spanakis said. The physician champion should be empowered to support people who have experienced an untoward event or error in the OR to make sure that they feel supported and that they can be helped to move past it.
Training of the OR staff at Dr. Spanakis's institution by the Arbinger Institute focused on the Influence Pyramid, which stresses that the most effective means of influencing people's behavior is by building relationships with them rather than sending them an email, which has virtually no impact. "What I'm saying is that this is going to take time. It's a process. It's not something that's going to happen overnight," Dr. Spanakis said.
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