5 – Quality Improvement

Eugenie S. Heitmiller,

Elizabeth A. Martinez,

Peter J. Pronovost

Key Points

1. Quality is a characteristic of the system in which care is delivered, and every system is perfectly designed to achieve the results that it achieves. If we want to improve the quality of care that we provide, we need to reorganize the way that we work.

2. The growing demand for improved quality and safety in health care from patients, providers, insurers, regulators, accreditors, and purchasers calls for anesthesiologists to evaluate the quality of care that they provide.

3. Improving quality of care entails measuring performance. However, health care providers have limited ability to obtain feedback regarding performance in their daily work, in part because of a lack of information systems and lack of agreement on how to measure quality of care.

4. The goal of measurement is to learn and improve. The measurement system must fit into an improvement system; caregivers must have the will to work cooperatively to improve, they must have ideas or hypotheses about changes in the current system of care, and the team must have a model for testing changes and implementing those that result in improvements.

5. Previous efforts to measure performance have focused predominantly on outcome measures, including in-hospital mortality rates. Although important, hospital mortality alone provides an incomplete picture in that it does not provide insight into all domains of quality. A balanced set of structures (how care is organized), processes (what we do), and outcome measures (results we achieve) is needed to obtain a more accurate picture of the quality of care.

6. Future efforts to improve quality of care in the field of anesthesiology should focus on the development of valid, reliable, and practical measures of quality.

7. Developing a quality measure requires several steps: prioritize the clinical area to evaluate; select the type of measure; write definitions and design specifications; develop data collection tools; pilot-test data collection tools and evaluate the validity, reliability, and feasibility of measures; develop scoring and analytic specifications; and collect baseline data.

8. One of the greatest opportunities to improve quality of care and patient outcomes probably will not come from discovering new therapies but from discovering how to better deliver therapies that are known to be effective.

9. Strategies that have been used successfully in the aviation industry to improve performance include interventions to reduce complexity and the creation of redundancies in the system to ensure that critical processes occur. These strategies have not been fully evaluated in the practice of anesthesia.

10. Health care providers can organize their patient safety and quality improvement efforts around three key areas: translating evidence into practice, identifying and mitigating hazards, and improving culture and communication. Although each of these areas requires different tools, they all help health care organizations to evaluate progress in patient safety and quality.