Boudreaux, Arthur M. MD; Vetter, Thomas R. MD, MPH
Optimizing the effectiveness, efficiency, integration, and satisfaction associated with delivered health care is not only highly principled but also good business practice.1 Value-based purchasing of health care,2–4 pay for performance,5,6 intense competition,7 and a changing payment paradigm8 are all powerful financial motivators to improve health care delivery and outcomes. In the near future, physicians will likely receive remuneration not for the quantity of services they provide but, rather, for how well they deliver those services as determined by standardized metrics.9,10 In addition, to become leaders, physicians will have to rely less on their own individual accomplishments and more on the accomplishments of their teams.11 Working together to improve quality and safety is part of that transition.
Furthermore, and quite pertinent to the academic medicine community, the development of programs that foster quality improvement and patient safety efforts while also promoting a scholarly focus can generate the incentives and organizational recognition needed to make quality improvement and patient safety bona fide components of the academic mission.12 To this end, previous authors have proposed that academic departments define and promulgate a quality improvement and patient safety strategy, develop the capacity to lead scholarly quality improvement and patient safety programs, streamline and support access to outcomes and financial data, improve interdisciplinary collaboration and information sharing, and, ultimately, recognize and elevate academic success in quality improvement and patient safety.12
Anesthesiology as a specialty has been a leader in patient safety, quality improvement, and the development of national practice standards.13 We describe here the development, implementation, and results of a dedicated Section on Quality and Patient Safety (SQPS) within our academic anesthesiology department.
Development of the Dedicated SQPS
Although most clinical academic departments have quality improvement committees that are responsible for tracking complications, performing case reviews, and holding morbidity and mortality conferences, most are not structured to handle the implementation of practice change. Likewise, because of insufficient commitment and resources, our existing departmental quality improvement committee was ineffective at implementing and sustaining quality improvement activity. Therefore, in an effort to improve the quality and safety of the care we delivered, in 2007 the University of Alabama at Birmingham (UAB) Department of Anesthesiology developed a dedicated SQPS, with an organizational structure (Figure 1) and the strategic elements that others have identified as needed for success in quality improvement and patient safety.14–16 We intentionally chose the designation “Section” because it would cross all departmental divisions and stakeholders.
Specifically, as posited by Lukas and colleagues,16 the elements critical to successful quality improvement and patient safety practices comprise (1) the impetus to transform, (2) leadership commitment to quality, (3) improvement initiatives that actively engage staff in meaningful problem solving, (4) alignment to achieve consistency among organizational goals, resource allocation, and actions at all levels of the organization, and (5) integration to bridge traditional intraorganizational boundaries among individual components. In turn, these critical elements drive change by affecting the components of the complex health care organization in which they operate, namely (1) the mission, vision, and strategies that set the organization’s direction and priorities, (2) a culture that reflects the organization’s informal values and norms, (3) operational functions and processes that encompass all the work done in patient care, and (4) an infrastructure, including information technology and human resources, that supports the delivery of patient care.16 If such an initiative is successfully executed, transformation subsequently occurs over time with iterative changes being sustained and spread across the organization.16
However, performance improvement efforts in health care have historically enjoyed only variable success and have lacked sustained gains unless a single person or a small group of like-minded and dedicated individuals championed the effort.17,18 With this history in mind, our departmental chair appointed a physician (A.M.B.) to champion a quality and patient safety program at a newly created vice chair level, and to lead a small group of faculty who would have, by virtue of their positions in the department, the ability to implement and promote practice change.15,16,19 We selected the faculty leaders of key departmental committees (i.e., the clinical practice, quality improvement, and education committees) whose positions gave them the authority to make practice decisions and implement operational change. These three committee chairs, along with our director of finance, constituted the departmental quality and patient safety management team (Figure 1). Throughout the development and implementation of the SQPS, these leaders played important roles in identifying and incorporating best practices, educating department members (i.e., anesthesiologists, resident physicians, nurse anesthetists, and student nurse anesthetists) on proposed changes, analyzing the resulting performance data, and reviewing the associated fiscal results.
We believed that seeking buy-in from and the active participation of these key leaders from the inception of our systematic performance improvement effort was paramount. The engagement of these leaders was crucial both for promoting innovative ideas and for preventing others from obstructing the implementation of new protocols or programs. Their endorsement also generated robust discussion on clinical best practices, compliance, the education of resident physicians, credentialing and ongoing professional practice review, and ways to better integrate the anesthesiology department’s methodology and results into the larger UAB health system. In 2011, we added the chief residents and chief certified registered nurse anesthetist to the SQPS, so these employee groups would have representation. We also added an affiliation with our anesthesia simulation center (Figure 1).
During the developmental stage of the SQPS, the core departmental quality and patient safety management team held in-person meetings every two weeks to generate a strategic plan and create vision, mission, and values statements (Box 1). This team also systematically informed all of our department members of the goals and duties of the new SQPS before its implementation.
The department budgeted a 0.3 full-time equivalent (FTE) position for the vice chair of the SQPS. The database management required an initial 1.0 FTE position. After the first year of operation, we partnered with our departmental and institutional information technology staff to assist both with database development and management and with the design and implementation of our intranet dashboard tool (see Results of the SQPS). The UAB Department of Anesthesiology has continued to internally fund a total of 3.0 FTE positions for information technology personnel. In addition, the UAB health system funds 4.0 FTE information technology positions within the department of anesthesiology.
Implementation of the SQPS
Our departmental quality and patient safety management team adopted quality improvement and performance improvement techniques that have been used in other industries.20,21 Some of the crossover quality and performance improvement techniques for health care include the systematic and robust employee engagement that began with successful new entrant airlines (e.g., Southwest Airlines) and similarly highly regulated hospitals.22,23 We also employed some Six Sigma tools (e.g., Pareto charts, Ishikawa diagrams, control charts) that were originally used in the exceedingly competitive pharmaceutical industry and in the field of surgery (to improve patient satisfaction with pain management).24–28 Further, we adopted some of the Toyota Lean Production methods used previously by both the Japanese automotive industry and emergency medicine departments (e.g., frontline workers [residents] and management [faculty] are responsible for the quality of work [patient care delivered], and both are involved in the problem-solving process, often participating in rapid continuous improvement sessions or kaizen [weekly departmental continuous quality improvement, or CQI, conferences]).29–31 Against this backdrop of innovative and various performance improvement techniques, we instituted an educational program, undertook a series of rapid-cycle performance improvement projects, and measured performance in a wide range of activities, providing very granular and transparent feedback to our faculty and residents. The end result has been a change in the culture of our department. We define the new culture of quality and safety as one in which members are not only willing to report any complications, unsafe conditions, or inefficiencies they observe in the practice but also confident that the organization will readily address those concerns.
Educating the department
In its preliminary stages of operation, we initiated a detailed educational plan whereby we frequently promoted and (re)iterated the mission and the goals of the SQPS to all members of the department. A core part of the educational effort was an SQPS quarterly report conference, which we strongly encouraged all employees to attend. During these conferences, we shared important aggregated clinical data on longitudinal performance, the occurrence and frequency of specific complications, and other key outcomes tracked by our departmental quality and patient safety management team. We also outlined other ongoing performance improvement projects and change efforts in a transparent fashion, encouraging the participation and engagement of all staff and faculty members (including resident physicians and nurse anesthetists). When doing so was appropriate, a willing individual provider presented the data that had been collected on his or her performance for a particular performance improvement project in this public forum. This transparency has proven to be a powerful motivator for achieving clinician buy-in and changing behavior.
Selecting performance improvement projects
At the inception of our SQPS, we selected a series of performance improvement projects that addressed pressing practice issues identified by the departmental quality and patient safety management team. At the initial stage of any change effort, selecting performance improvement projects that are not complex, that have potential for high impact, and that can be rapidly accomplished is vital.15 When such projects prove efficacious, their success generates positive reinforcement or an “affirmation circuit,” and practitioners recognize the real benefits of performance improvement. We selected a corneal injury reduction project, a wrong-sided regional nerve block protocol, a drug-eluting coronary stent protocol, and a resident self-evaluation database project. For three of these initial efforts (all but the coronary artery stent project), we used a standard plan–do–check–act performance improvement methodology to implement a change process.21 The corneal injury and regional nerve block protocols are examples of department-specific projects. The coronary drug-eluting stent protocol is an example of an institution-wide project, and the resident self-evaluation database project is specific to performance improvement education.
One important element of our performance improvement effort is a weekly departmental CQI conference that we encourage all department members to attend. Although a case-based review of complications—similar to a standard morbidity and mortality conference format—is part of the process, a root cause analysis of the complication is also required for every case. We use a standard root cause analysis methodology in considering potential causes of a complication and delineating them into specific categories. Some of the common root causes we have identified thus far are communication issues, failure to follow a policy or protocol, equipment failure, and lack of training or knowledge. As an example, a physician discovered a small, asymptomatic pneumothorax in a patient after that patient had already been discharged from our postanesthesia care unit (PACU) after a surgical procedure. A chest X-ray obtained in the PACU revealed the complication, but it went unrecognized because of a communications failure and the assumption that others were ultimately responsible. This case led both to a change in our PACU discharge policy and to the implementation of a discharge checklist to prevent similar events.
This weekly CQI conference has been a well-attended forum for anesthesiology department members to review complications and to present quality, patient safety, and compliance material and updates. Clinical faculty members are required to attend at least 50% of the weekly CQI conferences (recorded by an identification badge barcode scanner), to ensure adequate participation for educational purposes, to align behavior, and to enhance the educational discussion. Faculty attendance rate at the weekly CQI conferences is included in the individual performance data reviewed annually by our departmental chair.
The resident physician presenting at the weekly CQI conference is expected to propose systems changes that may prevent the complication from recurring. Residents learn how to work with other health system leaders and stakeholders to implement change. Follow-up on suggested changes typically occurs within one to two weeks, which “closes the loop” to ensure that a solution has been or is being implemented.
In addition to attending and occasionally presenting at the weekly CQI conference, select residents serve on the UAB health system patient safety committee. These resident experiences help to satisfy Accreditation Council for Graduate Medical Education core competency education requirements in practice-based learning and improvement as well as in systems-based practice.
Factors facilitating and impeding implementation
This global quality improvement effort required clear leadership and direction—essentially a mandate—at the department chair level. Such a systematic change effort relied heavily on the dedicated and targeted efforts of a physician champion who had strong peer credibility. A strategic action plan to improve our practice provided specific, pragmatic goals for clinical and operational effectiveness. The departmental quality and patient safety management team persistently delivered to all employees at every level the consistent message that improving patient safety by eliminating complications or significantly reducing their incidence not only was the right thing to do but also would make UAB more competitive.
As with any change effort, changing practice or implementing protocols was quickly accepted by some and initially resisted by others. Until we demonstrated the clear benefit of our change effort, some resistance among the faculty persisted. As we steadfastly remained transparent, continued our communication and education efforts, and provided and shared feedback on individual performance, over time we gained significant buy-in.
Results of the SQPS
As mentioned, one of our performance improvement projects was the development and implementation of a simple eye care protocol (a two-step method involving lubrication and the application of dressings to cover the entire eye area) to standardize the care of a patient’s eyes during general anesthesia in an effort to reduce the incidence of corneal injury, a common anesthesia complication. Our reiterative intraoperative corneal injury reduction program (CIRP) has resulted in a significant and sustained decrease in this complication in our practice across a four-year period.32 A total of 60 corneal injuries occurred in the 22 months before initiation of the CIRP as compared with 8 cases in the 51 months after program initiation.
Anesthesiologists commonly provide regional nerve blocks for anesthesia and postoperative analgesia for a variety of surgical procedures. On rare occasion, a physician performs such a nerve block at the wrong location. We developed another of our inaugural performance improvement projects to address this error. We implemented a standardized protocol (identify the procedure location, monitor the patient, check the equipment, and verify the medications), developed a checklist of key mandatory elements, and required a universal preprocedural time-out (involving, at the bedside, a nurse–physician–patient simultaneous confirmation of patient identity, the block to be performed, and its laterality) in an effort to eliminate this potential complication. The department has widely adopted this patient safety process. Since its implementation, no wrong-sided regional nerve blocks have occurred at our institution, and the preprocedural time-out has prevented one near-miss.
Our third inaugural performance improvement activity addressed the placement of drug-eluting stents for the treatment of coronary artery disease, which has become a common procedure.33 Uncertainty exists regarding how to manage antiplatelet drug therapy during surgical procedures on these patients; without perioperative continuation of appropriate drug therapy, these patients are at risk for acute stent thrombosis and death.34 In 2008, we sought multidisciplinary contributions from anesthesiologists, cardiologists, and multiple medical and surgical procedural specialists in developing our coronary artery stent protocol, which we designed to optimize the management of antiplatelet drugs (e.g., aspirin and clopidogrel) in the perioperative period. We successfully developed and implemented an evidence-based protocol that has been well accepted and used institution-wide. Further, since the perioperative management of coronary artery stent patients has evolved, we have updated the protocol to include developing criteria for patients eligible to undergo surgery at our satellite hospital without immediate, on-site access to a cardiac catheterization laboratory.35
The fourth of our early SQPS projects focused on resident learning. Specifically, we wanted to educate our resident physicians on how to objectively evaluate their clinical practices. Under the auspices of the SQPS, the Anesthesiology Resident Self-Evaluation Database encourages and equips residents to evaluate their own individual performance and to compare their performance with that of their peers. Each resident physician is required to enter a randomly selected sample of the anesthetics he or she performs each quarter. By abstracting the chosen patients’ records, completing an intranet-based questionnaire, and reviewing the results, anesthesiology residents now better understand the basics of quality improvement and longitudinal performance tracking.
Including these four inaugural projects, the SQPS has, since its inception in 2007, initiated or managed through to completion over 25 quality and performance improvement projects in a variety of areas. Some additional examples involve handoff communications, surgical care improvement project (SCIP) core measures compliance, operating room fire prevention, drug cost reduction, minimization of medical supply waste, documentation improvement, prevention of syringe swap errors, and reduction of nosocomial infection rates. We also have established an anonymous near-miss reporting process to help identify issues or risk points that may be addressed before a patient injury or complication occurs.
Further, we have developed a novel, intranet-based department dashboard that allows each physician to view his or her own performance and quality data in real time. This dashboard concept has grown into a sophisticated practice management tool that assists with scheduling, communicating, tracking of continuing medical education activities, and a variety of other tasks. It has proven very useful to our staff. We have used it to improve documentation for another of our performance improvement projects (i.e., the administration of antibiotics prior to surgical incision, which is an SCIP core measure that is publicly reported). Virtually all members of our department use the dashboard to help guide their daily practice. Providing such real-time performance data and feedback to a practitioner is a powerful peer motivator to change behavior (Supplemental Digital File 1, http://links.lww.com/ACADMED/A112).
Beyond Quality Improvement Projects
In addition to designing, implementing, managing, and evaluating quality and performance improvement projects, the SQPS encourages research and career development in the area of quality management. Several of our quality-related projects have been presented at national meetings and published,32,35 and one faculty member has completed the certification in quality management offered by the American Board of Medical Quality.36 This faculty member has assumed a key leadership role in creating an anesthesiology-staffed intensive care unit at our satellite university hospital and an anesthesiology-based perioperative surgical home care model. This anesthesiologist-led care model expands perioperative care by the anesthesia service from admission to discharge. Further, several of our anesthesiology faculty members have been appointed to important system-level committees involving quality, ethics, and patient safety.
Another task of the SQPS is staff development. To teach performance improvement methodology to department members, we have developed an organized quality educational plan that includes semiannual journal club meetings and a series of grand rounds lectures on topics such as complication avoidance, patient safety, using performance improvement tools to improve quality, systems-based practice, real-world metrics–measuring performance, and changing physician behavior.
The SQPS has significantly changed the way the UAB anesthesiology department provides patient care and conducts business. The SQPS has improved the culture around and changed our approaches to quality and safety.16,37
Anesthesiology was one of the earliest specialties to adopt performance improvement practices from aviation (e.g., crew resource management) and industrial production (e.g., standardization of processes).38–40 Perhaps because of its operational similarities with cockpit avionics and employing a team approach, as well as the expectation that its practitioners deliver a high-precision product very efficiently, anesthesiology was one of the best-suited specialties to adopt such practices. Nevertheless, we believe that similar quality improvement and patient safety programs can be instituted in academic departments of any specialty. The specific changes implemented will be specialty- and situation-dependent, given the unique priorities and needs of (for example) emergency medicine, internal medicine, pediatrics, or psychiatry. Because of the demonstrated success of the SQPS, the concept was highlighted at a health-system-wide leadership committee meeting, and UAB has embraced the concept of a departmental quality improvement model. The medical executive committee of UAB has approved a plan to require implementation of a quality organization similar to SQPS in each of the institution’s 17 clinical departments. All clinical departments are thus now developing like structures, in an effort to improve quality, safety, and clinical effectiveness across the UAB health system. Our hope is that other organizations nationally adopt a model such as ours to improve health care for all.
Acknowledgments: The authors wish to express their great appreciation for the strong leadership of their departmental chair, Dr. Keith “Tony” Jones, whose vision and support were vital to making the Section on Quality and Patient Safety a successful reality.
Other disclosures: None for either Dr. Boudreaux or Dr. Vetter.
Ethical approval: Not applicable.
Disclaimer: The abstract of some of the content of this article was presented at the 65th Post Graduate Assembly, New York State Society of Anesthesiologists, in New York, New York, on December 10, 2011.
1. Bohmer RMJ. Fixing health care on the front lines. Harv Bus Rev. 2010;88:62–69
2. Porter M, Teisberg EO Redefining Health Care: Creating Value-Based Competition on Results.. 2006 Boston, Mass Harvard Business School Press;
3. Porter ME. A strategy for health care reform—Toward a value-based system. N Engl J Med. 2009;361:109–112
4. Porter ME. What is value in health care? N Engl J Med. 2010;363:2477–2481
5. Rosenthal MB, Dudley RA. Pay-for-performance: Will the latest payment trend improve care? JAMA. 2007;297:740–744
6. Epstein AM. Pay for performance at the tipping point. N Engl J Med. 2007;356:515–517
7. Porter ME, Teisberg EO. Redefining competition in health care. Harv Bus Rev. 2004;82:64–76, 136
8. Mayes R. Moving (realistically) from volume-based to value-based health care payment in the USA: Starting with Medicare payment policy. J Health Serv Res Policy. 2011;16:249–251
9. Miller HD. From volume to value: Better ways to pay for health care. Health Aff (Millwood). 2009;28:1418–1428
10. Kaplan RS, Porter ME. How to solve the cost crisis in health care. Harv Bus Rev.. 2011;89:46–52, 54, 56–61
11. Lee TH. Turning doctors into leaders. Harv Bus Rev. 2010;88:50–58
12. Neeman N, Sehgal NL. Perspective: A road map for academic departments to promote scholarship in quality improvement and patient safety. Acad Med. 2012;87:168–171
13. Stoelting RK, Khuri SF. Past accomplishments and future directions: Risk prevention in anesthesia and surgery. Anesthesiol Clin. 2006;24:235–253, v
14. Pronovost PJ, Rosenstein BJ, Paine L, et al. Paying the piper: Investing in infrastructure for patient safety. Jt Comm J Qual Patient Saf. 2008;34:342–348
15. Wang MC, Hyun JK, Harrison M, Shortell SM, Fraser I. Redesigning health systems for quality: Lessons from emerging practices. Jt Comm J Qual Patient Saf. 2006;32:599–611
16. Lukas CV, Holmes SK, Cohen AB, et al. Transformational change in health care systems: An organizational model. Health Care Manage Rev. 2007;32:309–320
17. Compas C, Hopkins KA, Townsley E. Best practices in implementing and sustaining quality of care. A review of the quality improvement literature. Res Gerontol Nurs. 2008;1:209–216
18. Shulkin DJ. Commentary: Why quality improvement efforts in health care fail and what can be done about it. Am J Med Qual. 2000;15:49–53
19. Pronovost PJ. We need leaders: The 48th annual Rovenstine lecture. Anesthesiology. 2010;112:779–785
20. Spear SJ. . Fixing health care from the inside, today. Harv Bus Rev.. 2005;83:78–91, 158.
21. Langley GJ, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. . The Models for Improvement and Other Roadmaps. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 20092nd ed San Francisco, Calif: Jossey-Bass;
22. Bamber G, Gittel JH, Kochan TA. Up in the Air: How Airlines Can Improve Performance by Engaging Their Employees. 2009 Ithaca, NY: Cornell University Press;
23. Lowe G. How employee engagement matters for hospital performance. Healthc Q. 2012;15:29–39
24. DuPree E, Martin L, Anderson R, et al. Improving patient satisfaction with pain management using Six Sigma tools. Jt Comm J Qual Patient Saf. 2009;35:343–350
25. Goh TN. Six Sigma in industry: Some observations after twenty-five years. Qual Reliab Eng Int.. 2011;27:221–227
26. Nicolay CR, Purkayastha S, Greenhalgh A, et al. Systematic review of the application of quality improvement methodologies from the manufacturing industry to surgical healthcare. Br J Surg. 2012;99:324–335
27. Chaudhuri A. Simultaneous improvement in development time, cost and quality: A practical framework for generic pharmaceuticals industry. R&D Manag.. March 8, 2012 doi:10.1111/j.1467-9310.2012.00675.x.
28. Johnstone C, Pairaudeau G, Pettersson JA. Creativity, innovation and lean sigma: A controversial combination? Drug Discov Today. 2011;16:50–57
29. Holden RJ. Lean thinking in emergency departments: A critical review. Ann Emerg Med. 2011;57:265–278
30. Chalice RAmerican Society for Quality.Improving Healthcare Using Toyota Lean Production Methods: 46 Steps for Improvement.. 2007 Milwaukee, Wis ASQ Quality Press
31. Stone KB. Four decades of lean: A systematic literature review. Int J Lean Six Sigma. 2012;3:112–132
32. Vetter TR, Ali NM, Boudreaux AM. An intraoperative corneal injury prevention program: Holding the gains from a continuous quality improvement effort. Jt Comm J Qual Patient Saf. 2012;38:490–496
33. Newsome LT, Kutcher MA, Royster RL. Coronary artery stents: Part I. Evolution of percutaneous coronary intervention. Anesth Analg. 2008;107:552–569
34. Newsome LT, Weller RS, Gerancher JC, Kutcher MA, Royster RL. Coronary artery stents: II. Perioperative considerations and management. Anesth Analg. 2008;107:570–590
35. Vetter TR, Boudreaux AM, Papapietro SE, Smith PW, Taylor BB, Porterfield JR Jr. The perioperative management of patients with coronary artery stents: Surveying the clinical stakeholders and arriving at a consensus regarding optimal care. Am J Surg.. 2012;204:453–461.e2.
37. Doebbeling BN, Flanagan ME. Emerging perspectives on transforming the healthcare system: Redesign strategies and a call for needed research. Med Care. 2011;49(suppl):S59–S64
38. Gaba DM. Crisis resource management and teamwork training in anaesthesia. Br J Anaesth. 2010;105:3–6
39. Sundar E, Sundar S, Pawlowski J, Blum R, Feinstein D, Pratt S. Crew resource management and team training. Anesthesiol Clin. 2007;25:283–300
40. Seim AR, Sandberg WS. Shaping the operating room and perioperative systems of the future: Innovating for improved competitiveness. Curr Opin Anaesthesiol. 2010;23:765–771