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Measuring and Improving the Quality of Preprocedural Assessments

Manji, Farah MD, MPH*; McCarty, Kelsey MS, MBA; Kurzweil, Vanessa PhD; Mark, Eden MPH§; Rathmell, James P. MD; Agarwala, Aalok V. MD, MBA

doi: 10.1213/ANE.0000000000001834
Patient Safety: Original Clinical Research Report

BACKGROUND: Preprocedural assessments are used by anesthesia providers to optimize perioperative care for patients undergoing invasive procedures. When these assessments are performed in advance by providers who are not caring for the patient during the procedure, there is an additional layer of complexity in ensuring that the workup meets the needs of the primary anesthesia care team. In this study, anesthesia providers were asked to rate the quality of preprocedural assessments prepared by other providers to evaluate anesthesia care team satisfaction.

METHODS: Quality ratings for preprocedural assessments were collected from anesthesia providers on the day of surgery using an electronic quality assurance tool from January 9, 2014 to October 21, 2014. Users could rate assessments as “exemplary,” “satisfactory,” or “unsatisfactory.” Free text comments could be entered for any of the quality ratings chosen. A reviewer trained in clinical anesthesia categorized all comments as “positive,” “constructive,” or “neutral” and conducted in-depth chart reviews triggered by 67 “constructive” comments submitted during the first 3 months of data collection to further subcategorize perceived deficiencies in the preprocedural assessments. In May 2014, providers were asked to participate in a midpoint survey and provide general feedback about the preprocedural process and evaluations.

RESULTS: 37,611 procedures requiring anesthesia were analyzed. Of the 17,522 (46.6%) cases with a rated preprocedural assessment, anesthesia providers rated 3828 (21.8%) as “exemplary,” 13,454 (76.8%) as “satisfactory,” and 240 (1.4%) as “unsatisfactory.” The monthly proportion of “unsatisfactory” ratings ranged from 3.1% to 0% over the study period, whereas the midpoint survey showed that anesthesia providers estimated that the number of unsatisfactory evaluations was 11.5%. Preprocedural evaluations performed on inpatients received significantly better ratings than evaluations performed on outpatients by the preadmission testing clinic or phone program (P < .0001). The most common reason given for “unsatisfactory” ratings was a perception of “missing information” (49.2%). Chart reviews revealed that inadequate documentation was in reality the most common deficiency in preprocedural evaluations (35 of 67 reviews, 52.2%).

CONCLUSIONS: The overwhelming majority of preprocedural assessments performed at our institution were considered satisfactory or exemplary by day-of-surgery anesthesia providers. This was demonstrated by both the case-by-case ratings and midpoint survey. However, the perceived frequency of “unsatisfactory” evaluations was worse when providers were asked to reflect on the quality of preprocedural evaluations generally versus rate them individually. Analysis of comments left by providers allowed us to identify specific and actionable areas for improvement. This method can be used by other institutions to identify systemic deficiencies in the preprocedural evaluation process.

Supplemental Digital Content is available in the text.

From the *Department of Anesthesia, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; Department of Medicine, Boston Medical Center, Boston, Massachusetts; Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts; §Center for Quality and Safety, Massachusetts General Hospital, Boston, Massachusetts; Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts; and Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts.

Accepted for publication November 21, 2016.

Funding: No external funding.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Reprints will not be available from the authors.

Address correspondence to Aalok V. Agarwala, MD, MBA, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Gray Jackson 446, 55 Fruit St, Boston, MA 02114. Address e-mail to

© 2017 International Anesthesia Research Society
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