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The Quality Chasm Is Even Bigger than We Thought

Clark, Randall M., MD*†

doi: 10.1213/ANE.0000000000000013
Editorials: Editorial

From the *Department of Anesthesiology, University of Colorado School of Medicine; and Department of Anesthesiology, Children’s Hospital Colorado, Aurora, Colorado.

Accepted for publication September 15, 2013.

Funding: None.

The author declares no conflicts of interest.

Reprints will not be available from the author.

Address correspondence to Randall M. Clark, MD, Department of Anesthesiology, Children’s Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Ave., B090, Aurora, CO 80045. Address e-mail to

One might be forgiven for thinking that we have made more progress than we actually have in the areas of quality, patient safety, and process improvement. After all, it has been nearly 20 years since Lucian L. Leape, MD, published his seminal article in the Journal of the American Medical Association, Error in Medicine (1994),1 and well more than a decade since the Institute of Medicine’s widely hailed quality reports, To Err Is Human (1999)2 and Crossing the Quality Chasm (2001).3

Yet the scientific application of quality, patient safety, and quality improvement concepts in medicine is still in its infancy, and the anticipated benefits of a systematic and rigorous application of these techniques still remain largely unrealized. Part of the challenge may stem from the widely variable approach to quality taken by all the participants in health care delivery and the lack of coordination among these participants on defining common and concrete goals.

In this issue, Varughese et al.4 present a review of the science of quality improvement and describe how it has been applied to the anesthetic care of children over the past 10 years. Perhaps unintentionally, these authors have also demonstrated the immense nature of quality, patient safety, and process improvement as an area of study unto itself and the daunting task of applying these principles throughout health care.

Quality and safety are the health care catchwords of the 21st century. With the high cost and exquisitely personal nature of health care and the frequently permanent nature of poor outcomes, attention to quality is certainly justified. Systematic and measurable improvements in quality of care have only recently become priorities when one considers the history of modern medicine. Fortunately, advances in anesthesiology have kept pace with or exceeded medicine’s progress in recent decades, and anesthesiology as a specialty has been identified as a leader in promoting quality and safety in clinical care.5

Advocacy and the incentives for quality improvement come from many directions. The Institute for Healthcare Improvement Triple Aim includes improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care.6 While emphasized in the first aim, quality, safety, and process improvement underlie all legs of the Institute for Healthcare Improvement triangle. Bridging the gap from policy making to practice and recognizing the high cost of poor care, the creators of the Triple Aim were able to help move the U.S. federal government to use the considerable clout of its payment system to promote health care quality. Initially, these efforts were encouraged by financial incentives under the Physician Quality Reporting System.a But beginning in 2015, payments will be reduced for those physicians not actively engaged in Centers for Medicare and Medicaid Services (CMS)-defined quality programs or whose performance falls under the scrutiny of the not-yet-well-defined Value Based Purchasing Program. The Affordable Care Act will fund, and future payment systems will likely require an even greater application of the science of quality improvement to U.S. health care.b

While these programs represent the significant opening bid in the U.S. federal government’s promotion of quality care, they also dramatically illustrate the challenge of isolating the contribution of individual components of complex care to the patient’s ultimate outcome. The current CMS measures of interest for the specialty of anesthesiology are confined to a total of 3 performance measures. One of which, the timely administration of antibiotics, is arguably not a core element of the delivery of anesthesia care.

Fortunately, anesthesiologists and others are working to address these shortcomings both in payments systems and elsewhere.7 The American Society of Anesthesiologists has recommended additional performance measures to the National Quality Forum and CMS and is actively engaged in the analysis and development of additional tools to promote quality and patient safety. The American Society of Anesthesiologists-sponsored and relatively young Anesthesia Quality Institute (AQI) has collected information on >10 million anesthetics and is building perhaps the biggest anesthesia clinical registry through its National Anesthesia Clinical Outcomes Registry (NACOR).c AQI has also created the national Anesthesia Incident Reporting System for the broad-based collection of adverse anesthesia events and near misses.

But despite the uniform emphasis on quality of care, fundamental challenges remain. One of the primary challenges to improving quality of care is its multidimensional nature. Even within a single specialty, one may question whether the taxonomy of complications and event reporting are sufficiently advanced that we have universally accepted definitions and measures. Wake Up Safe, the Anesthesia Patient Safety Foundation, American Society of Anesthesiologists, AQI, and others have expended enormous resources developing data dictionaries so that meaningful measurements and comparisons can be made. Other challenges exist. The work to achieve quality improvements can have real costs. Can quality and cost-effectiveness truly coexist in all circumstances? Perceptions about quality may differ from reality. How much of patient satisfaction really depends on quality and how much depends on the comfort of the surroundings, the caregiver’s demeanor, and time spent with the patient?

From the perspective of a hospital-based physician, there is a remarkable disconnect among all the interest groups focused on quality. How can it be that patients, governmental and private payors, accrediting agencies, employers, hospitals, public policy makers, and physicians are all vitally interested in quality and safety, and yet the work of all these parties so infrequently overlaps in a meaningful way? The interest in the quality and safety techniques in the highly reliable aviation and nuclear power industries is high, but one must question how broadly applicable those tools are to patient care. Varuguese et al.4 have picked up the gauntlet and describe here how the principles of lean manufacturing and six sigma, to name 2 examples, can begin to be applied to the delivery of anesthesia care.

Significant challenges remain in the dissemination of accepted programmatic and institutional quality concepts down to the level of the physician–patient interaction. Quality and reporting programs sometimes become the victims of their own success. As the frequency of serious adverse events is reduced, significantly greater coordination and improved collection of data are necessary to find statistically valid results. The mathematics dictates the need to collect information across numerous institutions, networks, and possibly even countries if one is to be able to draw meaningful conclusions.

Quality improvement within the hospital has its own challenges. Hospital-driven quality programs may or may not have good overlap with the quality activities of a department of anesthesiology. Collecting common, subtle but significant events is the problem. Unplanned escalations of care related to perioperative decision making may require manual tracking and analysis by experienced clinicians. Hospitals do some of this now, but the hospital’s approach of using DRG-based analyses of complications and even mortality may not work its way down into the fine detail of anesthetic decision making. The solution to the mathematics challenge and the need for better outcomes research appear to be the creation of detailed clinical registries. But as the work in the area of neurodegeneration after exposure of the immature brain to anesthetic agents has shown, conclusions may require years of observation and analysis.

Finally, the dramatic escalation of various forms of clinical registries may present its own problems including the undesired aspects of competition between registries, questions of the considerable cost (in people, money, and time) to support these efforts, and the presently unaddressed question of who owns the data and the economic value derived from it. There seems little choice but to have much better coordination, including across medical specialties, among the clinical registries and their sponsors.

Perhaps, the biggest advancements in this type of analysis will wait for the time when clinical informatics improves to the point of automating data mining for not only complications but for less than optimal outcomes as well. One can hope that the proliferation of a relatively small number of vendors in health care information technology will foster the more rapid development of the needed software tools and techniques. In the meantime, we can work on building the steering committees, both within hospitals and across disciplines, which will be required to develop better awareness of the needs and results of the other players in the quality universe and which will be necessary to analyze complex care with multiple participants.

Real progress in quality and patient safety will require new thinking, new systems, and much better tools. It will require collaboration and reporting on a very large scale. Perhaps most importantly, it will require better planning and coordination among all the disparate players in the quality sphere. Building on the work of Varughese et al.,4 we have every reason to believe the significant remaining gaps can be breached.

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Name: Randall M. Clark, MD.

Contribution: This author helped in manuscript preparation.

Attestation: Randall M. Clark approved the final manuscript.

This manuscript was handled by: Peter J. Davis, MD.

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a Centers for Medicare and Medicaid Services. Available at: Accessed August 3, 2013.
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b CMS Innovation Center. Available at: Accessed August 3, 2013.
Cited Here...

c Anesthesia Quality Institute. Available at: Accessed August 3, 2013.
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1. Leape LL. Error in medicine. JAMA. 1994;272:1851–7
2. Kohn KT, Corrigan JM, Donaldson MS To Err Is Human: Building a Safer Health System. 1999 Washington, DC National Academy Press
3. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. 2001 Washington DC National Academy Press
4. Varughese AM, Rampersad SE, Whitney GM, Flick RP, Anton B, Heitmiller ES. Quality and safety in pediatric anesthesia. Anesth Analg. 2013;117:1408–18
5. Kohn KT, Corrigan JM, Donaldson MS To Err Is Human: Building a Safer Health System. 1999 Washington, DC National Academy Press
6. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27:759–69
7. Berenson RA, Pronovost PJ, Krumholz HM Achieving the Potential of Health Care Performance Measures. 2013 Princeton, NJ Robert Wood Johnson Foundation
© 2013 International Anesthesia Research Society