Health care systems throughout the industrialized world face a dilemma. On the one hand, new technology is becoming increasingly available, while on the other hand the population is ageing and unemployment and health care expenditure are rising continuously . In Germany the costs for health care have reached nearly 11% of the gross national product. Like many other countries, the German government is about to turn away from a fee-for-service reimbursement system and to introduce a fee per capita system (Australian Refined Diagnosis Related Groups1) in order to limit the budget for hospital care. According to a study by the Arthur Anderson Management Consulting Company, up to the year 2015, about 25% of hospitals and nearly 40% of hospital beds are expected to have their numbers cut. Furthermore, as the population, politicians and insurers want to know if they really are getting satisfactory value for the money put into health care, it is obvious that the nature of research into quality in health care and outcome will change completely [1,2]. Thus, the trend towards evidence-based medicine and health technology assessment will increase. Do our treatment algorithms work? These trends will obviously affect the non-curative discipline of anaesthesia and its further development [3,4] (Figure 1).
Thus, the objective of this review is to show what our speciality has already done to provide the best care for our customers and what we will have to cope with to face new demands in future in order to be a strong partner in perioperative care. The method of this review consists of a Medline literature review with the search terms quality, management, outcome and anesth* or anaesth*. Definitions concerning quality and quality management by the International Standardization Organisation (ISO) have been used.
Definition of quality in anaesthesia
According to the norm ISO 9000:2000, quality is defined as: ‘The ability of a set of inherent characteristics of a product, system, or process to fulfil the requirements of customers and other interested parties’ . ISO norm 9001:2000 specifies requirements for a quality management system that can be used by an organization to address customer satisfaction by meeting customer and applicable regulatory requirements. It can also be used by internal and external parties, including certification bodies, to assess the organization's ability to meet customer and regulatory requirements .
Quality in anaesthesia is multidimensional. The speciality of anaesthesia not only serves the patient, the surgeon and the hospital, but also has to satisfy the demands of health insurance companies and society . For each different aspect, quality has to be assessed in a different way. Challenges of quality management in anaesthetic practice can be stated as follows; first, of course, to ensure that the patient incurs no additional harm; second, to provide the best working conditions for the surgeon and to optimize perioperative care; and third, to develop treatment algorithms to achieve optimum clinical results [7,8].
Treatment must not be detrimental to the patient
Incident reporting and patient safety management has always been of great concern to anaesthesiologists . But even on the threshold of the third millennium, tragedies in anaesthesia continue to occur. These occur mostly as a result of failing to check the anaesthetic equipment, tolerating inadequate assistance, continuing to work when fatigued, errors in drug administration, leaving anaesthetized patients unattended or failing to provide adequate staff supervision . This does not take into account the fact that individuals can be expected to make mistakes and that errors are part of our everyday work . Comparing human errors in hospitals and industrial accidents, Spencer refers to an unpublished study on a European airline in 1979: ‘… a human error or an instrumental malfunction occurred every 4 min (!), all of which were promptly corrected by backup systems’ . In anaesthesia incidents, events and complications are well documented, and are thus an important part of perioperative outcome tracking . Moreover, excellent anaesthetic machines and monitoring equipment are available, with appropriate alarms giving way to the development of smart-alarm systems . In medicine this is outstanding. However, as discussed, it is inadequate to eliminate tragedies. Ongoing training of staff members and scientific clinical evaluation is necessary to further improve the quality of the anaesthetic performance and patient outcome.
Provide the best working conditions for the surgeon and optimize perioperative care
Anaesthesia has developed as a speciality in its own right, as it is realized that more invasive surgery is only possible when certain anaesthetic techniques and procedures are integrated into the perioperative setting. These include preoperative patient assessment, the anaesthetic plan or management including special intraoperative anaesthetic techniques (e.g. one-lung ventilation), monitoring techniques, regional anaesthesia, postanaesthesia care units, intensive care units, acute pain therapy and ambulatory anaesthesia. In this setting, the anaesthesiologist has to be a competent and equal partner in all the surgical disciplines. As a perioperative manager, he/she guides the patients and their surgeons from the preoperative assessment to their discharge, through all the intervening steps (Figure 2). Only by means of this co-operation can operating room utilization and schedules be improved and optimized .
Moreover, patient comfort and safety, and thus avoidance of postoperative morbidity and mortality, must, and can be minimized [14,15]. Each complication will extend the length of hospital stay and will consume an enormous part of the hospital budget. The results of an Australian study of incident monitoring showed that about 10% of patients were not assessed preoperatively by an anaesthesiologist, whereas 23% of the anaesthesiologists involved in patient care during surgery had not performed the preoperative assessment themselves. Poor airway assessment, communication problems and inadequate evaluation were the factors most commonly contributing to untoward incidents. Further, more than half of those incidents could have been prevented by sticking to well-accepted rules . Making use of anaesthesiologists as perioperative managers can play a substantial role in improving patient care: Van Aken and colleagues, for example, showed that the implementation of a multimodal pain therapy strategy based on patient-controlled epidural anaesthesia, early tracheal extubation and early mobilization can lead to substantial savings in intensive care unit utilization .
Developing treatment algorithms to optimize patient outcome/care
Anaesthesiologists primarily facilitate care. Apart from emergency medicine, intensive care medicine and pain therapy, they do not usually implement curative therapy. However, the management and therapy appropriate for any individual patient suffering from a specific disease is not always obvious. The patient's coexisting disease(s), age and the stage of the disease have to be taken into consideration. Unfortunately, while the American Society of Anesthesiologists' (ASA) Physical Classification correlates well with operative morbidity and mortality, it is unsuitable for assessing the specific anaesthetic risk for a patient [17,18]. In addition, apart from avoiding specific risks such as hypoxic brain damage or fractured incisor teeth, anaesthesiologists have to assist their surgical colleagues in optimizing patient outcome . This involves considering which surgical procedure should be carried out under what circumstances. Are there non-invasive or conventional methods of treatment, which would be preferable for a particular patient ? Or should surgery be avoided if the surgical and anaesthesiological risks outweigh the potential benefits for the patient? What about those patient outcomes when the defensive strategies of physicians involve costly and inhuman ‘treatment’ [21,22]. These questions must be answered before we can satisfactorily discuss quality in anaesthesia or perioperative care. Quality mainly means are we doing the right things in the right way. According to the Institute of Medicine,2 only a very small part of medical practice is evaluated for its effectiveness . This is where evidence-based medicine involves the anaesthesiologist . On 8 February, 2000, the Cochrane Anaesthesia Review Group was registered with the Cochrane Collaboration . This group will prepare systematic reviews on the topics of anaesthesia, perioperative care medicine, intensive care medicine, resuscitation and emergency medicine. But as long as well-conducted, randomized clinical trials are lacking, it will be difficult to establish evidence or effectiveness for medical practices. Merry, Davies and Maltby, in a recent editorial in the British Journal of Anaesthesia, stated that the outstanding feature of quality research published in this journal is its paucity ! Also, quality research must focus on the ‘real world’ and not on laboratory conditions. Whether patients really benefit from various treatments must be examined. That is the impact for larger multicentre studies, which provide statistical evidence as to whether one treatment is more effective than another. One of the greatest problems today is that traditional treatment algorithms are now accepted as the gold standard without ever having been objectively assessed . Unfortunately, to make a scientific career, professionals are forced to produce a large number of publications in a short time. However, well-conducted, randomized clinical trials need a long time to prepare, to conduct and to be evaluated.
Quality management in anaesthesia — now and then
In 1992, Eagle and Davis described seven attributes defining quality in hospital, which require assessment by all departments, including anaesthesia: safety, provider competence, acceptability, accessibility, efficiency, appropriateness and effectiveness .
In 1960, Donabedian designed a model of quality assurance in health care. The triad of structure, process and outcome were defined as different aspects of quality  (Table 1). Structure denotes all the hardware of a department: staff (e.g. qualification, supervision, on-call staff for emergencies), administration, buildings (e.g. central operating room area) and equipment. Figure 2 shows at which different levels process management occurs in anaesthesia. All the processes should be defined. General rules for a department should be defined and written down in a departmental service guideline or quality management handbook. This should include how to assess patients preoperatively, e.g. which patients could act as their own blood donors, and what anaesthetic strategy and perioperative monitoring should be employed for patients with different risks concerning their coexistent diseases and the surgical procedures planned. In this context, case discussions can be valuable in risk management and as a tool in continuing education. Incident monitoring systems should be regarded with caution, as there is evidence that reporting by the medical specialist involved is a more reliable method of identifying adverse outcome .
Outcome represents the final results of the department. Even if there is no scientific proof that an optimized structure and process are prerequisite for optimal results, it is a commonly held assumption . Talking of outcomes, we still have to face the six ‘d’s and their prevention: death, disease, disability, discomfort, dissatisfaction and dollars. Quality assurance in this context also means risk management.
However, quality management, as implied by Deming, Juran and others, is not only to assess quality but to work continuously for its improvement, as implied by the famous ‘plan-do-check-act cycle’. Thus, quality management is not a single assessment to obtain accreditation. Accreditation may help to assess the actual quality situation, but is worthless if it is not used in a continuous quality improvement setting . In German health care law, quality management has become an important issue since 2000. Organizations that do not implement quality assurance and improvement programmes will be paid less for the same service than those that do . Perhaps in future, health care insurance companies will only contract services with certified hospitals. Another aspect as to why it is important to be engaged in quality assurance/improvement measures is the increasing demand by customers for the best service .
With the enormous impact of cost containment in health care, the aspects of quality in anaesthesia are changing. Risk management tools to avoid anaesthetic tragedies still have to be implemented or improved. An economic evaluation shows that the introduction of Medicare rates would decrease the payment to anaesthesiology departments by 37% . Cuts of this order of magnitude inevitably represent a serious risk to the maintenance of quality of medical care. In this context, anaesthesiologists have to continue to show that they cannot be replaced by nurse anaesthesiologists . At the same time, anaesthesiologists will increasingly have to leave the safe harbour of the operating room and enter the field of perioperative medicine (postanaesthesia and intensive care units, and acute pain management). Anaesthesiologists have to be more concerned about issues of economics and critical thinking of outcomes. Here we have to step beyond monitoring for adverse events. The anaesthesiologist will have to take part in outcome studies together with those disciplines treating the patients. The spirit of quality management in the context of continuous quality improvement is a prerequisite for excellent performance and transparency. Let us throw out the old medical custom of searching for the ‘bad apples’ and throwing them away . Quality will only improve if we create a culture where faults can be a treasure if they are discussed openly and if we examine why they occurred.
But for the patient to benefit from the best outcome, the organizational structure of the health care provider (hospital) must change radically: barriers between the different departments have to be torn down and a real interdisciplinary approach has to be adopted. There should be an end to the separation of wards by disciplines. Instead, interdisciplinary wards should be established where interdisciplinary teams treat patients with a particular kind of disease.
The anaesthesiologist is traditionally accustomed to interdisciplinary work and will be prepared to face the future challenges of changing health care systems if he/she is aware of his/her role, and is willing and able to cope with those new tasks.
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1In Germany a DRG-classification system (German Diagnosis Related Groups) based on the Australian Defined Diagnosis Related Groups (AR-DRG) will be introduced by 2003. This classification system was chosen, as it seems to be the most modern DRG-system at this time. Since 1992, when the Australians initiated a DRG-classification system for hospital funding, a lot of work to continuously improve the system has been performed by the Australian Casemix Clinical Committee and the National Centre for Classification in Health.
2The Institute of Medicine founded in 1970, is one of four organizations, which form the National Academies in the USA. The Congress established its predecessor — the National Academy of Sciences — at the height of the Civil War in 1863. These non-profit organizations are intended to ensure independent advice on matters of science, technology and medicine (http://www.nationalacademies.org).