Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Neuroanaesthesia PPT 15 Quality Of Care In Anaesthesiology Lecture Notes
QUALITY OF CARE IN
ANAESTHESIOLOGY
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INTRODUCTION
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? Quality and safety are closely related to consistency and reduction in practice variation.
? The advancements in anesthesia techniques has necessitated assurance of quality anesthesia
services delivery.
? In anaesthesia, reducing the error rate increases quality and reduces preventable injuries to
patients, while also eliminating the additional costs resulting from those errors.
? The objective of quality assurance is to ensure a high standard of anesthetic care with a focus on
patient safety during perioperative period.
? In the health care sector, quality can have various meanings to different people.
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? In order to help standardize the definition of quality in health care, the Institute of Medicine
(IOM) published its own definition in a 1990 report titled Medicare: A Strategy for Quality
Assurance.
? The IOM defined quality as "the degree to which health services for individuals and populations
increase the likelihood of desired health outcomes and are consistent with current professional
knowledge."
? The IOM subsequently outlined six dimensions or aims of quality in its 2001 report, Crossing the
Quality Chasm.
? These aims have been adopted by many organizations, as a basis on which quality is evaluated
and improved.
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1) Safety -
? No patient or health care worker should be harmed by the health care system at any time,
including during transitions of care and "off hours," such as nights or weekends.
? As much as possible, patients should be informed about the risks and benefits of medical
care in advance.
? If a complication does occur, medical staff should make full disclosure, provide assistance to
the patient and family, and exercise due diligence in preventing any recurrences of the error
2) Effectiveness -
? Evidence based decisions about treatment for individual patients, when such evidence exists.
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? Clinical expertise and patient values combined in forming a treatment plan.
? With effective care, underuse and overuse is avoided.
3) Patient-centeredness ?
? Catering to individual patient preferences, needs and values and uses these factors to guide
clinical decisions.
? Examples of patient-centered care include ?
?Shared decision making.
?Patient ownership of medical records.
?Schedules that minimize patient inconvenience
?Unrestricted visitation hours.
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4) Timeliness -
? Reduced wait time is important to both patients and health care practitioners.
? Delays may not only affect patient satisfaction, but may impair timely diagnosis and
treatment.
? For health care workers, delays in availability of equipment or information may decrease job
satisfaction and the ability to perform their jobs adequately.
5) Efficiency ?
? Improved efficiency reduces waste and results in an increased output for a given cost.
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? Examples of efficiency measures include mean length of hospital stay, readmission rate, and
mean cost of treatment for a diagnosis.
6) Equity ?
? Equitable care does not vary in quality based on personal characteristics such as gender,
ethnicity, geographic location, and socioeconomic status.
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METHODS OF QUALITY ASSESSMENT
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? Numerous innovative efforts have been made globally.
? In 1979, Joint Commission on Accreditation of Hospitals (JCAH) introduced a quality assurance
standard.
? In 2009, ASA established the Anesthesia Quality Institute.
? A change in the system or process is required to reduce unwanted variation so that random
errors will be less likely.
? Following process helps in achieving the goal:
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? Feedback from patients and surgeons.
? Effective monitoring.
? Data collection methods should be meticulous.
?Electronic medical records (EMR).
?Anesthesia information management systems (AIMS).
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METHODS OF QUALITY IMPROVEMENT
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? Multidisciplinary approach - It involves:
?Identifying evidencebased interventions associated with improved outcome.
?Select goaloriented interventions that have the biggest impact on outcomes.
?Develop and implement measures that evaluate either the intervention or the outcomes.
?Measure baseline performance.
?Administering the required interventions through engagement, education, execution and
evaluation.
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? Comprehensive unit based safety program - It is a six step program to improve the quality in
intensive care units by learning from mistakes and improving culture ?
?Measuring safety culture.
?Presenting educational material.
?Forms to identify patient safety issues using questionnaires.
?Assigning a senior executive responsible for a specific area.
?Implementing projects.
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? Quality measures should include the following ?
?Process measures - that address the processes of health care delivery (e.g., perioperative -
adrenergic blocker administration for patients, antibiotic administration for prevention of surgical
site infection).
?Outcome measures - that address patient outcomes from delivery of these services, such as
clinical and functional outcomes or satisfaction with services (e.g., morbidity, mortality, length of
stay, quality of life, or perceptions of care).
?Balancing measures - that address the possible consequences of changes in the process (e.g.,
when process improvements are made to improve efficiency, other outcomes, such as patient
satisfaction, should not be adversely affected).
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? For measurement to be effective, the following principles are important ?
?Simple, small-scale measures that focus on the process itself and not on people.
?Practical, seek usefulness not perfection and fit the work environment and cost constraints.
?Data for measurement should be easy to obtain.
?Qualitative data (e.g., reasons for patient dissatisfaction) are often highly informative and easy to
obtain and should complement quantitative data (e.g., percentage of patients satisfied with care).
?Balanced set of measures can help answer the question, Are we improving parts of our system at
the expense of others?
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? Run charts and control (Shewhart) charts - These are graphic displays of data that enable
observation of trends and patterns over time. They are the best tools for determining whether
improvement strategies have had an effect.
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? A dashboard of measures functions like an instrument panel for an aircraft or automobile and
provides real-time feedback on what is happening.
? Balanced scorecards or "whole system measures" are similar to dashboards and are used to
provide a complete picture of quality.
? Flow charts / flow diagrams identify and clarify all steps in the process.
? Key Driver Diagram (KDD) is another approach to organizing the theories and ideas for
improvement that a team has developed.
? Daily goal sheets - A one-page checklist.
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? Briefing and debriefing tools are designed to promote effective interdisciplinary communication
and teamwork.
?A briefing is a structured review of the case at hand that takes place among all team
members before the start of an operative procedure.
?A debriefing occurs after the procedure; the team reviews what worked well, what failed, and
what could be accomplished better in the future
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? Checklists has following implications ?
?It reduces mortality and inpatient complications.
?Establishes good communication among members of the team.
?Ensures that every member of the surgical team has a stake in patient safety and good surgical
outcomes.
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SOURCES OF QUALITY IMPROVEMENT
INFORMATION
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? Incident reporting ?
?Voluntary incident reporting provides the potential to also learn from near misses--incidents
that did not lead to harm but were potentially hazardous.
?Reporting systems that have been developed ?
o Anesthesia
Incident
Reporting
System
(AIRS)
created
by
AQI
(www.aqihq.org/airs/airsIntro.aspx).
o United Kingdom's Serious Incident Reporting and Learning Framework
o Australian Incident Monitoring Study.
?Many events and near misses still frequently go unreported.
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?One way to capture these incidents is to survey local medical staff members.
? Published Literatures ?
?Literature reviews offer ideas for QI topics in specific areas and information to guide
interventions.
? National Initiative and Quality Matrix (NIQM) ?
?National professional organizations, such as the American Society of Anesthesiologists (ASA)
and the Society for Critical Care Medicine (SCCM), offer guidelines specific to the field.
?These guidelines cover a range of practices.
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? Outcomes Research ?
?Outcomes research offers a potential to identify variations in care and to determine whether
they improve outcomes for patients undergoing anesthesia.
? Internal or external institutional reviews -
? Private insurers ?
?Many private insurers now collect data on certain quality elements.
?The Leapfrog group is one such entity.
?Performance-based payments, are being introduced as a means of improving quality.
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?Pay for performance (P4P) refers to financial incentives that reward practitioners for the
achievement of a range of payer objectives.
?Measures that are incorporated into P4P and performance-based measures must be
evidence-based, consistent with national goals, or based on consensus in the absence of
evidence.
?Measures must be reliable, valid, and feasible and that the programs be voluntary.
?The PQRS (Physician Quality Reporting System) is a reporting program that uses a
combination of incentive payments and payment adjustments to promote reporting of
quality information by eligible professionals.
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COLLABORATIVE PROGRAMS
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? Participation of two or more health care teams working toward a shared goal.
? Single organization and/or across multiple health care organizations.
? Multidisciplinary representatives.
? Collaboratives bring a shared momentum and enthusiasm that can increase sustainability.
? Includes two process ?
?Evidence-based interventions.
?Data collection.
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? Element to the success of collaborative programmes are ?
?Educating members.
?Group discussions.
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INDICATORS FOR QUALITY OF ANAESTHETIC CARE
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? Define and delineate the various indicators or parameters of care.
? The improvement in quality of anesthesia services can be brought about by following measures,
which may include but are not limited to ?
?Adequacy of the preanesthesia evaluation.
?Perioperative adequacy/quality of anesthesia services - observing and recording any adverse
event such as ?
o Broken tooth,
o Need for reintubation and complications during difficult airway management,
o Identification and management of cardiac and other complications related to comorbid
diseases, fluid overload and many others.
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? Postoperative adequacy/quality during recovery and discharge may be evaluated by assessing
postsurgical complications such as ?
?Hypotensive episodes,
?Arrhythmias,
?Respiratory complications,
?Intakeoutput ratio,
?Temperature fluctuations,
?Causes for any prolonged stay in the recovery room.
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? Perception of anaesthesia quality: patient's perspective ?
?Postoperative nausea and vomiting and postoperative pain are considered the two most
important parameters for assessment of quality of recovery during the postoperative period.
?Pain in postanesthesia care unit can be measured by using a variety of scales such as visual
analog scale, numerical rating scale, verbal rating scale and behavioral scale, which is a
matter of subjective comfort.
?Different techniques for prevention of nausea and vomiting, and providing analgesia.
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CHALLENGES AND BARRIERS TO QUALITY
IMPROVEMENT
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? Multicentered and/or single-hospital projects can fail because of ?
?Inadequate resources.
?Lack of leadership support.
?Vague expectations and objectives for team members.
?Poor communication.
?Complex study plans.
?Inadequate management of data collection.
?Wasted efforts to "reinvent the wheel" rather than adopting practices proven to be effective.
?Local culture that is not ready for change.
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This post was last modified on 07 April 2022