8.1: Quality Assurance and Improvement

An anaesthetic department and an individual anesthetist should try to deliver the best healthcare with the fewest complications as soon as possible, given the resources available(equipment, personnel, funding).

Quality assurance can be defined as an Organized process that assesses and evaluates health services to improve quality of care. All departments of anaesthesia and individual anesthetists should participate in quality assurance.

Without a quality assurance program, anaesthetic related incidents might be thought of as isolated events and not seen to be a recurring problem, and anaesthetic departments and individual anesthetists cannot be compared to practice guidelines and standards of care.

A quality assurance program should evaluate safety, provider competence, accessibility,efficiency and effectiveness of care.

Standards of Care and Practice Guidelines

These are written documents which have been produced by the anaesthetic college or department. Standards of care should provide the absolute minimum requirements for patient care(e.g. monitoring, preoperative assessment, post- anaesthetic care units, anaesthetic record, checking equipment). These should be documented and readily available. Practice guidelines provide recommendations of management (e.g. conscious sedation, supervision of trainees, anaesthesia away from the operating room,anaesthetic assistants, infection control). These should be valid, reliable, clinically applicable, flexible, clear, scheduled for review and documented.

Auditing

An anaesthetic department and individual anesthetists need to know what their recent or current standard of care is so that they can identify abnormal events and evaluate future care. Retrospective and prospective audits should be performed on specific areas of anaesthetic care. The audits may be regular events evaluating standards of care or practice guidelines (e.g. chart review, postoperative pain, and preoperative assessment) or occur because of a specific incident (e.g. equipment failure, wrong drug given).

Incident Reporting

All members of the anaesthetic department should be encouraged to report adverse events or events that may have caused an adverse outcome and interesting cases.Anaesthetists work in isolation from each other. An incident may seem very infrequent to an individual anesthetist but may be occurring frequently in the department due to an error in the system. Up to 80% of anaesthetic incidents are due to human error but they occur within a complex system and can be avoided by changing the system.An incident may also be very rare. Rare incidents are very difficult to manage. If a rare incident is reported and discussed it will prepare other anesthetists.

An anaesthetic department should meet regularly to discuss reported incidents. They must not just document the incident, blame the anesthetist and say it should never happen again. The incident should be evaluated without blame, the cause identified and action taken to prevent it occurring again.

Sentinel Events

Some anaesthetic events should always be reported by the anesthetist or others (e.g.death, operation on the wrong patient or body part, haemolytic blood transfusion reaction and cardiac or respiratory arrest). Staff should be educated and a list of these events should be displayed in the operating theater.

Education

An anaesthetic department should have regular (e.g. weekly) meetings. All members should be encouraged to present interesting cases and reviews of journal articles.Some of these meetings should be dedicated to quality assurance (e.g. once a month).

The anaesthetic department must encourage peer review, incident reporting and audits.Departments should document their own standards of care and practice guidelines (or use those of their college). Incident and sentinel event reporting forms should be available. The senior members of a department should lead by example and report all incidents and interesting cases. No one should be blamed.

Quality of care can only be improved by evaluating the current quality.