Anesth Essays Res. 2014 May-Aug; 8(2): 134–138.

doi:  10.4103/0259-1162.134480

PMCID: PMC4173622

Quality control and assurance in anesthesia: A necessity of the

modern times
Sukhminder Jit Singh Bajwa and Ravi Jindal1

Corresponding author: Dr. Sukhminder Jit Singh Bajwa, House No-27-A, Ratan Nagar, Tripuri, Patiala - 147 001, Punjab, India.

E-mail: moc.oohay@1002awjab_rednimhkus

Copyright : © Anesthesia: Essays and Researches

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0

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Abstract

INTRODUCTION
The advancements in anesthesia techniques, availability of newer drugs, availability of newer
advanced monitoring gadgets, increased awareness among the patient population,
implementation of newer medico-legal laws and professional competitiveness has necessitated
assurance of quality anesthesia services delivery. Quality assurance has been defined as an
organized process that assesses and evaluates health services to improve practice or quality of
care.[1] The objective of quality assurance is to ensure a high standard of anesthetic care with
a focus on patient safety during perioperative period, risk reduction and continuous quality
improvement through rigorous self-examination.[2] Safety, effectiveness and patient's
experience about the whole anesthetic procedure are important indicators to measure the
quality of anesthesia in modern clinical practice.[3]

NEED FOR QUALITY ASSURANCE

In recent times, numerous innovative efforts have been made globally by anesthesia
specialists in improving the methodology of measuring and reporting the quality of care
delivered to patients. One of the important methods involves the feedback from patients and
surgeons to improve the quality of anesthesia services.[2] A continuous vigil over the
measurement of quality is essential, which can be gauged by an effective monitoring and thus
can contribute to maintenance and improvement of standards of care.[4] Monitoring is
essential to:

 To identify and understand the factors responsible for a variable level of quality care
 A continuous quest to identify and respond to various potential opportunities so as to
improve standards of anesthesia care
  Finally, to measure the significance of changes effected by the concerned anesthesia
services.[2]

The process of quality assurance is not complete by merely identifying measurable indicators.
To support and improve the standards of quality control, the data collection methods should
be meticulous with effective feedback. Transparency, reliability, measurability, flexibility to
improvement and above all a scientific platform are the essential parameters for serving as an
effective quality indicators.[2]

In 1979, Joint Commission on Accreditation of Hospitals (JCAH) introduced a quality

assurance standard aimed at focusing all quality related functions on problem-solving and on
their coordination into an organized comprehensive program. The underlying assumption was
that if review efforts are focused on identifying problems in patient care and solving these
problems, the end result will be that care will improve. The goal of this process is to
demonstrate improvement in care or clinical performance through the resolution of important
patient care problems.[5]

PERIOPERATIVE OUTCOMES
The process of measuring quality indicators and anesthesia outcomes is highly challenging
and difficult in routine daily practice. There is no end to the number of quality indicators has
been observed by various literary observations. In one of the systematic reviews, 108 quality
indicators have been identified and the majority of them are considered to possibly influence
the quality of anesthesia services. The remaining ones are also potentially helpful in
measuring surgical and post-operative care.[2]

Indicators for quality of anesthetic care

A lot has been written and observed in routine anesthesia practice related to risks and safety
concern in anesthesia practice.[6] 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 pre-anesthesia evaluation

As per the recommendations of JCAH standards, this initial step requires the evaluation to be
performed by a physician. This may be assessed through appropriateness of the choice of
medication relative to the age of patient or type of procedure being performed.

Perioperative adequacy/quality of anesthesia services

Assessment of quality during perioperative period can be carried out by observing and
recording any adverse event such as broken tooth, need for re-intubation and complications
during difficult airway management, identification and management of cardiac and other
complications related to co-morbid diseases, fluid overload and many others. Further, the
quality can be assessed by identifying the timeliness of delivery of anesthesia services or the
frequency of line infiltrates.
Post-operative adequacy/quality during recovery and discharge

Quality of the recovery care both in the recovery room and after discharge of patient may be
evaluated by assessing post-surgical complications such as hypotensive episodes, arrhythmias,
respiratory complications, intake-output ratio, temperature fluctuations or causes for any
prolonged stay in the recovery room.

Adequacy/quality in anesthesia documentation and record updating

The quality of anesthesia documentation and record keeping can be measured from the
information recorded during the pre-anesthetic visit. This include but is not limited to drug
history, history of systemic diseases including allergies, adverse drug reactions, addiction
history, previous anesthesia experience, current medications and so on. The adequacy of
anesthesia care documentation can also be assessed during the actual surgical procedure and
post-operative recovery room.[5]

It is essential to define and delineate the various indicators or parameters of care so that it
becomes easy to monitor the quality of anesthesia services at a specified time period, which
can be formulated and incorporated in the various standard operating procedures of the
department and monitored at intervals specified by the department itself.[5]

It is the evidence and scientific based churning of various procedures and anesthesia
techniques over the last few decades, which have brought a substantial improvement in
anesthesia delivery systems. It has also enabled a significant reduction in mortality and
morbidity associated with anesthesia to such an extent that mortality is considered an obsolete
indicator of quality anesthesia care. One of the prime reasons for exclusion of this indicator
form measurement of anesthesia quality is that mortality is a rare occurrence in modern day
anesthesia practice and is frequently related to factors, which are beyond the control of an
Anesthesiologist.[7]

Methods of quality improvement

Methods of quality improvement have also been mentioned in Miller's standard textbook of
anesthesiology and can be summarized as.

Voluntary incident reporting

It involves providing means of incident reporting to the health-care providers and is

considered to be an excellent method of quality improvement. Reporting of incidents, which
might compromise safety of the patients as well as the health-care providers forms the basis of
formulating policies and plans for improvement of services.[8]

Multidisciplinary approach
This requires a structured program with a shared goal between multidisciplinary participants
within the clinical area, across clinical areas or across multiple health-care organizations to
improve care.[8] It involves:

 Identifying evidence-based interventions associated with improved outcome

 Select goal-oriented 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.

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.[8] The steps include:

 Measuring safety culture: Assessing safety culture amongst the staff using the safety
attitudes questionnaire
 Presenting educational material: Through lectures and other educational techniques
 Forms to identify patient safety issues using questionnaires
 Assigning a senior executive responsible for a specific area: Who helps prioritize
safety efforts, remove barriers for system changes, provide resources and foster
relationships with staff
 Implementing projects: With a focus on two to three issues
 Repeat measurement of safety culture.

Quality improvement tools

Including daily goal sheets, briefings and debriefings and checklists.[8]

PERCEPTION OF ANAESTHESIA QUALITY: PATIENT'S PERSPECTIVE

Quality of anesthesia is closely related to the incidences of pain, nausea and vomiting and
overall experience during the recovery period after the surgical procedure. Measurement of
such attributes and parameters requires evidence based support in the form of objective scales
along with subjective perceptions tested on the basis of multiple dimensions by the primary
examiner.[9] Globally, numerous attempts have been made at 1 time or the other and in a
quest to assess post-operative patient satisfaction; multiple questionnaires have been
developed and validated during the course of these scientific studies by the respective
researchers.[10,11,12,13,14,15,16] Quality of recovery can be assessed by a nine point scale
formulated by Myles et al., which includes items derived from a larger 40-item measure such
as: General well-being, support from others, understanding of instructions, respiratory
function, bowel function, nausea and pain and many others.[16,17]
Post-operative nausea and vomiting and post-operative pain are considered the two most
important parameters for assessment of quality of recovery during the post-operative period.
Numerous studies have quoted different techniques for prevention of nausea and vomiting
during the post-operative period as well as during the discharge from the hospital in day care
surgeries.[18] However, the scientific reliability and validity can be assessed only after
examining in a large number of patients as these adverse effects have a strong negative
influence on patient satisfaction.[19] Moreover, these adverse outcomes are interrelated and
dependent on the balance between analgesic and antiemetic properties of the anesthetic drugs
and techniques, patient characteristics and the nature and duration of surgical procedure. Pain
in post-anesthesia 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.[20] Post-operative pain relief has been studied extensively in the last two
decades resulting in development of newer effective strategies and techniques to relieve the
same. The enthusiasm of fighting with this perioperative and post-operative menace can be
gauged from the fact that numerous societies of pain relief have come up globally in the last
two decades. These societies and associations are working tirelessly in bringing advancements
in our understanding of pathophysiologic basis of pain as well as modalities to treat the same
in simplest of the manners.

FEEDBACK: AN ESSENTIAL COMPONENT OF ASSURANCE

The information and data obtained from quality indicators is helpful in identifying variations
in the quality of care provided. These variations and data have to be converted into suitable
tool for further improvement in quality of anesthesia care.[21] The quality of monitoring
system related to quality control cannot be improved beyond certain limits if feedback is
missing. Providing feedback generally results in small to moderate positive effects on
professional practice.[22] The improvement initiatives and measures, which keep the
feedback reports out of their domain are usually less effective as compared with those which
use feedback reports, regardless of the fact that this is accompanied by an implementation
plan or not.[23,24] Certain barriers do exist, which can impede the information available from
feedback such as lack of trust in data quality, lack of intensity of feedback and lack of
motivation. The success of feedback mechanism is highly dependent upon these factors,
which include but are not limited to appropriate timeliness, dissemination of information, trust
in data quality and having a confidential or non-judgmental tone.[25]

To bring an organizational behavior change, simple information dissemination alone is rarely

effective especially in intense atmosphere of operation theatres and intensive care units.
Quality of anesthesia care can be improved by implementation of multifaceted interventions
that may involve educational components rather than simple passive interventions. However,
vigil should be exercised in identification and removal of barriers to quality improvement that
may include unawareness, lack of credible data, lack of supportive local management and lack
of hospital resources.[23]
Remedial actions need to be taken once the cause of a problem is identified by the individuals
entrusted with the responsibility to take corrective measures. Adjustments in departmental
policies and procedures, in service programs, staffing or systems or change in equipment
should be carried out as necessary. These indicators can also be helpful in the appraisal of
each staff member's performance.

For an effective and sustained quality improvement in anesthesia services, attention should be
paid to the problems, which have been identified and addressed so as to make sure they are
resolved or reduced permanently. To prevent the recurrence of the problem, follow-up and
monitoring the concerned problem is essential as it is considered to be one of the prime
indicators of anesthesia care.

This on-going process of monitoring and problem-solving is the nucleus of a hospital quality
assurance program. As such enthusiastic and effective efforts should be made to assist each
clinical support service and if the relevant information is shared and acted upon among other
hospital-wide or medical staff functions, the outcome of better patient care can be achieved.
[5] There is an increasing need felt to motivate the fellow colleagues as that can help
immensely in bringing about an organizational change. An in-depth analysis of motivational
factors in the health industry can also contribute largely in bringing about qualitative changes
in the anesthesiology practice.[26]

DISCLOSURE TO PATIENTS AND RELATIVES

Patients or relatives of the patient should be duly informed regarding any untoward
perioperative incident, which might have occurred during the conduct of anesthesia, which
may result in complications, immediately or at some time in the future or which may cause
undue distress to the patient when detected.[27,28] Usually, it is considered to be the primary
duty of attending anesthesiologist who is involved in the incident to narrate the entire incident
himself rather than prompting others to make a statement or communication. The
communication should be made as soon as the incident is recognized and anesthesiologist
should ensure that the patient is physiologically and psychologically able to receive
information. If it is not possible to communicate with patient, the first communication should
be made with the patient's family or caregiver(s) who will be making proxy decisions on
behalf of the patient.

CONCLUSION
The concepts of quality assurance and quality control are rapidly gaining popularity in
surgical sciences as the society is heading toward social, technical and clinical advancements
globally. In coming times, quality of anesthesia services will be largely monitored by quality
indicators and will determine the perioperative outcome. A possible change of large
magnitude is expected to take place in anesthesia practice for the betterment of humanity in
the near future. At present, the need of the hour is to adopt these evolutionary practices aimed
at improving anesthesia delivery services.
Footnotes
Source of Support: Nil

Conflict of Interest: None declared.

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