Current Questions in Patient Safety: Quality Assurance

Stephanie M. Duberman, M.D.

Question: My department of six physi6ans and eight CRNA’s has no real quality assurance pro8ram. How do we get started?

Answer: Learning which a departmental quality assurance program involves a series of steps that include:

(1) Learning which activities should be included in a quality assurance program and what these activities involve.

Departmental quality assurance programs are instituted in order to ensure that good quality patient care is both possible and present within the department. It is necessary to determine that conditions are adequate to provide good care (in terms of staff qualifications and numbers, physical facilities, equipment, and other resources, and administration); that good care is provided by department members; and finally that outcomes are appropriate

Activities that help to meet these goals include problem identification, evaluation, resolution, and reassessment to ensure resolution; evaluation of appropriateness of care; proper maintenance of equipment and other resources; monitoring of events and trends; and establishment of appropriate standards, guidelines, protocols, or policies.

Relevant literature and techniques for carrying out these activities should be explored.* Learning about the experiences of colleagues who have already set up quality assurance programs in their own departments is very helpful.

(2) Identifying the individual(s) or committee responsible for setting up the program.

To be effective, departmental review and evaluation of patient care should involve as many staff as possible.

The support and input of the chairman is crucial if the plan is to be taken seriously. In addition, when the issue of provider performance is raised, it may be appropriate for the chairman to act through established channels created by the medical staff bylaws or other hospital procedures, rather than through a departmental committee

All members of the department should have input into the planned quality assurance activities and should understand what will be expected of them in terms of compliance with criteria for evaluation of care and with specific policies.

However, for any quality assurance activity to be carried out successfully, it is important to identify the individual or committee responsible for implementation of that specific activity, and to ensure that the responsibility is recognized. This is equally true in identifying those individuals responsible for gathering the information necessary to set up the quality assurance program and for writing an initial plan to be reviewed and commented on by other members of the department.

(3) Identifying regulations and requirements that will affect the form and/or content of the program.

Requirements and regulations placed on the anesthesiology department by the hospital, the state and federal governments, and the JACH affect the administrative form of the program, the specific activities carried out, and the content of criteria and policies. These rules and regulations should be investigated when planning the program. Also, the public health laws governing the discoverability of quality assurance findings and the protection of medical personnel involved in quality assurance activities vary from state to state. Proper handling of matters such as maintaining confidentiality of data, writing of policies, methods of documentation and reporting, and dealing with issues of provider performance must be considered.

Therefore, in establishing or altering a quality assurance program, appropriate legal counsel should be sought.

(4) Assessing existing departmental and hospital quality assurance activities that can be included or adapted for inclusion.

Many of the activities necessary to a departmental quality assurance program may already be in place, although some may not be well coordinated or documented. It is important to inventory all existing department activities related to quality assurance as the preliminary plan is developed. For some activities it only will be necessary to document what is already being done. For some activities it will be possible to determine that expansion, reorganization, or modification can result in quality assurance activities that meet current expectations or requirements. For other activities it will be necessary to develop new parts of the program. AU of these activities eventually can be integrated into a consolidated quality assurance program.

The organization of the hospital’s quality assurance program and the hospital’s facilities can have significant effects on the mechanics of the departmental program. Utilizing available data sources and personnel from the hospital may avoid duplication of work, thereby reducing time, effort, and cost. The hospital may employ quality assurance nurses or other personnel to help the department, or the record room may be able to retrieve pertinent data from charts. These opportunities should he thoroughly investigated.

(5) Using this information to develop a quality assurance plan to meet the specific needs of the department.

While many of the techniques applied to, and the problems identified from, quality assurance activities will be similar from department to department, no two departments are identical. There are variations in staffing, patient characteristics, numbers of patients, surgical procedures, anesthetic procedures, locations of services, local requirements, affiliation, teaching status, and unique problems and issues. All these must be considered when developing a program that will meet the specific needs of the department.

It is important to remember that setting up a quality assurance program is only the first step in running a successful program. Quality assurance programs evolve as problems are identified and solved and new ones are discovered, as techniques are found to be inadequate for the needs of the department and are changed, as requirements change, and as new methods of quality assurance develop. These programs should be periodically reviewed and revised.

Answer by Stephanie M. Duberman, M.D., Columbia University, New York and a member of the 9-ISF Board of directors.

*Editor’s Note: “Quality Assurance in the Practice if Anesthesiology 1986,” written by Dr. Duberman, was published in October 1986 by the American Society of Anesthesiologists. It expands on the material summarized in this column and covers additional topics. It also contains a bibliography that will help individuals find information about quality assurance activities.