A contemplation of the problems of quality control in anesthetic practice suggests that one solution too often ignored is the identification and appointment of capable leaders who are given and will accept the authority to see that appropriate standards for education and patient care are set. If the chief of an anesthesia department is appointed on the basis of seniority alone, or a system is established where the members of a department serve as chief on a rotational basis, then I believe in most instances the department is doomed to mediocrity resulting in substandard medical care. This is not confined to anesthesia; it is true of any department. Leaders must be appointed by virtue of demonstrated qualifications:
1. Someone who understands the need for organization. A leader must be able to recognize and appoint capable lieutenants, delineate and delegate authority, define standards and goals, and expect in return appropriate performance.
2. A good business manager. It is difficult to believe that one can be a leader today in a health care area without understanding good business management. We have become cost conscious and realize that in the past we often were inefficient and wasteful. It is interesting to watch physicians set up their own for-profit organization or even a fee-for-service, not-for-profit department in an academic setting. When it is their money that is being spent or wasted, cost consciousness develops overnight. This, of course, is one basis for the recent development of chains of for-profit hospitals, which often stay away from tertiary care; it is too costly. Yet, in what they do, they attempt to provide equally good health care, and make a profit. A health care system without incentives is unlikely to compete effectively with systems that do have incentives.
3. One who can communicate effectively. Communication is the essence of leadership; without this ability, one cannot lead. In my experiences as dean of a medical school for 13 years, the chiefs who Sot into difficulties with their staff or the dean’s office displayed an inability to communicate well, hence they were ineffective leaders, yet, of note in every instance, they were excellent clinicians or scientists.
The leader is also to some extent “his brother’s keeper.” One must become aware of personal problems of staff and associates that may affect maximal performance. Similarly, the leader must be sensitive to physical or personality changes in departmental members that may suggest disease.
4. One who can establish credibility. A leader must be fair, recognize that there are two sides to every argument, be reliable in carrying through on what has been agreed to, and not be subject to snap judgments that too often have to be reversed.
5. A long range planner and developer. Too often, the members of an anesthesia department get bogged down in doing nothing but providing daily service taking care of the operative schedules. Their entire focus is on what needs to be done today with no one planning for the future. A personal example of long range planning concerns an early experience with Bob Dripps, a legendary name in anesthesia. When I returned to Pennsylvania after World War II and requested pharmacology training before working in the clinical situation, I learned midway in the training that the clinical anesthesia coverage was inadequate. I offered to give up pharmacology and help in the operating room. Dripps’ response was prompt and unforgettable because, as I now realize, it portrayed the great leader he was, “No, Jim, stay where you are. Two years from now you will be invaluable to anesthesia for your pharmacology training. Two years from now, no one will remember the day-to-day frustrations that we are now experiencing.”
Included in long-range planning is the development of one or more top associates who, if the leader becomes ill, would be qualified to take his/her place immediately. I would suggest that leaders should look within their departments and see if they have such backup, and if they don’t, why not? It is interesting how often chairmen, deans, and college or hospital presidents do not have strong number two persons. Sometimes developing number two hasn’t been thought of or wasn’t a top priority. More often the reason is the leader’s lack of security and the fear that if number two becomes too strong, he/she might be asked to take over number one’s job. Also strong number twos will be recognized by others and may be recruited away, but true quality programs are those that supply leaders to other institutions.
6. The leader of a clinical discipline must recognize that the discipline cannot function in a vacuum. There must be interdisciplinary teaching as well as a joint collaboration in patient care. Departmental chairmen and chiefs of service should meet with CEO’s regularly to discuss common problems, solutions to clinical concerns, standards of care, the impact of impending changes in health care delivery, budgets, and staffing complements. For this sort of interdisciplinary discussion to be successful, all chairmen must be of equal status.
Speaking specifically of anesthesiologists, I find it discouraging that some consider themselves of inferior status compared to surgeons, internists, or obstetricians. I certainly have never felt that way but I recognize there have been times I had to prove my knowledge compared to others. An anesthesiologist certainly does not establish status by taking refuse behind an ether screen or confining his activities to operating rooms. Also, causes of anesthetic complications must be discussed with all disciplines concerned. I don’t consider mortality and morbidity studies as self flagellation. Serving as a base for thoughtful discussion and carefully filed away, such studies can become important in the future. I can think of three syndromes resulting in death that were not understood in our initial reviews but are now fully explained: the absorption of distilled water during transurethral prostatic resection resulting in hemolysis, hypertension, muscle rigidity, and kidney failure; the malignant hyperthermia syndrome; and cardiac arrest that may follow the intravenous injection of succinylcholine in the paraplegic patient. I’m sure that there are additional examples.
7. A leader must recognize the importance of intellectual curiosity and research in maintaining and upgrading the standards of both medical cam and of teaching. Clinical programs that are bereft of libraries, seminars, case discussion meetings, and continuing education programs are likely to be below average. The absence of consultants, attendings, or faculty who will challenge the intellect of medical students and house staff can only lead to generations of doctors who will practice with unacceptable standards. Worse, in my personal estimation, would be the absence of medical students and house officers to challenge and question the faculty, attendings, or consulting doctors.
8. A final point in my litany of the attributes of a good leader. A leader must become divorced from personal gratification in the leadership role and substitute the pride of accomplishment of a department (or school or hospital) as it deals with the present and plans for the future I am dismissed with the number of faculty and chairman who conceive it to be their right to travel a major proportion of their time I know no leader who absents herself a majority of the time, year after year, who runs a good department or has a high caliber teaching program.
Physicians have traditionally preferred an independent and some an entrepreneurial approach to health care delivery. They do not like regimentation, direction, rules for practice, or anyone looking over their shoulders. But the practice of medicine has changed and is no longer a matter solely between a physician and a patient. Hospitals and physicians must respond to the recommendations of the Joint Commission on Accreditation of Hospitals as well as to professional, societal, and legal pressures of assuring quality control in the delivery of health care. Quality health care is a vast interest to the public. The public is the consumer, so we can expert that more and more will appear in our public press, leading to greater pressure on medicine. As much as we all abhor malpractice actions, we have to accept that there is some malpractice. We may be unsatisfied with the current climate, but let us not deny that we do have trouble that justifies some litigation.
In this country, clinical chairmen and service chiefs are being charged with annually approving the clinical privileges of those who work in their departments. In other words, the leaders must police the competence of their staffs. If the chairman cannot approve privileges due to compromised competence, then the physician should resign from the staff. In some examples of this, there were tortuous due-process procedures and, in several instances, charges that an institution should have known sooner the person was incompetent and thus didn’t remove privileges fast enough. This system puts a lot of pressure on a chairman or a chief, a pressure that may be inevitable even though it is mandatory for patient safety.
In addition to physicians surveying the competence of physicians, more and more hospitals have a staff-administration-trustees’ committee that regularly meets with a chairman or section chief to review the methods by which a department maintains quality control. In the event of malpractice action against a physician, the hospital is likely to be drawn into the suit to see if appropriate methods were in place to assure quality care and competence. One of the spin-off benefits of these so-called standards committees is that it forces administrators and board members to rub elbows with the physician and to discuss common problems.
Societal forces, governmental regulation, and legal pressures are causing us to change our ways of practice and effecting a very visible standard of care. Only with good leadership in the clinical arena can we adequately respond.
An abridged version of a lecture given before a seminar of the Royal Society of Medicine, London, and published in “Quality of Care and Anesthetic Practice” edited by J.N.Lunn, MacMillan Press, ltd, 1984.
Dr. Eckenhoff is Dean and Professor Emeritus, Northwestern University Medical School, and VA Distinguished Physician.