SAMBA Talks eNewsletter - April, 2006

Volume 5, Issue 11

S A M B A T A L K S - PAGE 2

April, 2006

JOIN THE DISCUSSION - TOP

Need advice about a problem case in ambulatory anesthesia? Want suggestions about a difficult situation in your ambulatory surgery center? Have a reply to questions others have raised about ambulatory anesthesia issues?

If you answered "yes" to any of these questions, or would like to share with other professionals a comment or opinion on a topic related to ambulatory anesthesia then please "Join the Discussion" here.

To enter the Discussion with a question, reply, or other comment, please contact us. Your submission will be published in this section of the next available issue of SAMBA TALKS. Include your name (or initials), city, and state, if you would like these published. Please note that because of the high volume of questions we receive, there is often a delay of 1 to 2 months before the questions can be published.

Questions and responses from previous months are now available at the eNewsletter Discussion Archive. If you have any comments regarding the previous questions, please submit them to SAMBA Discussion, and they will be published here next month.

Please note: The information presented in the replies below does not represent SAMBA policy. The replies are solely the opinions of the individuals who wrote them.

?? - LAST MONTH'S QUESTION WITH REPLIES - ?? - TOP

QUALITY ASSURANCE - HOW TO BEGIN?

Our anesthesia group has obtained the exclusive contract at a new outpatient surgery center to open in Feb 2006. I have been assigned the duty of QA/QI. Does anyone have any pointers on where to begin this process? I have been doing research on the JCAHO and OSHA web sites. Any other pointers? Thanks.

-- Shonna Parks

Quality assurance (QA) and quality improvement (QI) are typically seen as daunting tasks to undertake, but they can be straightforward if framed properly. Developing a QA or QI project is fundamentally the same as developing a scientific research project. First, find something that interests you or matters to you. Next, do some homework into the issue and see what areas need improvement. You can do some literature searches or web searches (to capture information from the non-academic press) as well as query any professional groups to which you belong. Then, develop an action plan. Having done the background work, develop some concrete steps to implement that you think will improve things. After this, collect the data and see if it made a difference. Lastly, study the results and either change the action plan or continue it as needed. There you have it- you have just done the classic Plan-Do-Check-Act (PDCA) cycle for quality improvement!

Keep in mind that there is a fundamental difference between QA and QI. QA is the “bad apple” approach. The idea is to find the underperformers or problems and weed them out. However, this has little to do with improving actual quality. QI, on the other hand, focuses on shifting the whole performance curve to a more favorable position. This is done by examining the fundamental processes and changing them when necessary. There is a role for both in modern practice. QA indicators can be used to screen for potential problems. For an outpatient surgery center, indicators such as hospital admissions or prolonged PACU stays are reasonable things with which to start. If the incidence of these is beyond a benchmark (determined by local practice, literature review, or consensus), a QI project looking at the issue can be developed.

Developing the project can start with brainstorming by interested parties. Use of fishbone diagrams and flowcharts can help clarify what the current process is and highlight areas where interventions may be successful. A critical incident may trigger a careful study of the process intended to identify key areas where improvement efforts might have the most bang for the buck. This is known as Failure Mode and Effects Analysis (FMEA). This web page has more information on FMEA: http://www.isixsigma.com/tt/fmea/ . Try to avoid the trap of looking at the last three months’ (or quarters’) data and drawing conclusions. Trending data over time and using run charts or, even better, control charts, to find statistically significant deviations in the process will keep you from chasing the usual “blips” that occur in any process. The Memory Jogger™ is a convenient pocket sized reference for these, and other, tools. Remember, the plural of “anecdote” is not “data”.

As a benefit of your ASA membership, you have access to information on the ASA website (www.asahq.org) that can help you get started. The Quality Management Template is available on the "members only" section, as well as the Manual for Anesthesia Department Organization and Management (MADOM) and QA/QI software.

-- Alan Marco, MD, Toledo, OH

The task of Quality Assurance using the tool of Quality Indicators is an important one. The credentialing agency that will give their stamp of approval for the center will have a framework set of guidelines they expect followed in their QA/QI policies. I suggest you use their format and requirements. The ASA also has a very good outline in the Ambulatory Section/Office Based that is Outcome Indicators for Office Based and Ambulatory Surgery Centers that was put forth by the ASA's Ambulatory Committee in 4/03. You could use this template and the credentialing agency's template to customize your own. Lastly you may be able to use the one from your hospital if you amend its applicability. Most importantly, this QA/QI must be done with the review processes at the credentialed center as that data is legally protected and undiscoverable. It must also be comprehensively applied to each patient and have an accurate tracking method to be meaningful.

-- Dr. M. Desai, MD, Villanova, PA

?? -- THIS MONTH'S QUESTION -- ?? - TOP

DRIVING AFTER COLONOSCOPY

When should a patient be allowed to drive after receiving propofol anesthesia for a colonoscopy?

-- Naguib R. Khan, MD, Los Angeles, CA

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