The UCLA Department of Anesthesiology and Perioperative Medicine is deeply committed to quality improvement and patient safety. Accordingly, our quality and safety program is comprised of education, case review, process improvement, and communication. Faculty, fellows, residents, and nurse anesthetists all participate in each of these areas.
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All faculty and residents are required to complete the Basic Certificate in Quality and Safety from the Institute for Healthcare Improvement. In addition, residents receive additional didactics in quality improvement and patient safety, and participate in quality improvement projects during their residency. These projects are then presented at our annual spring Scientific Evening and at the annual Western Anesthesia Residents Conference. Many of these projects are based on adverse events and near misses that have been reviewed by the Quality Improvement/Quality Assurance (QI/QA) Committee.
In order to capture all events, all clinicians must report adverse events and near misses prior to closing the anesthetic record in Care Connect, the UCLA version of the Epic electronic medical record. Each month, the QI/QA Committee, comprised of 47 faculty anesthesiologists, residents, and nurse anesthetists, and co-chaired by Drs. Kenneth Kuchta and Emily Methangkool, reviews these reports to identify potential areas of process improvement. The focus of the committee is to find the gaps within processes that lead to adverse events and near misses, realizing that the root cause often lies within multiple systemic problems rather than individual performance deficiencies.
Potential process improvements identified from case review are then discussed with and implemented by the Quality Council, which is comprised of anesthesiology department leaders who have roles in clinical operations, quality, and informatics. Dr. Nirav Kamdar serves as the overall Director for Quality within the department. For the 2018-2019 academic year, the Quality Council is focusing on the following areas for process improvement:
- Safety in non-operating room locations – Improvement in preoperative evaluation for patients undergoing procedures in non-operating room locations; establishment of criteria to guide non-anesthesiology physicians in deciding when to consult anesthesiology for procedural care in non-operating room locations;
- Medication safety – Increased education in neuromuscular blockade monitoring and reversal;
- Perioperative delirium – Preoperative identification and mitigation of risk factors for patients at high risk for perioperative delirium
- Communication and handoffs – Standardization of communications regarding patient care in the transition to and from OR to ICU;
- Burnout and wellness – Continued implementation of a peer-support system as a resource for clinicians who have had an adverse or near-miss event
- Distractions in the OR – Elimination of distractions during induction of anesthesia.
Residents, faculty, and nurse anesthetists are involved with each of these projects.
In order to communicate timely patient safety issues and reminders, the Quality Council initiated a monthly newsletter in July 2018, with reminders from the QI/QA Committee, the clinical operations team, and recent literature published within the area of quality and safety. In addition, interesting cases with learning points are reviewed during resident didactics and our department's morbidity and mortality conference.
The goal of the QI/QA Committee and the Quality Council is to foster a “just culture” that avoids blame and where everyone shares responsibility for maintaining patient safety and quality. We encourage everyone to speak up for patient safety when needed. Finally, through these process improvement efforts, we hope to continue to improve the care that we deliver to our patients.
Digital Quality Improvement
As physician anesthesiologists, we constantly strive to improve the care we provide to our patients. Continuous quality improvement is the expectation in contemporary anesthesia practice and medicine in general.
Our group believes in the potential of quality improvement processes based on information technology (IT) to provide results more quickly than traditional processes do. In this new paradigm, the implementing/informatics group drives the process, in a change from the typical designer-led project. While the designers play an important part in outlining an initiative, the implementation group understands what is feasible and which technologic tools are best suited to accomplish a set of goals.
The IT-based model fosters a symbiotic relationship where the implementation group benefits from novel ideas, education, and inspiration, while the designer group benefits from the use of existing IT infrastructure. This model facilitates communication, decreases the time from conception to implementation, and drastically reduces the time to implement modifications. We term this system “Digital Quality Improvement”.
Using IT to drive quality improvement processes is a natural next-step for anesthesiology. Everything in our perioperative environment is connected to everything else. We can continuously monitor metrics that directly relate to the quality of perioperative care. Using these data in day-to-day practice can provide clinicians with real-time decision support, including reminders and best-practice advisories. We have implemented real-time guidance in the automated anesthesia record for reduction of postoperative nausea and vomiting, and advisory warnings about hypotension that has exceeded 10 minutes in duration.
Overall, digital quality improvement has potential to be applied throughout perioperative medicine. It can be applied for the implementation of care pathways, for the development and application of Enhanced Recovery after Surgery (ERAS) protocols, and for the development and implementation of a Perioperative Surgical Home. Technically savvy providers can leverage our ubiquitous digital devices to redesign care and monitor the results.