In health care, quality improvement (QI) is the framework used for systematically improving patient care.1 Professionals must be able to measure, analyze, improve and control all processes across health care practices.1 QI includes evidence-based strategies to standardize practices among clinicians and institutions and to improve outcomes for patients, providers and the health care system.1 QI is generally systems-focused and emphasizes teamwork and peer review.1 Though it became a focus of research over 20 years ago, QI in health care has recently become more widespread.2 QI is now a core aspect of medicine, given contemporary health care changes such as genome sequencing, health care commercialization, consolidation of health care organizations, new types of provider organizations, deprofessionalization of health care providers, changing population demographics and different sources of disease.2 Studies on QI strategies range from heart health care in small primary care centers3 to monetary practices in substance abuse treatment facilities.4 Given their important role in health care, anesthesiology practitioners should consider various QI strategies and the efficacy of QI programs.
QI in anesthesiology involves observation of outcomes, analyzing causation, making changes in care and observing resulting differences.5 Anesthesiology benefits from QI through identification of rare complications and serious adverse events, systematic collection of data from routine care, release of educational products and efforts to improve anesthesia equipment.6 Drastic efforts to bring QI to anesthesiology began in 1985 with the creation of the Anesthesia Patient Safety Foundation (APSF).6 During this era, QI efforts in anesthesiology were focused on improving patient safety. Thus, the APSF’s goal was to “help avoid preventable adverse clinical outcomes, especially those related to human error.”7 Since 1985, the APSF has funded safety research; the production of educational materials; and the design of safer machines, more intuitive monitors and better anesthetic drugs.6 The introduction of electronic medical records to anesthesiology in the early 2000s was accompanied by the founding of the Anesthesia Quality Institute (AQI), which focused on quantifying clinicians’ performance through data collection.8 The AQI was responsible for the creation of the National Anesthesia Clinical Outcomes Registry (NACOR), a Qualified Clinical Data Registry (QCDR) that includes millions of patient cases.9 This plethora of evidence, including performance monitors, performance gap analyses, patient outlier identification and peer-to-peer comparisons, informs treatment choices and helps control costs.9 NACOR even contributes to QI by providing anesthesia professionals with patient care tools, educational resources and links to anesthesia information technology (IT) experts.9 Evidently, QI in anesthesiology can range from patient safety improvements to technology innovations.
Given the wide range of possibilities for QI integration in anesthesiology, QI programs can target a variety of aspects of care. For example, a paper by Jankowski and Walsh on QI in ambulatory anesthesia focuses on improving cost efficiency for both patients and providers.10 Meanwhile, a study by Kurth et al. focused on the development of the Wake-Up Safe program, which aimed to determine the rate of serious adverse events (SAE) in pediatric anesthesia and to apply QI to reduce SAE rates.11 The authors recommend using education and safer practices to reduce SAE.11 According to Christensen et al.’s study on WUS, specific QI recommendations for patient safety in pediatric radiation oncology include correct programming of propofol infusions, proper positioning of patients and improved use of machinery.12 A study by Al-Qahtani and Messahel found that QI to reduce sore throat and hoarseness after intubation involved efforts such as use of a small tube in intubating the trachea, lubricating the tube with water soluble jelly, careful airway instrumentation, intubation only when the patient was fully relaxed, careful suctioning techniques and extubation when the tracheal tube cuff was fully deflated.13 Furthermore, Deeds et al.’s QI initiative consisted of an evidence-based, multimodal analgesic regimen to decrease postoperative opioid usage, pain ratings, time in the PACU and opioid-related side effects for patients undergoing hysterectomy.14 Evidently, applying QI initiatives to various anesthetic situations can be useful for data collection and improvements in patient care.
Improving quality in anesthesia is a largescale task, involving policymakers, organizations, institutions and individual clinicians. QI in anesthesia includes collecting data and making changes in patient safety measures, technology, anesthetic induction processes and use of pharmacological agents. QI initiatives can be quite successful when properly implemented. Future research should investigate outcomes of standardized QI initiatives across different geographic and institutional settings.
1. Module 4. Approaches to Quality Improvement. Practice Facilitation Handbook. Rockville, MD: Agency for Healthcare Research and Quality; May 2013.
2. Johnson JK, Sollecito WA. McLaughlin & Kaluzny’s Continuous Quality Improvement in Health Care. Burlington, MA: Jones & Bartlett Learning; 2018.
3. Balasubramanian BA, Marino M, Cohen DJ, et al. Use of Quality Improvement Strategies Among Small to Medium-Size US Primary Care Practices. Ann Fam Med. 2018;16(Suppl 1):S35–S43.
4. Hunt P, Hunter SB, Levan D. Continuous Quality Improvement in Substance Abuse Treatment Facilities. Journal of Substance Abuse Treatment. February 2017:8.
5. Dutton RP, DuKatz A. Quality Improvement Using Automated Data Sources: The Anesthesia Quality Institute. Anesthesiology Clinics. 2011;29(3):439–454.
6. Dutton RP. Quality improvement and patient safety organizations in anesthesiology. AMA Journal of Ethics. 2015;17(3):248–252.
7. Stoelting RK. Foundation History. Anesthesia Patient Safety Foundation: About APSF 2020; https://www.apsf.org/about-apsf/foundation-history/.
8. American Society of Anesthesiologists. About Us. Anesthesia Quality Institute 2017; https://www.aqihq.org/about-us.aspx.
9. American Society of Anesthesiologists. National Anesthesia Clinical Outcomes Registry (NACOR). Anesthesia Quality Institute 2017; https://www.aqihq.org/introduction-to-nacor.aspx.
10. Jankowski CJ, Walsh MT. Quality Improvement in Ambulatory Anesthesia: Making Changes that Work for You. Anesthesiology Clinics. 2019;37(2):349–360.
11. Kurth CD, Tyler D, Heitmiller E, Tosone SR, Martin L, Deshpande JK. National Pediatric Anesthesia Safety Quality Improvement Program in the United States. Anesthesia & Analgesia. 2014;119(1):112–121.
12. Christensen RE, Nause-Osthoff RC, Waldman JC, Spratt DE, Hearn JWD. Adverse events in radiation oncology: A case series from wake up safe, the pediatric anesthesia quality improvement initiative. Pediatric Anesthesia. 2019;29(3):265–270.
13. Al-Qahtani AS, Messahel FM. Quality improvement in anesthetic practice—incidence of sore throat after using small tracheal tube. Middle East Journal of Anaesthesiology. 2005;18(1):179–183.
14. Deeds JL, Shaw PN, Elliot AR, Morgan BT. An Anesthesia Quality Improvement Plan to Improve Postoperative Pain Outcomes after Hysterectomy. Anesthesia eJournal. 2016;4(1).