February 1999

Setting Performance Standards for an Anesthesia Department
Vitez TS, Macario A.
J Clin Anesth. 1998; 10:166-175

Commentary by David Lubarsky,


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[ see abstract below ]

Whether we like it or not, we will be judged by those who pay for the care we provide. That judgment used to come in the form of whether the patient said thank you when we made our postoperative visit. If they were really happy, a tin of cookies showed up in the department a few days after discharge. Now, levels of satisfaction are part of the business of medicine. It's no longer a nicety-it's a necessity to make sure everyone is satisfied with the care they receive. A more satisfied customer is a marketable competitive advantage for health plans and administrators are focused on it. As in a previous article on report cards from Yale, it is clear that the academic medical centers are "getting it" (see AnesthesiaWeb, August 1998.)

This article is a report about how two smart guys at Stanford decided what to measure and how to measure it. Personally, I would have preferred that the initial approach to this concentrated more on patients, but I still have great regard for the methodology they used. I feel it is worthwhile to review this article since everyone, at some point in the next few years, will probably be asked to participate in a similar exercise.

Vitez and Macario began their investigation with basic precepts of quality improvement-identifying their most important customer groups, defining their requirements, measuring anesthesia performance according to those requirements, setting goals and standards, and measuring changes in performance after implementing the standards of performance.

Problem one: After identifying four important customers-surgeons, nurses, hospital administrators and patients-the surgeons were targeted. Paraphrasing Dr. Rajiv Grover, a marketing professor from the executive MBA program at Duke, "The guy who delivers the money is your customer." At Duke, that's the patient (or his/her health plan). On the other hand, in many institutions the surgeons decide which anesthesia team they will work with, and they deliver the patients who pay. So, in those cases, the surgeon is (and has always been) the most important customer. At Stanford, the academic anesthesiology group competes with an independent private practice anesthesiology group for assigned cases, so, in that instance, focusing on the surgeon is a very reasonable approach to the business of providing care. The ideal, of course, is focusing solely on the patient-making the quality of care you deliver the determining factor in the choice of provider. But, reality intrudes.

Several subspecialty surgical groups were asked to characterize the important qualities of the anesthesia department. A grid was constructed with two axes: importance of service attribute versus perceived performance for that attribute. The authors rightfully concentrated their efforts on things that were judged to be important, but were not highly regarded by the surgeons. These then made up the targets for improvement. Initially, first case start time and turnaround time was cited. Let's forget for a moment that anesthesia controlled turnaround time has been proven mathematically to be inconsequential. [1] Perception IS reality.

First case start times were measured. On time meant anesthesia tasks were sufficiently done by start time so that the surgeon could begin prepping and draping. They started with 36% LATE STARTS. Since what gets measured gets attention, it was no surprise that late starts decreased to 13% and voila -- happy satisfied surgical customers. Most of the days on which cases continued to start late occurred following the weekly departmental conference. The half- hour between end of lecture and start time was not sufficient for complex cases to start. So, not only did the process markedly improve performance, but it identified why and where major roadblocks to further success lay.

Vitez and Macario were unable to affect turnover times to a significant extent with this process. Two reasons were cited. First, faculty were required to help with the data collections (FUHGEDDABOUTIT), as opposed to first case time tracking which could be entirely gleaned from the OR information system without help. Second, the causes of excess turnaround time are so interrelated with other services' responsibilities that simple solutions cannot be applied. Improvements in first case start times have been previously described as fixable. [2] Highly visible, it is an area we can all chart, follow, and improve. Our patients will be better served as on time first cases means a more predicable start time for all the patients who follow. Surgeons are happier as their day gets off to a predictable start. And we are happy as no one whines and moans. Is this a real quality of care issue? Not really, but it is an important process issue, and we have to address both as we seek to add value to our role in the OR. This paper serves as a roadmap to help us develop a focus on what patients and colleagues feel is important. Is it worth the effort? Probably. But it is certainly not the stuff of Nobel Prizes or even a mention on Good Morning America. Here we are. Embrace it if you can, for it is our future.

I will conclude with one word of caution. Controlling the data is essential. The potential danger is that someone will use the data to your distinct disadvantage. Be forewarned: Hard numbers can be forged into a blunt instrument with which to bludgeon you.

References

1. Dexter F, Coffin S, Tinker JH. Decreases in anesthesia-controlled time cannot permit one additional surgical operation to be reliably scheduled during the workday. Anesth Analg. 1995; 81:1263-1268.

2. Overdyk FJ, Harvey SC, Fishman RL, Shippey F. Successful strategies for improving operating room efficiency at academic institutions. Anesth Analg. 1998:86:896-906.

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