Quality Measures

[BobLoblaw78]

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As we try to pacify some and maybe even try to improve our own work and profession, what quality measures do you guys like and dislike? I have seen many gripe about the quality measures. Especially when it is mainly paperwork/paper care. Which do you find to actually be helpful? Any interesting or novel measures that we should be pushing and aren't? It seems like there is a dearth of EBM in them, but I would rather pick something and find out it is wrong then straddle the fence and take no position. Obviously providers shouldn't be punished for not complying if there is lack of evidence, but then how do you "move the needle" if not?

 

[Psai]

I like that the measure of my worth as an anesthesiologist is determined by whether or not I click on a computer screen that I gave antibiotics prior to incision.

 

[MoMoGesiologist]

turn over times sound like a good quality measure ...

 

[Monty Python]

Timeliness of abx.
Proper prophylaxis in patients with multiple emesis risk factors.
Use of appropriate warming modality(ies) on cases likely to lose body heat.
Tight glucose control in diabetics on long cases.
Active participation in the pre-incision timeout (which I used to think was lame, until I saw several near misses at a locums gig).
Late addition. Statistically significant rate of PDPHs with labor epidurals.

Would disagree with room turnover as a quality measure, as there are many non-anesthesia variables involved beyond our control (housekeeping, sterile instrument readiness, patient in preop holding waiting on chaplain and/or family member to arrive at bedside, etc). In addition, its only true value as a quality measure is from the bean counters perspective which has nothing to do with patient care quality.

 

[pgg]

Would disagree with room turnover as a quality measure, as there are many non-anesthesia variables involved beyond our control (housekeeping, sterile instrument readiness, patient in preop holding waiting on chaplain and/or family member to arrive at bedside, etc). In addition, its only true value as a quality measure is from the bean counters perspective which has nothing to do with patient care quality.

Yeah I don't want to be judged by the motivation and performance of nurses who turn into pumpkins at 2:59 PM ... but I think he probably meant anesthesia turnover time, i.e. the time from arrival in the room until the shouting of "anesthesia ready" at those same almost-pumpkins.

 

[Monty Python]

Yeah I don't want to be judged by the motivation and performance of nurses who turn into pumpkins at 2:59 PM ... but I think he probably meant anesthesia turnover time, i.e. the time from arrival in the room until the shouting of "anesthesia ready" at those same almost-pumpkins.

Agreed; one of the times captured is "TOTS" (turnover to surgeon). Love when it takes <5 minutes after in-room time for the patient to be induced, airway secured, to be turned over to the surgeon, only to then experience 30-45 minutes of pre-incision roadblocks. There's a report in S3 you can run to show these various times. Came in handy more than once when the DCCS tried to blame anesthesia for poor OR productivity.

 

[dhb]

Timeliness of abx.
Proper prophylaxis in patients with multiple emesis risk factors.
Use of appropriate warming modality(ies) on cases likely to lose body heat.
Tight glucose control in diabetics on long cases.
Active participation in the pre-incision timeout (which I used to think was lame, until I saw several near misses at a locums gig).
Late addition. Statistically significant rate of PDPHs with labor epidurals.

Would disagree with room turnover as a quality measure, as there are many non-anesthesia variables involved beyond our control (housekeeping, sterile instrument readiness, patient in preop holding waiting on chaplain and/or family member to arrive at bedside, etc). In addition, its only true value as a quality measure is from the bean counters perspective which has nothing to do with patient care quality.

Funny but i don't agree with any of your metrics, i value results more than methods:
For emesis i wouldn't look at prophylaxis but at PONV percentage in PACU same for temperature; appropriate warming modalities doesn't count as much as PACU arrival temp.
Tigh glucose control has shown no added value.
Who has a significant rate of PDPH?
What i would look at is TOTS, TO from end of dressing to PACU (wake-up time), lowest pain score in the first 15min in PACU, time to discharge ready in PACU

 

[nimbus]

Turnover time is not a quality issue for morning patients. They could not care less. Afternoon patients don’t care either so long as they are provided another room and team so their case starts on time. It’s actually possible to provide high quality care with terrible turnover times. They are 2 separate things.

 

[kmurp]

If your group will pay for it, there are firms that will phone survey a sample of your groups’ patients on a variety of patient satisfaction items. We do that , and it was a bit eye opening for me on the quality of perceived pain control for my patients.

 

[Monty Python]

Funny but i don't agree with any of your metrics, i value results more than methods:
For emesis i wouldn't look at prophylaxis but at PONV percentage in PACU same for temperature; appropriate warming modalities doesn't count as much as PACU arrival temp.
Tigh glucose control has shown no added value.
Who has a significant rate of PDPH?
What i would look at is TOTS, TO from end of dressing to PACU (wake-up time), lowest pain score in the first 15min in PACU, time to discharge ready in PACU

I think you and I are wanting the same things, just stated from different perspectives. I was listing suggested methods; you were suggesting outcomes. Your outcomes are what I had in mind when I listed methods. And the significant rate of PDPH was meant to identify an outlier who could possibly benefit from mentoring, should his/her PDPH rate be significantly higher than the group's average or accepted post-residency norms.

 

[BobLoblaw78]

I think you and I are wanting the same things, just stated from different perspectives. I was listing suggested methods; you were suggesting outcomes. Your outcomes are what I had in mind when I listed methods. And the significant rate of PDPH was meant to identify an outlier who could possibly benefit from mentoring, should his/her PDPH rate be significantly higher than the group's average or accepted post-residency norms.

I think methods are great in the manner that it doesn't penalize if you do the right things but have a patient population that is more difficult. Outcomes are great if you believe you can manage the patient better without algorithms/protocols. It would be a novel approach to have methods monitored and if not followed then you must show you are doing a better job through outcomes. That way it doesn't take autonomy totally out of our hands. Good luck trying to blaze your own path against current standards on antibiotics. I don't think any surgeon would want to follow that path with postop infections on the line.

I agree that these measures are annoying about showing our "worth" but those anesthesiologist that are substandard cry out the same thing about these showing their value. You know a good anesthesiologist when you see one. I find that a good anesthesiologist will do these measures well, but someone that does well on these measures isn't necessarily a good anesthesiologist.

 

[Monty Python]

I think methods are great in the manner that it doesn't penalize if you do the right things but have a patient population that is more difficult. Outcomes are great if you believe you can manage the patient better without algorithms/protocols. It would be a novel approach to have methods monitored and if not followed then you must show you are doing a better job through outcomes. That way it doesn't take autonomy totally out of our hands. Good luck trying to blaze your own path against current standards on antibiotics. I don't think any surgeon would want to follow that path with postop infections on the line.

I agree that these measures are annoying about showing our "worth" but those anesthesiologist that are substandard cry out the same thing about these showing their value. You know a good anesthesiologist when you see one. I find that a good anesthesiologist will do these measures well, but someone that does well on these measures isn't necessarily a good anesthesiologist.

Perhaps following the money might provide some ideas. I think the current alphabet soup of CMS/Medicare quality measures specific to anesthesia might be helpful.

https://www.cms.gov/Medicare/Qualit...d-Certified-Registered-Nurse-Anesthetists.pdf

 

[Mr.S]

Perhaps following the money might provide some ideas. I think the current alphabet soup of CMS/Medicare quality measures specific to anesthesia might be helpful.

https://www.cms.gov/Medicare/Qualit...d-Certified-Registered-Nurse-Anesthetists.pdf

Yes. Follow the money. Absolutely.
This is the reason why all these quality measures and quality departments are popping up. THey want to squeeze as many cases in as possible and pay you the least. Hence, turnover time, turnover time to surgeon etc etc. Brave new world.

 

[Monty Python]

Yes. Follow the money. Absolutely.
This is the reason why all these quality measures and quality departments are popping up. THey want to squeeze as many cases in as possible and pay you the least. Hence, turnover time, turnover time to surgeon etc etc. Brave new world.

Trust me, I don't like it any more than you. Unfortunately it's become the world we live in. Unless you work in an all-cash boutique practice we are, to a large extent, beholden to those who control the purse strings. This is especially prevalent in my mid-size town, where two freestanding ambulatory day surgery centers have sucked the majority of private insurance/private pay patients out of the hospital, leaving the hospital with predominantly indigent care and Medicare reimbursement. The hospital bean counters are exquisitely attuned to all the nuances of Medicare reimbursement, as imperfect and bureaucratic as the associated quality methodology might be which affects those monies.