In the September 1987 issue of the APSF Newsletter, “accident analysis” was discussed by Dr. David M. Gaba. The summary of his work not only addressed several factors that have been identified as increasing accident rates in general as well as in anesthesia practice, but also provided several reasons for system failures and/or accidents (for example, multiple fail-safe mechanisms providing a false sense of security).
In 1985, MMI Companies, Inc., a professional liability insurance carrier, recognizing the spiraling malpractice crisis, developed an anesthesia risk modification program that focused on clinical practice patterns which lend themselves to system failures, accidents, and potential liability exposures. The program addressed systems, issues, and standards in anesthesia practice.
The intent of the program was both to identify practice patterns and change undesirable practices with the goal of improved patient care and decreased liability exposure. In addition, the program was designed to assist in developing an effective defense against allegations of negligence, should an adverse outcome or patient injury occur.
Closed anesthesia claims were examined, and high liability exposure practice patterns were identified. The frequency and severity in terms of insurance pay-out were trended to determine the relationship of the two. Severity was correlated to patient outcome. The claims review revealed that more than 50% of dollars paid went to claims with the allegation of “failure to monitor”.
A further analysis of the “fa4ure to monitor” issues revealed high exposure in all are-as of anesthesia practice, including:
* pre-anesthesia evaluation
* intra-op attendance and equipment to monitor patients
* post-anesthesia recovery and follow-up
Other allegations of significant frequency that were identified are listed below in ranked descending order of severity:
* Improper administration of anesthesia”
* Intubation and IV related
* Improper positioning
* Equipment related
Following the claims review, a task force comprised of practicing anesthesiologists from around the country was assembled. This group provided input into the development of a risk modification program to address the allegations identified in the claims review process.
One essential element of the program that the task force identified was the need for leadership in anesthesia departments to provide directions and facilitate change in warranted areas. It was felt that focused leadership is critical to reducing claims in anesthesia.
The Anesthesia Risk Modification Program
The task force drafted guidelines which outline practices that contribute to the effective management of liability exposures related to the provision of anesthesia services. The guidelines address the responsibilities of the Director or Chairperson of the Anesthesia Department, credentials of anesthesia staff, anesthesia equipment, and patient care issues in pre-, intra-, and post-anesthesia areas. They were designed to set minimum goals that an anesthesia department would strive to achieve.
These guidelines form the foundation of a three part comprehensive risk modification program developed to identify, monitor, and mitigate risks associated with anesthesia practice. The three parts of the program are designed to provide data on compliance with the guidelines, on-going monitoring of statistics, and clinical case review.
1. Self Audit Questionnaire
The self audit questionnaire is completed by the Director of the Anesthesia Department. It allows an assessment of the anesthesia services compared to the program guidelines. The results of the self audit assist risk management efforts to modify practice patterns that have been identified as potential risks in the department. An annual review and repeat of the self audit questionnaire allows the Risk Manager and Director of the department to recognize change in the practice patterns of the department.
2. Statistical Data
An ongoing assessment of the department occurs through the use of a criteria-based statistical form. This tool is comprised of volume and outcome criteria that categorize department activities.
Volume statistics (e.g. general and conduction anesthetics in out-patients vs. in-patients) provide the department with a means to review staffing patterns, peak load times, and patterns in utilization.
Outcome indicators, such as deaths, cardiac arrest, neurological or peripheral nerve injuries, etc., provide the Director of the department with a snapshot view of the number of “serious patient outcomes” that have a high potential for claim consequences. The patient outcome information is collected on a monthly basis and submitted into a national data bank. Again, the statistical information is designed to provide a mechanism for liability-focused clinical risk modification, as opposed to a traditional process-oriented quality assurance program.
3. Clinical Case Review
A mechanism was established to provide insight into cases that meet a serious outcome criterion or had a higher degree of loss exposure (increased potential severity). This step has become the most beneficial and valued mechanism in the process.
Specific outcome indicators were identified for required review by the departments involved. In general, required review is expected in cases that resulted in actual or potentially liable situations and the goal is to minimize both. For example, any time a cardiac arrest occurred, the case was intensively reviewed. If the outcome was due to an anesthesia related factor, a detailed in-depth review of the anesthetic occurs. This system of clinical case review allows a follow-up mechanism that goes beyond the mere numbers collected on a monthly basis in the statistical form.
The importance of the clinical case review rests on the process and goal of the process. The key point of the review mechanism is the focus on issues of safety in practice, not on discipline of practitioners. Issues raised need to be addressed and resolved. Adverse trends identified lead to changes intended to prevent future recurrences. The result of this effort is improved patient care.
The clinical case review process allows the interaction of people from the multiple disciplines involved with perioperative patient care. The perioperative committee, therefore is comprised most often of the Medical Director of Anesthesia, Medical Director of Surgery, Nursing
Managers of OR and PACU, CRNA, and the Risk Manager. This committee functions as the anesthesia “risk management” committee. The group works directly with the hospital risk manager to set into motion activities to modify identified risk exposures.
This approach to anesthesia risk modification has been in operation for 18 months. While the program is very young, early results are encouraging.
* The number of anesthesia departments instituting a perioperative committee or an interdepartmental, interdisciplinary patient care committee has increased considerably.
* Numerous hospitals have reworked the anesthesia record. The clinical case review has prompted the supported positive changes in these records because the review process needs a clear, detailed chronology of events to work with.
* Some significant changes are occurring in equipment. Departments are examining their old and outdated equipment and slating it for replacement. Administrations are supporting these efforts since, again, the emphasis is on reduction of exposure practices that may increase insurance pay-out.
* A recent credit system was initiated for anesthesiologists using pulse oximetry and capnography.
* One significant change is in departmental leadership. Department he-ads have been assigned the additional responsibility of assuring that all members of their departments are quality care providers, which includes risk conscious practitioners.
In essence, the risk modification program described here is a risk management program for the anesthesia department. A risk management approach that is squarely set on prevention. Patient protection and consequent protection of the anesthesia practitioner is its ultimate goal.
Dr. DeBruine is Chairman of the Anesthesia Department at Decatur Memorial Hospital, IL and Medical Consultant to MMI Companies, Inc. Ms. Napier is Assistant Director, Risk Management and Manager, Physician Services at the MMI Companies, Inc.