Preoperative Process Quality Improvement: Value Is in the Eye of the Beholder

“When you can’t change the direction of the wind, adjust your sails.” – H. Jackson Brown, Jr. The preoperative assessment is the foundation of safe and effective perioperative care. Although programs differ in structure, financial support, and daily operations, they share the common goal of preparing patients to proceed safely through the perioperative period. Efficient, highly reliable preoperative processes are essential for successful anesthetic management, optimal patient outcomes, enhanced recovery protocols, and meeting quality metrics. Consequently, in this continually changing world of perioperative medicine, scientific advancement alongside quality improvement (QI) efforts to enhance these programs is vitally important to demonstrate added value.1 In this issue of Anesthesia & Analgesia, Manji et al2 highlight a common concern of preoperative medicine—how to meet the expectations of the final customer of the preoperative clinic, the day of surgery (DOS) anesthesia provider. In their manuscript, Measuring and Improving the Quality of Preprocedural Assessments, the authors describe a QI project to gauge DOS anesthesia providers’ satisfaction with preprocedure evaluations with the added goal of identifying deficiencies for remediation. They report on the challenges of obtaining valid and comprehensive information preoperatively and transmitting this in an acceptable way to the end users in the procedural areas. In this single-center study at an academic institution, surveyed members of the anesthesia care team were more satisfied with in-patient preprocedural evaluations done by anesthesiology residents. These were perceived to be of higher quality than those performed in their preoperative clinic by nonanesthesiologists. Most significantly, the in-person preoperative clinic visits were rated more favorably when compared to remote-access phone screens conducted by registered nurses. The authors used a QI questionnaire embedded in their electronic health record, which required DOS anesthesia providers to complete and rate preprocedural evaluations before finalizing the anesthesia record. A midpoint online survey using SurveyMonkey polled anesthesia care providers on their general perception of the institution’s preoperative evaluation process and overall satisfaction with the assessments. Interestingly, satisfaction ratings were more favorable for individual patient preoperative assessments collected by DOS forced entry than ratings for the overall preoperative process collected by delayed survey months later. This study highlights the importance of timing and quality feedback, essential components of a QI process, as well as anesthesia providers’ perceptions of preoperative evaluations. It appears the timing of survey questions may have a significant impact on the actual feedback provided.3 The authors of this study found that the frequency of unsatisfactory evaluations was higher when providers were asked to comment on the quality of preoperative evaluations at a time that was remote from their immediate access to these assessments. When rating a specific preoperative evaluation on an individual patient at the end of an encounter, providers felt “mostly satisfied” with the data provided. However, when reflecting on the general quality of the process, providers were less satisfied. This begs the question, as time progresses past the initial event, are we just more likely to recall a few select negative experiences rather than the positive ones, or are we more thoughtful about our ratings when providing feedback about an individual person rather than an overall system? If one hopes to make adjustments to processes via the “Plan, Do, Study, Act” paradigm of QI, it is vital that we understand how various factors impact these steps. The ideal time to obtain the most accurate, valid responses has not been determined despite research by cognitive psychologists and others. So, when asking for feedback, one must carefully consider when and how those questions are posed. Not only the timing but also the type of survey questions can impact responses and therefore reported data.3 In Manji et al’s2 study, the focus of their QI project was to evaluate the anesthesia care team’s satisfaction with preprocedural assessments and obtain feedback on specific deficiencies via free-text comments during their review. Analysis of comments identified actionable items for improvement. The authors state, “If we had gathered only quality ratings without free text comments, we would not have obtained the level of detail needed to make rapid improvements.” Suggested reasons for dissatisfaction with preoperative evaluations were a lack of standardization and a paucity of guidelines directing clinic providers as to what should be included in the assessments. As a result, proposed changes included upgrading the electronic health record template for their preanesthesia clinic to integrate more detailed questions and checklists, developing institutional guidelines, and providing focused education for clinicians performing the evaluations. Ideally, QI initiatives such as these go well beyond simply trying to make sure everyone is happy. QI should use data to describe how effectively systems are working and what happens when changes are applied. When developing or improving preoperative processes, it is crucial to assess the needs of the end user and involve the anesthesia team in developing changes. Defining current processes and deficiencies and engaging stakeholders in upgrades can provide the needed guidance to ensure acceptance and cultivate positive perceptions of the final product. Indeed, the added value of the preprocedural assessment depends on the perception of its overall quality relative to its actual cost. To the everyday anesthesiologist, the validity or necessity of preoperative assessment clinics may yet be unclear despite the breadth of supportive literature.1,4–8 The additional expense, personnel, and time required to develop and sustain this entity may not appear immediately cost-effective. Detsky and Naglie9 said, “for each intervention, the costs and clinical outcomes associated with that strategy must be compared with an alternate strategy for treating the same patients.” Because anesthesia providers must always conduct a preoperative evaluation on every patient as part of the bundled payment for anesthesia services, it seems essential to develop an effective preoperative process that enhances DOS efficiency, ensures medical optimization, improves documentation, and delivers a well-informed, consented patient to the holding area on the DOS. Traditionally, anesthesiologists have relied on primary care physicians, specialists, and surgeons to prepare patients for anesthesia and surgery. This approach has been shown to result in excessive testing, unnecessary delays, added costs, and even increased mortality.10,11 Preoperative evaluation clinics staffed or directed by anesthesiologists have been shown to decrease mortality, enhance operating room efficiency, decrease DOS cancellations, reduce hospital costs, and improve the quality of patient care.4,5 Furthermore, as illustrated in this study, the value of face-to-face, in-person evaluations by trained anesthesia providers before the DOS were favored by the anesthesia care team. Limiting interactions with patients to the DOS perpetuates the assumption that medical optimization can be accomplished by the surgeon or primary care physician’s history and physical examination or worse yet, validates the proverbial statement “cleared for surgery.” This short-sighted approach inadvertently isolates anesthesiologists to the intraoperative arena. This is a seemingly treacherous maneuver in an era of bundled payments and need to justify “added value” to the service line. The survey data in Manji et al’s2 study suggested that clinicians trained in anesthesia with experiences in intraoperative management may have provided more complete preoperative evaluations than nonanesthesia trained providers. Nurses performing phone screens and advanced practice providers conducting history and physical examinations were rated as missing information more often than attending anesthesiologists or residents in training. While this acknowledges the expertise of anesthesia trained providers, this suggests a deficiency in education for nonanesthesia providers conducting preoperative evaluations. This last step is paramount to ensure consistent, relevant information is delivered to the anesthesia care team on the DOS. It is the responsibility of anesthesiologists medically directing preoperative processes to implement clear guidelines and educate providers how to best apply recommendations. Education can be provided through formal didactic lectures, guideline development, problem-based learning opportunities, protected time to attend local or national meetings, and on-site supervision by trained anesthesiologists specializing in preoperative medicine.12 Even though all anesthesia providers conduct preoperative evaluations as part of perioperative care and are expected to be competent in evaluating straightforward patients, some may not possess the skills and knowledge to optimize complex patients. Likewise, it is not surprising that nonanesthesiologists working in preoperative clinics may not fully understand the needs of the anesthesia care team. In our specialty, we do not expect anesthesia providers to typically provide the same level of care to critically ill postoperative patients in an intensive care unit as they do to average patients in the postanesthesia recovery unit. Just as we depend on intensivists to be part of the perioperative team, we also need specialty trained providers in the preprocedure arena. Preoperative medicine is a burgeoning specialty of medicine and development of subspecialty education is necessary now more than ever. To evolve as perioperativists, anesthesiologists need to respond to the call for direct leadership in preoperative process QI. Quality standards guiding optimal performance can be found in the literature1,8 and through guidelines provided by subspecialty societies. Recommendations and risk assessment tools provided by the Society for Perioperative Assessment and Quality Improvement (http://www.spaqi.org/), the American College of Chest Physicians (http://www.chestnet.org/), and the American College of Surgeons National Quality Improvement Project (https://www.facs.org/quality-programs/acs-nsqip) provide the foundation for preoperative clinic directors to develop institution-compatible guidelines and quality metrics that benefit their patients and colleagues. The future of preoperative medicine depends on delivering high-quality, reliable care, which improves the perioperative experience for patients, their families, surgeons, and health care systems. Continued QI efforts, such as those demonstrated by Manji and coauthors,2 enable anesthesiologist-led preoperative clinics to have a positive impact throughout the surgical continuum of care. We are grateful to the Massachusetts General Hospital, Partners Healthcare and the authors of this study for sharing their findings with us. QI efforts such as this gather data to assist with redesigning a preoperative process that provides an opportunity for anesthesiologists to actualize the Institute of Medicine’s 6 competencies for quality patient care: patient centeredness, interpersonal communication skills, professionalism, systems-based practice, practice-based learning, and knowledge; thereby, adding value as perioperativists.6 As quality standards evolve and regulatory requirements increase, anesthesiologists will be required to demonstrate added value through effective perioperative leadership. It behooves anesthesiologists to step forward and lead efforts in preoperative medical education and clinical innovation. In the future, our added value, even our existence and incomes, will depend on our ability to clearly differentiate ourselves as perioperative physician specialists, patient advocates, and collaborators across the surgical continuum. DISCLOSURES Name: Angela F. Edwards, MD. Contribution: This author originated the concept for this article, provided initial outline, and organized and directed authorship for the final manuscript. Name: BobbieJean Sweitzer, MD, FACP. Contribution: This author originated the concept for this article, supplemented the outline, and directly participated in authorship of the final manuscript. This manuscript was handled by: Richard C. Prielipp, MD.