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Introduction: Clinical record (CR) is the primary tool used by healthcare workers (HCWs) to record clinical information and its completeness can help achieve safer practices. CR is the most appropriate source in order to measure and evaluate the quality of care. In order to achieve a safety climate is fundamental to involve a responsive healthcare workforce thorough peer-review and feedbacks. This study aims to develop a peer-review tool for clinical records quality assurance, presenting the seven-year experience in the evolution of it; secondary aims are to describe the CR completeness and HCWs' diligence toward recording information in it., Methods: To assess the completeness of CRs a peer-review tool was developed in a large Academic Hospital of Northern Italy. This tool included measurable items that examined different themes, moments and levels of the clinical process. Data were collected every three months between 2010 and 2016 by appointed and trained HCWs from 42 Units; the hospital Quality Unit was responsible for of processing and validating them. Variations in the proportion of CR completeness were assessed using Cochran-Armitage test for trends., Results: A total of 9,408 CRs were evaluated. Overall CR completeness improved significantly from 79.6% in 2010 to 86.5% in 2016 (p<0.001). Doctors' attitude showed a trend similar to the overall completeness, while nurses improved more consistently (p<0.001). Most items exploring themes, moments and levels registered a significant improvement in the early years, then flattened in last years. Results of the validation process were always above the cut-off of 75%., Conclusions: This peer-review tool enabled the Quality Unit and hospital leadership to obtain a reliable picture of CRs completeness, while involving the HCWs in the quality evaluation. The completeness of CR showed an overall positive and significant trend during these seven years., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Surgical rating scales (SRSs) enable the surgeon to uniformly quantify surgical working conditions. They are increasingly used as a primary outcome in studies evaluating the effect of anaesthesia or surgery-related interventions on the quality of the surgical work field. SRSs are especially used in laparoscopic surgery due to a renewed interest in deep neuromuscular block. There are however no guidelines regarding the uniform use of SRS and the uniform reporting of results., Methods: A systematic search was conducted in the databases of PubMed, Web of Science and Embase for studies that reported the use of an SRS to evaluate surgical conditions in laparoscopic surgery. Only original human research in English language with full text availability through the Leiden university library was considered for this review. The full texts of eligible abstracts were independently reviewed by the first and second author. The quality of SRSs and methodology of rating were systematically reviewed., Results: The search yielded 2830 reports, of which 17 were identified using a surgical rating scale (SRS) in laparoscopic surgery. Ten of these reports used a unique SRS, these were systematically appraised for their quality. The overall quality of the SRSs was low: the majority of the scales were poorly described and lacked assessment of inter- and intra-rater reliability. In addition, considerable differences exist in the methodology of rating and the reporting of results., Conclusion: There is substantial inconsistency in SRS quality, methodology, and results reporting. The uniform use of high-quality surgical rating scales is needed to improve the quality and reproducibility of future research.

Background: Perianesthetic mortality (death occurring within 48 hours of an anesthetic) continues to vary widely depending on the study population examined. The authors study in a private practice physician group that covers multiple anesthetizing locations in the Southeastern United States. This group has in place a robust quality assurance (QA) database to follow all patients undergoing anesthesia. With this study, we estimate the incidence of anesthesia-related and perianesthetic mortality in this QA database., Methods: Following institutional review board approval, data from 2011 to 2016 were obtained from the QA database of a large, community-based anesthesiology group practice. The physician practice covers 233 anesthetizing locations across 20 facilities in 2 US states. All detected cases of perianesthetic death were extracted from the database and compared to the patients' electronic medical record. These cases were further examined by a committee of 3 anesthesiologists to determine whether the death was anesthesia related (a perioperative death solely attributable to either the anesthesia provider or anesthetic technique), anesthetic contributory (a perioperative death in which anesthesia role could not be entirely excluded), or not due to anesthesia., Results: A total of 785,467 anesthesia procedures were examined from the study period. A total of 592 cases of perianesthetic deaths were detected, giving an overall death rate of 75.37 in 100,000 cases (95% CI, 69.5-81.7). Mortality judged to be anesthesia related was found in 4 cases, giving a mortality rate of 0.509 in 100,000 (95% CI, 0.198-1.31). Mortality judged to be anesthesia contributory were found in 18 cases, giving a mortality of 2.29 in 100,000 patients (95% CI, 1.45-3.7). A total of 570 cases were judged to be nonanesthesia related, giving an incidence of 72.6 per 100,000 anesthetics (95% CI, 69.3-75.7)., Conclusions: In a large, comprehensive database representing the full range of anesthesia practices and locations in the Southeastern United States, the rate of perianesthestic death was 0.509 in 100,000 (95% CI, 0.198-1.31). Future in-depth analysis of the epidemiology of perianesthetic deaths will be reported in later studies.

Purpose of Review: The Task Force for Children's Surgical Care, an ad-hoc multidisciplinary group of invited leaders in pediatric perioperative medicine, was assembled in May 2012 to consider approaches to optimize delivery of children's surgical care in today's competitive national healthcare environment. Over the subsequent 3 years, with support from the American College of Surgeons (ACS) and Children's Hospital Association (CHA), the group established principles regarding perioperative resource standards, quality improvement and safety processes, data collection, and verification that were used to develop an ACS-sponsored Children's Surgery Verification and Quality Improvement Program (ACS CSV)., Recent Findings: The voluntary ACS CSV was officially launched in January 2017 and more than 125 pediatric surgical programs have expressed interest in verification. ACS CSV-verified programs have specific requirements for pediatric anesthesia leadership, resources, and the availability of pediatric anesthesiologists or anesthesiologists with pediatric expertise to care for infants and young children., Summary: The present review outlines the history of the ACS CSV, key elements of the program, and the standards specific to pediatric anesthesiology. As with the pediatric trauma programs initiated more than 40 years ago, this program has the potential to significantly improve surgical care for infants and children in the United States and Canada.

Background: Patient safety depends on effective teamwork. The similarity of team members' mental models - or their shared understanding-regarding clinical tasks is likely to influence the effectiveness of teamwork. Mental models have not been measured in the complex, high-acuity environment of the operating room (OR), where professionals of different backgrounds must work together to achieve the best surgical outcome for each patient. Therefore, we aimed to explore the similarity of mental models of task sequence and of responsibility for task within multidisciplinary OR teams., Methods: We developed a computer-based card sorting tool (Momento) to capture the information on mental models in 20 six-person surgical teams, each comprised of three subteams (anaesthesia, surgery, and nursing) for two simulated laparotomies. Team members sorted 20 cards depicting key tasks according to when in the procedure each task should be performed, and which subteam was primarily responsible for each task. Within each OR team and subteam, we conducted pairwise comparisons of scores to arrive at mean similarity scores for each task., Results: Mean similarity score for task sequence was 87 % (range 57-97 %). Mean score for responsibility for task was 70 % (range = 38-100 %), but for half of the tasks was only 51 % (range = 38-69 %). Participants believed their own subteam was primarily responsible for approximately half the tasks in each procedure., Conclusions: We found differences in the mental models of some OR team members about responsibility for and order of certain tasks in an emergency laparotomy. Momento is a tool that could help elucidate and better align the mental models of OR team members about surgical procedures and thereby improve teamwork and outcomes for patients.

Background: The quality assurance of care and patient safety, with increasing cost pressure and performance levels is of major importance in the high-risk and high cost area of the operating room (OR). Standard operating procedures (SOP) are an established tool for structuring and standardization of the clinical treatment pathways and show multiple benefits for quality assurance and process optimization., Objectives: An internal project was initiated in the department of anesthesiology and a continuous improvement process was carried out to build up a comprehensive SOP library., Material and Methods: In the first step the spectrum of procedures in anesthesiology was transferred to PDF-based SOPs. The further development to an app-based SOP library (Aesculapp) was due to the high resource expenditure for the administration and maintenance of the large PDF-based SOP collection and to deficits in the mobile availability. The next developmental stage, the SOP healthcare information assistant (SOPHIA) included a simplified and advanced update feature, an archive feature previously missing and notably the possibility to share the SOP library with other departments including the option to adapt each SOP to the individual situation. A survey of the personnel showed that the app-based allocation of SOPs (Aesculapp, SOPHIA) had a higher acceptance than the PDF-based developmental stage SOP form., Conclusion: The SOP management system SOPHIA combines the benefits of the forerunner version Aesculapp with improved options for intradepartmental maintenance and administration of the SOPs and the possibility of an export and editing function for interinstitutional exchange of SOPs.

Background: Anesthesiologists face increasing pressure to demonstrate the value of the care they provide, whether locally or nationally through public reporting and payor requirements. In this article, we describe the current state of performance measurement in anesthesia care at the national level and highlight gaps and opportunities in performance measurement for anesthesiologists., Methods: We evaluated all endorsed performance measures in the National Quality Forum (NQF), the clearinghouse for all federal performance measures, and classified all measures as follows: (1) anesthesia-specific; (2) surgery-specific; (3) jointly attributable; or (4) other. We used NQF-provided descriptors to characterize measures in terms of (1) structure, process, outcome, or efficiency; (2) patients, disease, and events targeted; (3) procedural specialty; (4) reporting eligibility; (5) measures stewards; and (6) timing in the care stream., Results: Of the 637 endorsed performance measures, few (6, 1.0%) were anesthesia-specific. An additional 39 measures (6.1%) were surgery-specific, and 67 others (10.5%) were jointly attributable. "Anesthesia-specific" measures addressed preoperative antibiotic timing (n = 4), normothermia (n = 1), and protocol use for the placement of central venous catheter (n = 1). Jointly attributable measures included outcome measures (n = 49/67, 73.1%), which were weighted toward mortality alone (n = 24) and cardiac surgery (n = 14). Other jointly attributable measures addressed orthopedic surgery (n = 4), general surgical oncologic resections (n = 12), or nonspecified surgeries (n = 15), but none specifically addressed anesthesia care outside the operating room such as for endoscopy. Only 4 measures were eligible for value-based purchasing. No named anesthesiology professional groups were among measure stewards, but surgical professional groups (n = 33/67, 47%) were frequent measure stewards., Conclusions: Few NQF performance measures are specific to anesthesia practice, and none of these appears to demonstrate the value of anesthesia care or differentiate high-quality providers. To demonstrate their role in patient-centered, outcome-driven care, anesthesiologists may consider actively partnering in jointly attributable or team-based reporting. Future measures may incorporate surgical procedures not proportionally represented, as well as procedural and sedation care provided in nonoperating room settings.

Background: The current situation in hospitals is characterized by financial limitations and simultaneously by increasing demands on quality and safety. The operative interface between anesthesia and transfusion medicine affects both factors., Aim: A detailed analysis was performed to evaluate the process quality at this operative interface at the University Hospital of Göttingen. The aim of the project was to revise und develop the structures and responsibilities at this interface, to dispose of weak points and to realize the optimization potential in the supply of blood products., Material and Methods: A databank-based electronic data processing solution was established with the clear definition of responsibilities for the various workflow procedures and the written documentation of these definitions in standard operating protocols. In order to guarantee the necessary transparency a routine reporting system to the department of surgery was established. In addition, a continuous further development of the blood supply standard based on electronic report data was implemented., Results: By implementing the above named measures the rate of supplied to transfused blood products could be increased from 43.1 % to 55.7 %. The compliance with the blood supply standard improved continually over the first 18 months from 60.3 % to 92.3 %. The rate of supplied blood product deliveries without subsequent operation could be reduced from 9.0 % to 4.6  %. As a result of this optimization the supply costs in the internal cost allocation were reduced from 9,406  to 3,544 ., Conclusion: The measures described are appropriate to cost-effectively improve quality and patient safety. The optimization measures presented in this article can be implemented in other hospitals to increase quality and safety after individual adjustment to the local circumstances.

Purpose of Review: This review concerns quality assurance for gastrointestinal endoscopic procedures, especially colonoscopy and will emphasize research and guidelines published since January 2011. Important articles from previous years have been included for background., Recent Findings: Critical lapses in endoscope processing and administration of intravenous sedation alerted us to the infection risk of endoscopy. Increases in cost of colonoscopy, evidence for overuse and studies demonstrating missed cancers have led some to question the value of endoscopy. Despite these setbacks, the National Polyp Study (NPS) consortium published their long-term follow-up of the original NPS patients and confirmed that colonoscopy with polyp removal can reduce the risk of colorectal cancer for an extended period. In this article, we will focus on ways to improve the value of outpatient colonoscopy., Summary: The United States national quality improvement agenda recently became organized into a more coordinated effort spearheaded by several public and private entities. They comprise the infrastructure by which performance measures are developed and implemented as accountability standards. Understanding wherein a gastroenterology (GI) practice fits into this infrastructure and learning ways we can improve our endoscopic practice is important for physicians who provide this vital service to patients. This article will provide a roadmap for developing a quality assurance program for endoscopic practice.

After recent UK policy developments, considerable attention has been focused upon how clinical specialties measure and report on the quality of care delivered to patients. Defining the right indicators alone is insufficient to close the feedback loop. This narrative review aims to describe and synthesize a diverse body of research relevant to the question of how information from quality indicators can be fed back and used effectively to improve care. Anaesthesia poses certain challenges in the identification of valid outcome indicators sensitive to variations in anaesthetic care. Metrics collected during the immediate post-anaesthetic recovery period, such as patient temperature, patient-reported quality of recovery, and pain and nausea, provide potentially useful information for the anaesthetist, yet this information is not routinely fed back. Reviews of the effects of feeding back performance data to healthcare providers suggest that this may result in small to moderate positive effects upon outcomes and professional practice, with stronger effects where feedback is integrated within a broader quality improvement strategy. The dominant model for use of data within quality improvement is based upon the industrial process control approach, in which care processes are monitored continuously for process changes which are rapidly detectable for corrective action. From this review and experience of implementing these principles in practice, effective feedback from quality indicators is timely, credible, confidential, tailored to the recipient, and continuous. Considerable further work is needed to understand how information from quality indicators can be fed back in an effective way to clinicians and clinical units, in order to support revalidation and continuous improvement.

Background: There is no nationwide evaluation of the quality of anaesthesia in Germany. Thus, the aim of this study was to perform analyses using administrative routine data relating to this topic., Methods: Nationwide hospital claims data of patients insured with the local healthcare insurance fund (AOK) in the year 2007 were analyzed. Indicators from International Statistical Classification of Diseases and Related Health Problems-10, German modification (ICD-10-GM) diagnosis codes for possible anaesthesia complications were selected., Results: Based on the present data, it was not possible to validate indicators which can be applied to detect the quality of anaesthesia., Conclusions: Administrative data seem to be an appropriated basis for measurement of quality of outcome in anaesthesiology. Further investigations should be performed to include the diagnosis present on admission. Moreover, there is a need for comparing routine data to the standardized data set, known as the "core data set anaesthesia".

Background: Opinions about satisfaction with care are rarely obtained from children and few studies of this type exist in the area of paediatric anaesthesia. In this study, we developed a comprehensive self-administered questionnaire to measure the level of paediatric and, as a substitute in younger children, parental satisfaction with anaesthesia. In addition, we aimed to identify factors influencing satisfaction and compare results between hospitals., Methods: We followed a rigorous protocol including construction of a pilot questionnaire and qualitative and quantitative analysis. The questionnaire was adapted for confounding variables. We analysed satisfied and dissatisfied groups and compared satisfaction scores between participating hospitals., Results: A questionnaire was developed which comprised 37 questions assessed on a five-point Likert scale. With a response rate of 71%, a total of 1052 patients completed the questionnaire. In the final analysis, 760 questionnaires (72%) were included. Most questionnaires were answered by the parents [705 (92.8%)]. The mean age of children was 6.7 (4.97) yr. Multivariate analysis found a history of previous anaesthetic problems and the identity of the person answering the questionnaire as influencing factors on the sum score. The most important differences between satisfied and dissatisfied children were found for the dimensions 'privacy and waiting', 'information giving', and 'discomfort'. Scores differed between hospitals., Conclusions: Our psychometric questionnaire provides a novel approach to paediatric patient satisfaction with anaesthesia care and covers areas deemed important by children, parents, and carers. Significant differences between satisfied and dissatisfied groups and between participating hospitals were found.

Purpose of Review: Quality improvement efforts are increasingly applied in transplant medicine and are related to graft/patient outcomes and reimbursement from third-party insures. Perioperative care of transplant patients has only recently attracted attention and quality improvement efforts are not well established., Recent Findings: Research investigations in perioperative care of transplant patients frequently focus on only one variable (i.e., transfusion rate) and, therefore, are of limited significance., Summary: In order to improve perioperative care of transplant patients, perioperative quality improvement protocols have to be established at transplant centers. These protocols need to include a comprehensive electronic database that can be easily queried, a periodic review of practice pattern based on existing data, and a well established mechanism for necessary practice adjustments.

Clinical indicators are increasingly developed and promoted by professional organizations, governmental agencies, and quality initiatives as measures of quality and performance. To clarify the number, characteristics, and validity of indicators available for anesthesia care, the authors performed a systematic review. They identified 108 anesthetic clinical indicators, of which 53 related also to surgical or postoperative ward care. Most were process (42%) or outcome (57%) measures assessing the safety and effectiveness of patient care. To identify possible quality issues, most clinical indicators were used as part of interhospital comparison or professional peer-review processes. For 60% of the clinical indicators identified, validity relied on expert opinion. The level of scientific evidence on which prescriptive indicators ("how things should be done") were based was high (1a-1b) for 38% and low (4-5) for 62% of indicators. Additional efforts should be placed into the development and validation of anesthesia-specific quality indicators.

Interventional radiology (IR) encompasses a broad and expanding array of image-guided, minimally invasive therapies that are essential to the practice of modern medicine. The growth and diversity of these non-OR procedures presents unique challenges and opportunities to anesthesiologists and interventional radiologists alike. Collaborative action has led to better patient care and quality management. This discussion considers some angiographic and cross-sectional IR procedures in more detail and comments on some of the anesthesia choices and considerations. In addition, specific concerns regarding anesthesia in the area of IR are reviewed.

Objective: Although oesophagogastroduodenoscopies (OGDs) are associated with few medical complications, substantial pre-procedural anxiety and discomfort during the procedure have been reported. The aims of the present study were to evaluate OGD-related discomfort assessed by the patient and to identify the possibilities for improvement., Material and Methods: All outpatients undergoing OGDs at a single centre during 2004 were eligible for the study. On site, the endoscopy team completed a questionnaire on age of patients, gender and the use of sedation/anaesthesia. After the examination, the patients were given a questionnaire focusing on discomfort during and after the examination. The questionnaire was to be completed at home the following day and returned in a prepaid envelope., Results: During the study period, 1283 examinations were registered, giving 92% coverage of OGDs. The patient response rate was 80%. Patients' mean age was 55 years, and 45% were men. The sedation rate was 7.3%. None or only slight discomfort was experienced by 68% of the patients and severe discomfort by 14%. In patients, the odds ratio (OR) for experiencing moderate or severe discomfort decreased with increasing age (OR 0.96, 95% CI 0.95-0.97, p < 0.001). There were significant differences in patient discomfort depending on the level of experience of the endoscopists., Conclusions: The majority of patients reported no or only slight discomfort during the examination, but as many as 32% did not. Increased use of sedation in selected patients is recommended. Our quality assurance program included a limited number of variables for registration, with satisfactory compliance by endoscopists and patients.

Patients, general public and health insurance funds focus more and more on the quality of medical performance. Anaesthesia related severe morbidity and mortality are unsuitable to judge the quality of an anaesthesia procedure. Other aspects like rapid and comfortable postoperative recovery or satisfaction of the patients with the anaesthesia procedure experience therefore rising attention. With this critical review we aim to give support for appraisal of already published studies and for design and realization of future trials.

The purpose of benchmarking is to settle improvement processes by comparing the activities to quality standards. The proposed methodology is illustrated by benchmark business cases performed inside medical plants on some items like nosocomial diseases or organization of surgery facilities. Moreover, the authors have built a specific graphic tool, enhanced with balance score numbers and mappings, so that the comparison between different anesthesia-reanimation services, which are willing to start an improvement program, is easy and relevant. This ready-made application is even more accurate as far as detailed tariffs of activities are implemented.

The S2e Guidelines for sedation practice of the German Society for Anaesthesiology and Intensive Care recommend a clear prior definition of depth of sedation to be achieved in a given case, monitoring of depth of sedation by means of scoring systems, appropriate selection of analgesics and sedatives and the use of patient-oriented treatment regimens. These measures not only reduce significantly length of artificial respiration, length of time spent on the intensive care unit and overall length of stay in the hospital but also the frequency of complications. Therefore, implementation of the Guidelines will result in significant reductions in costs in a given case. This is a decisive economic benefit for any hospital working under the restraints of the DRG system.

The Quality Review in Anesthesia (QRIA) newsletter is a significant, evolving resource to the Certified Registered Nurse Anesthetist (CRNA) in clinical practice. Since its inception in 1997, the newsletter has been modified to meet the changing needs of anesthesia practice. The goal of the newsletter is improvement in patient care and risk avoidance by keeping CRNAs abreast of the latest changes in risk management, quality assurance, and malpractice concerns. By incorporating reports of patient safety adverse events, it is anticipated CRNAs will better understand the need for compliance and adherence to the standards of care. A chronological history of the development of the QRIA newsletter is provided. The methodology of how an article is conceived, reviewed, and published is presented so the CRNA can appreciate the mechanisms involved in putting together each publication. The QRIA newsletter now has a chronological and alphabetical index on the AANA website. This electronic format allows the CRNA to access articles that might be of special interest to a certain aspects of practice. Each issue of QRIA is planned carefully to meet the needs of the CRNA and is offered as a valuable membership service.

Anesthesiology has served as a model for patient safety in health care and was the first medical profession to treat patient safety as an independent problem. Anesthesiology has implemented widely accepted guidelines on basic monitoring, conducted long-term analyses of closed malpractice claims, developed patient simulators as meaningful training tools, and addressed problems of human error. The National Surgical Quality Improvement Program is the first national, validated, and peer-controlled program that uses risk-adjusted outcomes for the comparative assessment and improvement of the quality of surgical care. The program has reduced postoperative complications in the Veterans Administration, at both national and local levels. It is becoming more evident that processes and events during surgery can be important determinants of long-term outcomes after anesthesia and surgery.

A monitoring system for cardiac surgery has been in use at Papworth Hospital for 10 years. We wished to determine whether this system would have detected an increase in deaths associated with a single practitioner, whether a poorly performing doctor or a serial killer such as Dr Harold Shipman, whose activities went undetected in the absence of a monitoring system for nearly a quarter of a century. Random extra deaths were artificially introduced into the practice of a surgeon and an anaesthetist in a way that broadly reproduced Shipman's pattern. The standard monitoring system was then used to analyse the hypothetical data thus generated. Using the current standard monitoring, the excess deaths would have been detected in less than 10 months. Suspicions would have been raised even earlier. Robust local quality monitoring of risk-adjusted outcomes is possible and, in our opinion, essential.

Learning Objectives: After studying this article, the participant should be able to: 1. Discern the importance of the physician's office administrative capacity. 2. Recognize the necessity of a system for quality assessment. 3. Assess which procedures are safe in the office-based setting. 4. Know the basic steps to properly evaluate patients for office-based plastic surgery., Background: At least 44,000 Americans die annually as a result of preventable medical errors. Medical mistakes are the eighth leading cause of death in the United States, costing between $54.6 billion and $79 billion, or 6 percent of total annual national health care expenditures. Office-based procedures comprise a 10-fold increase in risk for serious injury or death as compared with an ambulatory surgical facility., Methods: This article reviews the literature on office-based patient safety issues. It places special emphasis on the statements and advisories published by the American Society of Plastic Surgeons' convened Task Force on Patient Safety in Office-Based Settings. This article stresses areas of increased patient safety concern, such as deep vein thrombosis prophylaxis and liposuction surgery., Results: The article divides patient safety in health care delivery into three broad categories. First, patient safety starts with emphasis at the administrative level. The physician or independent governing body must develop a system of quality assessment that functions to minimize preventable errors and report outcomes and errors. Second, the clinical aspects of patient safety require that the physician evaluate whether the procedure(s) and the patient are proper for the office setting. Finally, this article gives special attention to liposuction, the most frequently performed office-based plastic surgery procedure., Conclusions: Patient safety must be every physician's highest priority, as reflected in the Hippocratic Oath: primum non nocere ("first, do no harm"). In the office setting, this priority requires both administrative and clinical emphasis. The physician who gives the healing touch of quality care must always have patient safety as the foremost priority.

Today, quality is part of our practice. Anaesthetists are involved in a medical science and want to be excellent at it. Anaesthetists are also involved in departmental organisation and are providers of care, a service to the patients. Quality is a method to obtain efficiency (efficacy and economical advantages). We consider our patients no longer as such, but as health-customers. Anaesthetists are health providers. The patients-customers have their own expectations and they compare the service between the different hospitals. On the other hand, health care is a public matter and in most countries depends on a governmental financing. Quality means efficacy, ethics and economics, including medico-legal aspects. But how can we use a quality and management concept (QMDA) in our daily practice? This is the subject of the paper.

In this study, we aimed to construct, validate, and apply an instrument for assessing resident performance at outpatient preanesthesia consultation (PAC). A focus group and a Delphi panel of experts defined component items of a typical outpatient PAC, which could be used as indicators of competence. Items were incorporated in a checklist, which was further validated in a sample of consultations performed by board-certified anesthesiologists. The resulting instrument contained 37 items, grouped into five domains (physician-patient relationship, medical history, physical examination, patient education, and preanesthesia records), with high construct validity, high discriminant validity, moderate internal consistency, and high probability of inter-raters agreement. The instrument was applied to evaluate the performance of seven first-year residents at 317 consecutive PAC. Data were analyzed by constructing exponentially weighted moving average charts for domain and total scores. Statistically significant differing levels of performance could be consistently detected. Applying exponentially weighted moving average charts to the sequential analysis of the developed checklist scores can reliably assess resident performance at the devised criteria. The Preanesthesia Consultation Scoring Checklist is a potentially useful instrument for both formative and summative assessment of residents during their training in processes involved in outpatient preanesthesia evaluation.

The paper describes a mobile information system to collect patient information for anaesthesia quality control. In this system we use handheld computers, to collect patient data at the bedside with a daily synchronization of the data of the anaesthesiologist's handheld with the anaesthesia database center, later used for quality control analysis. Further, we design mobile clinical guidelines to be used on the same handhelds.

As part of a quality assurance program, the quality of the anesthesia service at Siriraj Hospital was assessed by using a newly developed data collecting system to find the incidence of clinical indicators. During a 7-month period (June-December 2001), 14,036 anesthetics were included for evaluation. The mortality rate within 24 hours and CPR rate during anesthesia were equal at 20.6/ 10,000. Other clinical indicators were major anesthetic complications (mainly airway, respiratory and cardiovascular system) 144.8/10,000, drug mishaps and adverse drug reactions 6.4/10,000, anesthetic equipment related complications 3.5/10,000 and patient's dissatisfaction 30.6/10,000. Patterns of some complications were also reported. The implications of the results; comparison to international standard, prioritization of the problems, baseline information before intervention, recognition of complication patterns and guidance to future system management and research projects; were discussed. In conclusion, we demonstrated the effective data collecting system and its results and implication for quality assurance program.

Assessing adequacy of anesthesia requires evaluation of its components: hypnosis, analgesia, and neuromuscular transmission. In order to do this, many methods have been developed that process signals representing different modalities. Assessment of hypnosis requires cortical measures of the central nervous system (CNS); methods that assess analgesia concentrate on subcortical and spinal levels of the CNS; and neuromuscular transmission is a peripheral phenomenon. This article presents an overview of the current state of methods available for measuring each of these components. We conclude that, whereas important gains have been made in the area of assessment of hypnosis, mainly owing to the advancement of methods using EEG and auditory evoked potentials, and whereas neuromuscular transmission can be objectively monitored using motor nerve stimulation, assessment of analgesia still contains many challenges.

Elective surgical procedures are moving from hospital-affiliated and freestanding ambulatory centers to the physician office. Anesthetic risk has decreased dramatically during the past decade; however, perioperative safety is ill defined when the surgical procedure is performed in the physician office. Perioperative risk may vary depending on the surgical location (hospital, freestanding unit, or physician office). Regulation of office-based surgery is now being addressed by specialty organizations and Departments of Health or Boards of Medical Examiners. A comprehensive study of perioperative risk for patients receiving office-based surgical care is needed., (Copyright 2001 by American Society of PeriAnesthesia Nurses.)

Objective: To audit the recently established Critical Incident Reporting System in the Department of Anaesthesia and Critical Care Medicine, University of Zimbabwe Medical School. The system was set up with the purpose of improving the quality of care delivered by the department., Design: Cross sectional study. A critical incident was defined as 'any adverse and reversible event in theatre, during or immediately after surgery that if it persisted without correction would cause harm to the patient'. The anaesthetic or recovery room staff filled a critical incident form anonymously. Data was collected from critical incident reporting forms for analysis., Setting: The anaesthetic service in the two teaching hospitals of Harare Central and Parirenyatwa General Hospitals., Subjects: Between May and October 2000, 62 completed critical incident forms were collected., Main Outcome Measures: The nature of the incident and the monitoring used were recorded, the cause was classified as human, equipment or monitoring failure and the outcome for each patient reported. There was no formal system for reminding staff to fill in their critical incident forms., Results: A total of 14,165 operations were performed over the reporting period: 62 critical incident forms were collected, reporting 130 incidents, giving a rate of 0.92% (130/14,165). Of these, 42 patients were emergencies and 20 elective. The incidents were hypotension, hypoxia, bradycardia, ECG changes, aspiration, laryngospasm, high spinal, and cardiac arrest. Monitoring present on patients who had critical incidents was: capnography 57%, oxymetry 90% and ECG 100%. Other monitors are not reported. Human error contributed in 32/62 of patients and equipment failure in 31/62 of patients. Patient outcome showed 15% died, 23% were unplanned admissions to HDU while 62% were discharged to the ward with little or no adverse outcome., Conclusion: Despite some under reporting, the critical incident rate was within the range reported in the literature. Supervision of juniors is not adequate, especially on call. The stress under which everyone has to work includes poor morale, drug shortages, poor equipment and power cuts with no backup generator. Despite this, the challenge for senior personnel is to improve quality of care. In other countries similar audits have led to change of practice and improvement in the safety features of the service provided by the hospital and staff.

Health care systems throughout the world are faced with continuously rising health care expenditure. In Germany, a fee per capita system will be introduced by 2003 to keep the budgets for hospital care within limits. As a result, numbers of hospital beds and hospitals will be cut in the coming years. On the other hand, more and more patients and health care providers are asking if they are really receiving an adequate value for their money in the treatment they receive. All this will have a strong impact on the anaesthesiologist's work and her/his perception of the different facets of quality. Quality has various aspects for the anaesthesiologist. The patient as a customer should not incur any detrimental effects after a surgical procedure, and is accompanied by the anaesthesiologist throughout the perioperative setting. The surgeon needs optimal conditions to perform a procedure. The hospital must balance equally costs and income; this requires optimal operating room utilization. Finally, health insurance companies and the government are responsible for covering the cost of treatment according to the quality of the care delivered. Quality assessment concerning structure, process and outcome has to take these demands into account. Continuous quality improvement in the spirit of Deming's 'plan-do-check-act cycle' has to be part of anaesthesiologist's everyday routine. In future, the traditional barriers between the specialities treating a patient will be disrupted when reimbursement for treatment is made according to quality and efficacy of treatment.

Quality of care and costs are getting closer together. Whereas costs and quality management did not play a substantial role 30 years ago, the consumption of resources nowadays is part of the outcome of quality of care. The definition of quality must be seen in the dimensions of structure, process and result. Resulting from newly developed clinical practice, guidelines are planned as instruments for cost containment in near future. Those guidelines may end up in a quality management system. The most wellknown european basic of such a quality management system are the DIN EN ISO 9000 f and the EFQM. The ISO 9001 and the European Quality Award became the most common base of evaluation for certification of quality management systems in Organisations European wide. Whereas the ISO 9001 does not give any information about the real achieved quality, the European Quality Award reflects the process. Guidelines are necessary to prove the cost effectiveness of measures of quality control and quality assurance since too much quality control and assurance may result in increased overall consumption of resources, leading to a reduction in the quality of care when ensuring that the overall budget is covered.

Purpose: Since 1992 421,851 anaesthesias were documented by 39 institutes with a standard dataset issued by the German Society of Anaesthesiology and Intensive Care (DGAI). The project was run by the Association for Quality Assurance (EQS) in Hamburg. Some results of the evaluation of this datapool are presented questioning the feasibility of the project to support improvement processes within the participating institutions and which adjustments should be done considering these experiences., Methods: Data from machine-readable protocols and documentation software representing all anaesthesia cases were recorded since 1992 in a pilot project and since 1994 compulsory with a standard dataset issued by the DGAI. Comparing statistics of these data was produced at the EQS project office. In the steering committee and in meetings of the project participants the contents, policy and results of the project office. In the steering committee and in meetings of the project were critically analysed and adjustments initiated whenever necessary. Validity of data and feasibility of the method used was also questioned on the background of comparable studies., Results: With an incidence of 14.1% of all anaesthesias with special occurrences (AVB) the results are in the same range if compared with most other studies. However, documentation of data is not complete. This is assumed to be due to the large size of the dataset with 112 items and the additional workload associated with it. Nevertheless the participants mostly consider the project to be a very useful support for internal improvement projects., Conclusion: The project method used so far is not mature yet. The data set must be streamlined and rendered more concise, quality indicators should be defined and tested, and the availability of statistically proven limits of tolerance should be the immediate aims in the further development of the project.

Voluntary anonymous reporting of incidents which occur during anaesthesia is a mechanism for obtaining information about such problems. Our objective was to estimate with reporting such incidents. For 3 months, alongside the incident report form, another form, which had to be completed for every patient, was used. This form listed a series of defined events which could occur intra-operatively. Compliance with the incident reports was estimated by comparing the data obtained from the two sets of forms. Overall compliance was only about 30%. There were differences in compliance for different events. Compliance was high with more serious events and poor in the case of common events, or when successful recovery had occurred. In order to improve compliance, incident report forms should be available on each anaesthetic machine and staff should be made more aware of the fact that reportable incidents are not limited to events which harmed the patient, but also include those which could have affected patient safety.

Formal Quality Assurance programmes have been widely promoted and applied in anaesthesia departments in the United States of America. The rationale of three well-known programmes is examined. Although they may be of use as a method of examining one's own practice, there is little objective evidence to support the idea of measuring an anaesthesiologist's competence. There is also a danger that licensing authorities will misuse such spurious information.

Although the literature concerning quality assurance (QA) is voluminous, little information exists about the costs or benefits of departmentally based QA programmes. We measured the direct costs and then investigated the financial and nonfinancial benefits derived from a well-funded QA programme over a period of five years. Data were obtained from departmental budgets, annual reports of the QA programme, and several databases used by the programme. The average annual cost was $79,900, with salaries being the largest component, while $14,300 each year were recovered through the activities of the programme. True costs were higher than those calculated since time volunteered by medical staff and resources shared with other programmes could not be determined. Some of the costs encountered at the outset of this programme were later offset by the use of commercial software and employment of volunteers and casual staff. Fifty-three projects were identified over the five-year period. Most lacked directly measurable financial outcomes (because they were based on education, research, patient or practitioner satisfaction). The benefit of the programme has been greater to the department than suggested from cost analysis alone. Although this programme could not be justified on a simple cost recovery basis, the authors felt it to be worthy of continued support because of the nonfinancial benefits. However, modification is required to minimize costs.

Objective: To assess the quality of anaesthesia care from the patients' viewpoint compared with the hospital record., Design: Prospective study during 1988-9., Setting: Four teaching hospitals (A-D) in Canada., Patients: 15,960 inpatients receiving anaesthetic requiring at least an overnight stay, for whom an interview and review of hospital records within 72 hours of surgery were complete., Main Measures: Rates of postoperative symptoms of discomfort (nausea or vomiting, headache, back pain, sore throat, eye symptoms, and tingling) according to the hospital record versus interview and the relation between symptoms and patients' satisfaction with the anaesthetic experience., Results: The preparation of completed interviews ranged from 31.0% to 72.7%, owing mainly to patients discharge (hospitals A and B) and severity of illness (C and D). Interviewed patients were similar to all inpatients in the hospitals but were younger and healthier and more had had effective operations and were general surgical than cardiovascular or neurosurgical patients. In all, 26% to 46% of patients at the four hospitals reported at least one symptom of discomfort. Agreement between interviews and hospital records was low, symptoms being more commonly reported by interview than in the record (for example, headache was reported for 5.8%-17% of patients compared with 0.3%-3.0% in hospital records). After controlling for case mix patients who reported at least one symptom were 2.91 times (95% confidence interval 1.89 to 4.50) more likely to be dissatisfied with their anaesthetic care than patients who did not., Conclusions: Anaesthesia services are typically neglected in studies of hospital quality, yet patients express considerable anxiety about anaesthetic care. Monitoring and recording patients' discomfort clearly need to be improved if the quality of anaesthesia is to be properly evaluated.