Department of Anesthesiology & Perioperative Care: School of Medicine: University of California, Irvine

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Quality Assurance

Anesthesiologists in OR

The UC Irvine Health Department of Anesthesiology & Perioperative Care Quality Assurance's Role is to provide:

  • Documented and approved systems to ensure consistent application of defined processes that are developed through evidence based medicine and faculty experience to produce predictable positive patient outcomes
  • Defined, documented and provider trained processes that are reviewed at regular intervals to ensure that they are current and effective, based on evaluation of collected data, industry standards and regulatory compliance requirements
  • Processes and practices that minimize the risk exposure for patients and ensure that the appropriate standard of care is met
  • Monitoring and analysis of process and provider data to continually reduce patient risk exposure, improve outcomes and improve provider performance
  • Internal audit system to verify program and system compliance
  • Quality management review to provide comprehensive review of all quality assurance system components, data analysis results and identify improvement opportunities
  • Continuous quality improvement with total employee involvement

The continuous quality improvement component manages the:

  • Quality Assurance strategic plan
  • Near Miss System
  • Best practices identification and implementation
  • Drives improvement through the application of six sigma (DMAIC), lean, statistical analysis, root cause analysis, trend analysis, project management and event review
  • Documentation, review and analysis of events relative to our key quality indicators regardless of final outcome

The defined event review process is confidential, documented and produces open and critical discussions within the Quality Assurance Committee, often resulting improvement actions that are tracked to closure and monitored as appropriate, such as policy revision, creation, peer review, presentation at grand rounds for educational points, etc. Documentation is the record available for quality reviews in a post event evaluation. Memory is a poor substitute and generally not acceptable to regulatory authorities, which has a, "if it isn't documented, it didn't happen", mind set.

Secondary to effectiveness is efficiency through value stream process mapping to coordinate resources and flows such as personnel, materials, information and communication. This helps maximizes value to our community, personnel, patients and teammates within the hospital.

Critical Components of Quality Assurance Systems

  1. Management review system
  2. Defined, documented processes/procedures (with supporting rational when not followed, to ensure standard and quality patient care with minimized risk)
  3. Training requirements list maintained and approved and documentation demonstrating requirements met (including revised and newly created SOPs)
  4. Quality Assurance case review, with disposition, along with root cause determination, corrections, corrective actions (eliminate or reduce future occurrences, and effectiveness monitoring as appropriate
  5. Regulatory compliance (not billing)
  6. Collection, analysis and reporting of data to monitor performance, verify compliance with requirements and identify improvement opportunities.
  7. Near Miss System, with backend analysis and information distribution.
  8. Continuous improvement through analysis results, research, best practices, effectiveness monitoring
  9. Have a system in place that ensures communication between departments, the entire hospital, as well as, within department
  10. Root cause analysis and identification (DMAIC - 6 sigma)
  11. Auditing system (defined as to departments, parameters, frequency, follow-up)
  12. Application processes such as Lean, Theory of constraints, etc, to improve efficiency, reduce operational costs and reduce employee frustrations

Regulations and Standards References

Regulatory Compliance

Industry/Practice Standards

Quality Improvement

Near Miss Reference Articles

Near Miss Project Newsletter
Ethan Fried, MD
February 2009 - Volume I Issue 3

Why Worry About Near Misses
William M. Marella, MBA
Patient Safety & Quality Healthcare - September/October 2007

Surprise Wire
Jeffrey M. Pearl, MD, Nancy E. Donaldson RN, DNSc
AHRQ Patient Safety Network - July-August 2005

Adverse events and near miss reporting in the NHS
R. Shaw, F. Drever, H. Hughes, S. Osborn, S. Williams
BMJ Quality & Safety - April 27, 2005