QUALITY MANAGEMENT DEPARTMENT & HOSPITAL REPRESENTATIVE(S)
(Interview together)

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REQUIRED QUESTIONS

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1. Is safety the top priority in the anesthesia department?
2. Is there open and effective collegial communication between the hospital quality management service and the anesthesia department?
3. Is there an established process by which sentinel events are referred to the anesthesia (or hospital) QM and/or risk management department?
4. Is there an identified quality management professional for the department?
5. Do sentinel events and major issues/cases reported to risk management go through a root-cause analysis?
6. Can the department demonstrate that improvement ideas derived from root-cause analysis (RCA) have been implemented, and that subsequent review confirms a correction or improvement of a previous problem?
7. Are there on-going chart reviews for quality, consistency, and legibility of documentation?
8. Do quality assurance/improvement meetings occur regularly?
9. Are indicators reviewed by the department and process improvements suggested?
10. Has the department established methods and criteria for granting non-anesthesia personnel privileges to perform sedation, including re-privileging and testing? If hospital policy permits non-anesthesiologists to administer or supervise deep sedation, has the department defined and monitored the training, experience, and qualifications necessary for these professionals to administer deep sedation?
11. Does the department have a locally derived policy addressing management of pediatric patients?
12. Is there a CME (hospital or state) for anesthesiologists and CRNAs and do all meet its provisions?
13. Does the department have a process to address poor outcomes that cross departmental boundaries, i.e., joint M&M conferences?
14. Does the department regularly communicate specific issues related to quality and safety to department members?
15. Is there a peer-review process in place?

OPTIONAL QUESTIONS

1. Are periodic quality reports made available to department members?
2. Is the department actively involved in achieving and documenting SCIP protocols?
3. Is there an anonymous mechanism for reporting compliance issues?
4. Is a method of reporting "near miss" events available, are practitioners aware of it, and is it utilized?
5. Does the department have processes in place to allow feedback from patients, nurses, surgeons, and administrators (i.e. patient surveys, peer review, evaluations?)
6. Do patients' comments enter the quality cycle?
7. Does the department continuously review clinical data and outcomes in an effort to deliver high-quality and cost-effective patient services (if not in place, is this a stated goal of the department?)
8. Is the anesthesia department actively involved in a recycling program and/or efforts to reduce waste?
9. Does the department have a policy and procedure manual and is it retrievable electronically?
10. Does the department have "best practice" pathways or are they developing such pathways (i.e., total joint pain, epidural wet tap, nausea and vomiting management, sleep apnea management, neuraxial anesthesia and anticoagulants, stents and plavix?) Are these published and routinely used?
11. Does the department utilize a large quality data repository (such as AQI*) in order to obtain statistically significant benchmarking?
12. Does the department participate in a hospital-wide quality program? Does the anesthesia department participate in development of quality goals?
13. Is the department outcomes data shared with other (involved) departments?
14. Do patients on chronic beta-blockers have their medication continued through the perioperative period?
15. Are there locally derived benchmarks for PONV and postoperative pain?
16. Is a policy in place (and followed) to assure maximum sterile barrier technique (MSBT) and the ultrasound for the placement of invasive lines?
17. Is perioperative temperature tracked per ASA standards?
18. Are audit mechanisms in place to ensure non-fraudulent billing?

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