Authors: Susan Curling, M.D., M.B.A.
ASA Monitor 10 2015, Vol.79, 18-19.
Susan Curling, M.D., M.B.A., is former Medical Director for Quality, Memorial Hermann Hospital Northeast, Humble, Texas.
The core goal of leadership is to develop an inspired culture that changes a job into a calling. Several physician anesthesiologists have been instrumental in accomplishing this goal. In a TED Talk, Simon Sinek (www.youtube.com/watch?v=sioZd3AxmnE) refers to starting with “why.” Why do we train extended years, work long hours and sacrifice family and friends? We do it because we are privileged to keep patients safe, alive and pain-free. I say safe before pain-free because we are known as the medical specialty that pioneered safety, beginning with the leadership of Dr. Ellison “Jeep” Pierce, Jr., M.D.
At a time when the safety of anesthesia and surgery came under public attack, Dr. Pierce had the option as an ASA leader to fight for tort reform and decrease malpractice insurance costs or make anesthesia safer. The ABC network aired a “20/20” episode in April 1982 called, “The Deep Sleep: 6,000 Will Die or Suffer Brain Damage.” Going back to the “why” of what we profess in our profession, Dr. Pierce decided to improve safety. He created an ASA standing committee on safety and risk management, which led to the formation of the Anesthesia Patient Safety Foundation (APSF). With his leadership, we were to be dubbed the safety innovators of medicine. The vision of the APSF, led by Robert Stoelting, M.D., for many years, “that no patient be harmed by anesthesia,” was to become the battle cry of the quality and patient safety leaders of today. Nobody on earth thought of ZERO HARM1 or organized around patient safety prior to the 1980s.
But that was only the beginning. What led to the complimentary mention of anesthesia as a profession in the 1999 Institute of Medicine publication To Err Is Human2 was a multi-modal process of quality improvement. The insistence on electronic monitoring and the proof of proper intubation of the trachea dramatically decreased the incidence of brain damaging/death-causing esophageal intubation. ASA established standards of basic monitoring, and other leaders appeared.
James Arens, M.D., was an influential chair for many years as leader of the ASA Committee on Standards and Practice Parameters. Guidelines created by this committee cannot be edited on the floor of the ASA House of Delegates (HOD), but must be passed up or down, leading to thoughtful wording. The HOD passed the first standards of basic anesthesia monitoring in 1986, very early in the patient safety/quality movement. The guidelines are written to advance safety while including the caveat that these measures might be limited in the circumstance of emergencies where life-support measures might take precedence. This fact promotes the coexistence of standardized and customized patient care and makes innovation more palatable. Dr. David Eddy developed the concept of evidence-based medicine, which was barely mentioned in publications in the 1980s. Yet ASA was an early-adopter, incorporating the evidence-based literature with experience-based consensus of opinion in a way that has saved lives and decreased variation in practice in the United States and around the globe. (www.asahq.org/resources/standards-and-guidelines).
We were fortunate for the development of pulse oximetry3 and capnography, but every innovation involves a fight to establish value and benefit over added cost. The battle for change takes leaders … not only nationally, but among physician anesthesiologists in hospitals, surgical centers and office-based practices in every city. Private practice anesthesiologists, such as 1991 ASA President Betty Stephenson, M.D., showed us what could be accomplished by influencing national and state policy to protect patients and the profession. But every anesthesiologist can find a part to play. Vigilance is our motto. We must use it to constantly search for improvements as we have in the past. We are scientists and innovators. As such, we can use process improvement techniques, such as lean/six sigma/DMAIC and FEMA,4 to move health care forward every day. We are leaders and consultants, and the administrators of our hospitals need our insight to make enlightened choices when allocating funds to innovative projects. Our specialty should rotate residents through administrative levels to emphasize this aspect of leadership. State specialty societies can support research grants and presentations. H.A. Tillman Hein, M.D., Ph.D. (twitter@anesthesia6sigm) started such a program as president of the Texas Society of Anesthesiologists in 2011.
We can proudly say that our specialty (taking credit for those who came before us) created the patient safety and zero-harm movement. Our specialty of medicine is within reach of six sigma-level performance, which is a standard used by all industries. There has been a dramatic decrease in anesthesia-related deaths over the past 25 years, from two deaths per 10,000 anesthetics administered to fewer than two deaths per 400,000 anesthetics (or 5.92 sigma). The Florida Agency for Health Care Administration notes the number of deaths at ambulatory surgery centers to be less than one per 100,000 (or 5.76 sigma).5 A six sigma process is one in which 99.99966 percent of all opportunities to produce some feature of a part are statistically expected to be free of defects (3.4 defective features/million opportunities). We need to accomplish six sigma/high-reliability anesthesia quality this decade. By doing so, we will demonstrate leadership the medical world deserves. After all, leading this inspiring effort to make patients safe and pain free is our “why.”
Chassin MR, Loeb JM . High-reliability health care: getting there from here.Milbank Q. 2013;91(3):459–490.
Kohn LT, Corrigan J, Donaldson MS . To Err is Human: Building a Safer Health System. Washington, D.C: National Academy Press; 2000.
Cooper JB, Newbower RS, Kitz RJ . An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection. Anesthesiology. 1984;60(1)34-42.
Langley GJ, Moen RD, Nolan KM, Nolan TW, Norman CL, Provost LP . The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. San Francisco: Jossey-Bass; 2009.
Apfelbaum J. Statement on CMS report regarding Joan Rivers’ death and overall anesthesiology safety [press release]. Schaumburg, Illinois: American Society of Anesthesiologists; November 14, 2014.
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