Anesthesia Quality Improvement: Current State and Future Opportunities
Megha Karkera Kanjia, MD, and Lynn D. Martin, MD, MBA
Original Article
Tung A, Dutton RP. Anesthesia Quality Improvement: Current State and Future Opportunities. Anesthesiology 2025; 142:217-29. doi: 10.1097/ALN.0000000000005252. PMID: 39655985
The focus of today’s PAAD is a review article on anesthesia quality improvement (QI) in general and that is not focused on pediatric patients.1 These reviewers have had the opportunity to personally witness and advance true improvements in quality and patient safety as viewed through the lenses of Safety 1, 2, and 3.2 To give the reader a better sense of how far we have come, we need to describe where we started. It seems that not long ago that what is considered a “standard monitor” today was not always the case. My father, Mohan Karkera, a recently retired pediatric anesthesiologist who practiced for over 45 years, reminded me that when he started his residency, they would keenly watch their patients to ensure that they remained “pink”, which was the original “version” of a pulse oximeter. The invention of the pulse oximeter by Takuo Aoyagi in 1974 began to change systems and outcomes. During my residency (LDM), I realized I could not distinguish pink in the dark OR and thus found myself fighting to gain access to one of the few pulse oximeters in the department. Fortunately for me children were considered very ‘scary’ patients, so I was frequently successful. This single QI intervention (pulse oximetry) correlated with a 90% reduction in anesthesia-related mortalities.3 Anesthesiology has continued to make great strides since, thanks to the hard work of many anesthesiology teams members through Quality Improvement and Patient Safety research. Tung and Dutton1 review the massive improvements in Quality and Safety that the field of anesthesia has achieved over the last 70 years, discusses current anesthesia QI definitions and thinking, outlines recommended local departmental QI efforts, and suggests future projects to further improve patient and clinician outcomes.
Current QI practice key points made by Tung and Dutton that the reviewers wish to highlight include:
1) Quality is multidimensional with an asymptotic limit that can be approached but never reached (i.e., we are never done with improvement). They describe the significant evolution in anesthesia practice over time with initial quality efforts focused on mortality which led to closed claims reviews that formed the framework of Safety 1 through standard monitors and national anesthesiology monitoring guidelines.
2) The Institute of Medicine (IOM) defines quality in six domains (effective, equitable, timely, efficient, safe, and patient centered).4 By keeping the IOM domains of quality care in mind, this article highlights the importance of local QI projects, improvement through tracking common adverse events, identifying novel events, measuring patient experience, as well as future opportunities to improve our field.
3) They note the huge gap described by Daniel Sessler in the 2023 ASA Rovenstine Lecture that safety risk does not end with patient arrival in the PACU and that current data systems rarely close this post-PACU “blind spot” for anesthesiologists. They discuss strategies to address these gaps, such as threshold (trigger) laboratory values from the EMR to detect automated anesthesia outcomes and cross departmental collaboration to merge medical center data with the anesthesia database.
4) Event reporting systems serve as an ‘early warning’ method to alert practitioners to real or potential unsafe conditions during clinical practice. They note shortcomings of self-reporting and define the departmental culture that prioritizes cooperation, transparency and information sharing is a key requirement for the warning system to be successful.
5) QI leaders are required to prioritize efforts to better utilize the limited, available resources to yield the greatest impact on outcomes. Common barriers to QI include insufficient departmental support (failing to recognize a lack of alignment to hospital goals necessary to garner hospital support), vague/ambiguous or over ambitious goals, and lack of individual or group QI expertise. I (LDM) believe they also failed to identify one of the nearly universal barriers for all anesthesiologists: lack of timing and easy access to process and outcome data from the EMR to monitor, learn and improve. Strategies to address these barriers include use of SMART (specific, measurable, achievable, relevant, and time bound) aims, formal approval of project and associated resources, and use of team-based approach with formal mentorship to provide the needed expertise.
Where do we go from here? What does the future look like? Tung and Dutton do a thorough job of discussing some future opportunities.
1) Newer Safety frameworks, namely Safety 2 and 3, highlight the importance of having a resilient team to build a High Reliability Organization (HRO) by learning from the failures and creating safety nets that truly function as intended. The controversial practice of conducting Root Cause Analyses (RCAs) for sentinel events is deeply rooted in the Safety I framework and commonly associated with an undercurrent of placing blame on both the individual and the organization. Safety 2 would highlight why this same process followed on a daily basis goes well 99% of the time, while Safety 3 would also highlight how the failed design of the process or product allowed for the 1% event to occur.5,6 Tung and Dutton’s Table 2 illustrates the differences in the three safety perspectives using infiltrated IV as an example.
2) They provide to me (LDM) a new and exciting discussion on decision making and the possibly origins of cognitive biases. Table 3 has excellent examples of cognitive bias specific to anesthesiology.
3) Much to my (LDM) delight, they included a brief overview of implementation science where we use methods to translate and disseminate evidence-based best practice into routine clinical care. QI leaders must acquire knowledge and experience in this emerging field if they are going to make meaningful and timely improvements in clinical experiences and outcomes. We urge PAAD readers to go to last fall’s SPA program and view the keynote presentation by Dr. Meghan Lane-Fall titled “Growing the impact of pediatric anesthesia through implementation science”. Here is the link to this session (lecture is from minutes 22:00 to 51:00 follow by the Q&A session): https://search.app/M2qpFiRM7SCqRyMG9.
4) Tung and Dutton suggest that the ability of our field to accurately perform risk stratification for our patients as another area for future improvement. Because many of our serious safety events are so rare, it is quite challenging statistically to build a large enough profile to be able to generate a true risk stratification. While the emergence of ASA classification in 1963 offers some kind of ballpark risk idea, this score is subjective and is not as useful for true predictive value, which we currently lack. Better risk stratification will enhance internal and external benchmarking efforts.
5) An area only now starting to receive badly needed attention is patient (and family) engagement. Tung and Dutton provide an excellent description of what an ‘ideal patient experience’ would look like. Perioperative leaders should focus more time, effort, and resources in this soft practice domain.
6) They close with the need for better integration of quality across the entire perioperative experience. Not only pre, intra, and postoperative integration, but across specialties (anesthesiology, surgery and nursing).
In conclusion, anesthesiologists have an increasingly complex group of patients that we care for in a high-risk environment—the opportunity for error is always at our fingertips. How do we pivot in a world with such challenges? It is clear to us that anesthesiologists truly comprise a group of incredibly resilient individuals who utilize many modalities to improve the care that is provided in every department, institution, team, and community. How do we appropriately support the individuals with goals aligned with the greater organization or institution? Abandoning the former Safety I goals of “find and fix it” would be one of the first things that should be considered—this may include safety frameworks such as RCAs that have been highly embraced over the last 20 years. Newer Safety 2 and 3 approaches focus on the Human Factors influence in decision making as well as the fundamental idea that the design of a system is the most important piece of the Safety process. People will innately take a “shortcut” or find a simpler way to perform complex tasks- so how do we make it easier to do the right thing? Perhaps the more widespread use of positive deviance (spreading best practice) highlighted in implementation science could facilitate the achievement of this objective?7 How do we continue to think from a Safety 3 perspective and make the design of the system better able to accommodate the process and team rather than making changes after the process is already in place? These are critical intersections as we design our systems and processes—are the safeguards functioning as intended? If not, how can we change our process and system to make the process more streamlined? It is critical that the department culture is one that highlights cooperation and transparency for improved safety culture within itself.2
References
1. Tung A, Dutton RP. Anesthesia Quality Improvement: Current State and Future Opportunities. Anesthesiology 2025; 142(1):217-29. doi:10.1097/ALN.0000000000005252. PMID: 39655985.
2. Kanjia MK, Kurth CD, Hyman D, et al. Perspectives on Anesthesia and Perioperative Patient Safety: Past, Present, and Future. Anesthesiology. 2024;141(5):835-848. doi:10.1097/ALN.0000000000005164. PMID: 39377708.
3. Bhattacharya K. Takuo Aoyagi - a Tribute to the Brain Behind Pulse Oximetry. Indian J Surg. 2020 Dec;82(6):1332-1333. doi: 10.1007/s12262-020-02365-x. Epub 2020 May 20. PMID: 32837057; PMCID: PMC7237228.
4. Institute of Medicine Committee on Quality of Healthcare in America: Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C., National Academies Press, 2001.
5. Hollnagel E, Wears RL, Braithwaite J: From Safety-I to Safety-II: A White Paper. Denmark: Resilient Health Care Net. 2015. Available at: https://www.england.nhs.uk/signuptosafety/wp-content/uploads/ sites/16/2015/10/safety-1-safety-2-whte-papr.pdf.
6. Leveson N. Safety III: A Systems Approach to Safety and Resilience. MIT Engineering Systems Lab. Available at: https//sunnyday.mit.edu/safety-3.pdf.
7. Lawton R, Taylor N, Clay-Williams R, et al. Positive deviance: a different approach to achieving patient safety. BMJ Qual Saf 2014;23(11):880-3. doi:10.1136/bmjqs-2014-003115. PMID: 25049424.