Administrative Components of All Anesthesiology Practices

Operational and Information Resources
1. The American Society of Anesthesiologists (ASA) provides extensive resource materials to its members regarding practice management (www.asahq.org) (Table 2-1: Practice Management Materials Provided by the American Society of Anesthesiologists).
2. These documents are updated regularly by the ASA through its committees and House of Delegates.
3. The Web site for the Anesthesia Patient Safety Foundation (www.apsf.org) is useful in promoting safe clinical practice.
The Credentialing Process and Clinical Privileges
1. The system of credentialing a health care professional and granting clinical privileges is motivated by the assumption that appropriate education, training, and experience, along with an absence of an excessive number of adverse patient outcomes, increase the likelihood that the health care professional will deliver high-quality care.
2. Models for credentialing anesthesiologists are offered by the ASA.
3. An important issue in granting clinical privileges, especially in procedure-oriented specialties such as anesthesiology, is whether it is reasonable to grant “blanket” privileges (i.e., the right to do everything traditionally associated with the specialty).
Maintenance of Certification in Anesthesiology
1. Anesthesiologists certified as diplomats by the American Board of Anesthesiology after January 1, 2000, are issued a “time-limited” board certification valid for 10 years. A formal process culminating in the recertification of an anesthesiologist for an additional and then subsequent 10-year intervals is designated Maintenance of Certification in Anesthesiology (MOCA).
2. The MOCA program introduced in 2000 is subdivided into four components or modules that include professional standing, lifelong learning and self-assessment, cognitive examination, and practice performance assessment and improvement.
Professional Staff Participation and Relationships
1. Medical staff activities are increasingly important in achieving a favorable accreditation status from The Joint Commission (JC).
2. Anesthesiologists should be active participants in medical staff activities (Table 2-2: Examples of Anesthesiologists as Participants in Medical Staff Activities).
Establishing Standards of Practice and Understanding the Standard of Care
1. American anesthesiology is one of the leaders in establishing practice standards that are intended to maximize the quality of patient care and help guide anesthesiologists make difficult decisions, including those about the risk–benefit and cost–benefit aspects of specific practices (Table 2-3: Materials Provided by the American Society of Anesthesiologists Designed to Establish Practice Standards).
2. The standard of care is the conduct and skill of a prudent practitioner that can be expected at all times by a reasonable patient.
  1. Failure to meet the standard of care is considered malpractice.
  2. Courts have traditionally relied on medical experts to give opinions regarding what the standard of care is and whether it has been met in an individual case.
3. Leading the Way. Anesthesiologists have been very active in publishing standards of care (see Table 2-3: Materials Provided by the American Society of Anesthesiologists Designed to Establish Practice Standards).
4. Practice Guidelines. A practice guideline has some of the same elements as a standard of practice but is intended more to guide judgment, largely through algorithms.
  1. Practice guidelines serve as potential vehicles for helping to eliminate unnecessary procedures and to limit costs.
  2. Guidelines do not define the standard of care, although adherence to the outlined principles should provide anesthesiologists with a reasonably defensible position.
5. JC standards focus on credentialing and privileges, verification that anesthesia services are of uniform quality, continuing education, and documentation of preoperative and postoperative evaluations.
6. Review Implications. Another type of regulatory agency is the peer review organization, whose objectives include issues related to hospital admissions, utilization, and quality of care.
Policy and Procedure
1. An important organizational aspect of an anesthesia department is a policy and procedure manual.
2. This manual includes specific protocols for areas mentioned in the JC standards, including preanesthetic evaluation, safety of the patient during anesthesia, recording of all pertinent events during anesthesia, and release of the patient from the postanesthesia care unit (PACU).
3. A protocol for responding to an adverse event is useful (Anesthesia Patient Safety Foundation Newsletter, 2006:21:11, www.apsf.org).
Meetings and Case Discussion
1. There must be regularly scheduled departmental meetings.
2. The JC requires that there be at least monthly meetings at which risk management and quality improvement activities are documented and reported.
Support Staff. There is a fundamental need for support staff in every anesthesia practice.
Anesthesia Equipment and Equipment Maintenance. Compared with human error, overt equipment failure rarely causes critical intraoperative incidents. The Anesthesia Patient Safety Foundation advocates that anesthesia departments develop a process to verify that all anesthesia professionals are trained to use new technology being introduced in the operating room.
1. Service. Equipment maintenance and service may be provided by factory representatives or in-house engineers.
2. Replacement of obsolete anesthesia machines (10 years often cited as the estimated useful life) and monitoring equipment is a key element in a risk-modification program.
Malpractice Insurance
1. Occurrence means that if the insurance policy was in force at the time of the occurrence of an incident resulting in a claim, the physician will be covered.
2. Claims made provide coverage only for claims that are filed when the policy was in force. (“Tail coverage” is needed if the policy is not renewed annually.)
3. A new approach in medical risk management and insurance is advocating immediate full disclosure to the victim or survivors. This shifts the culture of blame with punishment to a just culture with restitution.
Response to an Adverse Event
1. Despite the decreased incidence of anesthesia catastrophes, even with the very best practice, it is statistically likely that an anesthesia professional will be involved in a major anesthesia accident at least once in his or her professional life.
2. A movement to implement immediate disclosure and apology reflects as shift from the “culture of blame” with punishment to a “just culture” with restitution. Laudable as the policy of immediate full disclosure and apology may sound, it is recommended for the anesthesia professional to confer with the involved liability insurance carrier, the practice group, and the facility administration before pursuing this policy.

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