KEY POINTS

1. The 1999 IOM report, "To Err is Human," estimated that there are 44,000 to 98,000 preventable deaths every year in U.S. hospitals—more annual deaths than from AIDS, motor vehicle accidents, or breast cancer in the United States.
2. There is a growing demand for improved quality and safety in health care from patients, providers, insurers, regulators, accreditors, and purchasers, and anesthesiologists must be able to evaluate the quality of care they provide.
3. Traditional approaches to quality improvement, including EBM and evidence-based clinical practice guidelines, professional education and development, assessment and accountability, patient-centered care, and total quality management have produced disappointing results, or their impact on patient outcomes has not been adequately evaluated.
4. If we want to improve the quality of care that we provide, we must be able to measure performance. Nevertheless, health care providers have limited ability to obtain feedback regarding performance in their daily work, in part because of a lack of information systems and a lack of agreement on how to measure quality of care.
5. The goal of measurement is to learn and improve. The measurement system must fit into an improvement system, there must be the will among caregivers to work cooperatively to improve, there must be ideas or hypotheses about changes to the current system of care, and the team must have a model for testing changes and implementing those that result in improvements.
6. Prior efforts to measure performance have predominantly focused on outcome measures, including in-hospital mortality rates. Although important, hospital mortality alone provides an incomplete picture of quality in that it does not provide insight into all domains of quality. A balanced set of structures (i.e., how care is organized), processes (i.e., what we do), and outcome measures (i.e., results we achieve) are needed to get a more accurate picture of the quality of care.
7. Future efforts to improve quality of care in the field of anesthesiology should focus on the development of valid, reliable, and practical measures of quality that provide insight into multiple domains of quality, such as those outlined in the IOM report. Developing a quality measure requires several steps: prioritize the clinical area to evaluate; select the type of measure; write definitions and design specifications; develop data collection tools; pilot test data collection tools, and evaluate the validity, reliability, and feasibility of measures; develop scoring and analytic specifications; and collect baseline data.
8. Quality is a characteristic of the system in which care is delivered, and every system is perfectly designed to achieve the results that it gets. If we want to improve the quality of care we provide, we need to reorganize the way we work.
9. One of the greatest opportunities to improve quality of care and patient outcomes probably will not come from discovering new therapies, but from discovering how to deliver therapies that are known to be effective. One practical model for improvement combines EBM with quality improvement: pick an important clinical area; identify interventions that improve outcomes for this area; measure whether we are doing what we should; redesign work to ensure patients receive those interventions; and evaluate whether patient outcomes improved as a result.
10. Two strategies that have been successfully employed in the aviation industry to improve performance include interventions to reduce complexity and to create redundancies in the system to ensure that critical processes occur. Examples include care bundles and checklists. These strategies have not been fully evaluated in the practice of anesthesia.